Screening for dementia in a primary care practice

Dementia is a common condition of the elderly; yet it often is unrecognized by primary care providers. This article presents a compelling argument for screening for dementia in a primary care setting. It also provides a protocol for effective screening, instructions on how to use it, and steps to follow if the screening indicates the patient may have dementia.

Noninvasive quantification of ascorbate and glutathione concentration in the elderly human brain

In this study, ascorbate (Asc) and glutathione (GSH) concentrations were quantified noninvasively using double-edited (1)H MRS at 4 T in the occipital cortex of healthy young [age (mean ± standard deviation) = 20.4 ± 1.4 years] and elderly (age = 76.6 ± 6.1 years) human subjects. Elderly subjects had a lower GSH concentration than younger subjects (p < 0.05). The Asc concentration was not significantly associated with age. Furthermore, the lactate (Lac) concentration was higher in elderly than young subjects. Lower GSH and higher Lac concentrations are indications of defective protection against oxidative damage and impaired mitochondrial respiration. The extent to which the observed concentration differences could be associated with physiological differences and methodological artifacts is discussed. In conclusion, GSH and Asc concentrations were compared noninvasively for the first time in young vs elderly subjects.

Results of a two-center study comparing hepatic fibrosis progression in HCV-positive liver transplant patients receiving cyclosporine or tacrolimus

A 2-center retrospective analysis was performed in 60 patients undergoing liver transplantation for hepatitis C virus (HCV)-related disease (cyclosporine in 20, tacrolimus in 40). Mean (±SEM) follow-up was 23.6 ± 22.5 and 22.3 ± 13.7 months in patients receiving cyclosporine or tacrolimus, respectively. Clinically indicated biopsies were performed in 15/20 cyclosporine patients (75%) and 22/40 tacrolimus patients (55%; P = .17). The Ishak fibrosis score was significantly lower in cyclosporine-treated patients versus tacrolimus-treated patients (mean 1.7 ± 0.4 vs 3.1 ± 0.4; P = .023), as was percentage of fibrosis grade Ishak ≥4 (7% vs 41%; P = .028). The mean time to moderate fibrosis (Ishak score ≥3) was 38.2 ± 15.1 months in cyclosporine patients (4/15) and 23.5 ± 12.6 months in tacrolimus patients (14/22); the difference was not statistically significant (P = .09). This retrospective study suggests that cyclosporine-based immunosuppression is associated with less severe hepatic fibrosis in HCV-positive liver transplant recipients compared with tacrolimus-based regimens, but a larger prospective comparative trial is necessary to confirm these findings.

The experience and meaning of compassion and self-compassion for individuals with depression or anxiety

OBJECTIVES

The objective of this study was to explore the meaning and experiences of compassion and self-compassion for individuals with depression and anxiety.

DESIGN

An interpretative phenomenological analysis (IPA) epistemology and methodology were adopted as the study was focused on understanding the meaning and experiences of participants towards self-compassion from existing theory.

METHODS

Ten participants were selected based on a Diagnostic and Statistical Manual of Mental Disorders, 4th Ed.-text revision diagnosis of depression or an anxiety disorder. Individuals were excluded from this study if they had additional diagnoses which impacted significantly on their disorder or on ethical grounds if participation was seen as psychologically distressing. Participants completed a semi-structured interview with questions were based on existing self-compassion research. Interviews lasted an hour and were analysed using IPA methodology.

RESULTS

Participants' reflections suggested that they saw compassion having two central qualities: kindness and action. Participants reported that they thought having compassion for themselves felt meaningful in relation to their experiences and useful in helping with their depression or anxiety. However, participants reflected that they felt being self-compassionate would be difficult either because the concept itself felt challenging to enact or their experience of psychological disorder had negatively impacted on their ability to be self-compassionate.

CONCLUSIONS

Participants' positive perceptions of self-compassion offer encouragement to clinicians as it appears people can connect with the concept meaningfully as well as seeing it as being useful. Clinicians focusing on self-compassion may gain greater efficacy when they incorporate both aspects within interventions. Findings about the difficulties associated with self-compassion provide valuable information as to why people find it difficult to adopt which can be used in the development of future clinical interventions.

Fluorodeoxyglucose positron emission tomography of mild cognitive impairment with clinical follow-up at 3 years

BACKGROUND

Alzheimer's disease (AD) is the most common dementing illness. Development of effective treatments directed at AD requires an early diagnosis. Mild cognitive impairment (MCI) often heralds AD. Thus, characterizing MCI is fundamental to the early diagnosis of AD.

METHODS

19 MCI patients referred from a memory loss clinic and 27 healthy subjects, all followed up for 3 years. Metabolism scans (MCI minus controls) were compared voxel-wise after anatomic normalization and were examined both visually and with a computerized classifier.

RESULTS

Agreement between raters as to whether the individual scans were normal or abnormal was high. Agreement between raters of the eventual clinical diagnosis and baseline metabolic pattern was poor. A computerized classifier was unsuccessful at classifying MCI from normal; however, its performance improved when using only prototypic AD-like MCI scans, indicating the classifier worked well when shared patterns existed in the data. Outcomes on follow-up were nine of 19 AD, five of 19 remained MCI, and five of 19 developed dementias other than AD. Both MCI cases of early Lewy body dementia (LBD) showed an AD-like metabolic pattern.

CONCLUSIONS

Visual inspection proved reliable in determining normal from abnormal scans, but it proved unreliable at predicting diagnosis on follow-up. Computerized classification of MCI by using an AD-like metabolic template (such as derived from the averaged MCI images) showed potential to identify patients who will develop AD. However, the metabolic pattern in early LBD did not differ from that in AD.

Negotiating 'depression' in primary care: a qualitative study

Psychiatry has provided primary care physicians with tools for recognising and labelling mild, moderate or severe 'depression'. General practitioners (GPs) in the UK have been guided to manage depression within primary care and to prescribe anti-depressants as a first-line treatment. The present study aimed to examine how GPs would construct 'depression' when asked to talk about those anomalous patients for whom the medical frontline treatment did not appear to be effective. Twenty purposively selected GPs were asked in an interview to talk about their experience and management of patients with depression who did not respond to anti-depressants. GPs initially struggled to identify a group, but then began to construct a category of person with a pre-medicalised status characterised by various deviant features such as unpleasant characters and personalities, manipulative tendencies, people with entrenched social problems unable to fit in with other people and relate to people normally. GPs also responded in non-medical ways including feeling unsympathetic, breaking confidentiality and prescribing social interventions. In effect, in the absence of an effective medical treatment, depression appeared to become demedicalised. The implications of this process are discussed in relation to patients' subsequent access or lack of access to services and the way in which these findings highlight the processes by which medicine frames disease.

Short series of emergency stent-graft repair of symptomatic penetrating thoracic aortic ulcers (PTAU)

Abstract

Acute penetrating thoracic aortic ulcers (PTAU) are associated with vessel rupture, particularly when intramural haematoma (IMH) is present. Although surgical repair is the treatment of choice for PTAU in the aortic arch, definitive treatment of PTAU in other locations of the thoracic aorta remains controversial, particularly in this frail cohort of patients. Recent series of elective and semi-elective endovascular stent-graft repair of PTAU of the descending thoracic aorta show comparable results with the previously advocated best medical management. We report our results from a retrospective, observational study of acute stent-graft repair of symptomatic PTAU. Between 2000 and 2005, 11 patients (seven male, four female; median age 71 years) presented with acute PTAU. CT scans demonstrated an associated IMH in six, a contained leak in three or rupture in four unstable patients. All were covered by a single endovascular stent [Gore (5), Talent (5), Zenith (1); 10 inserted via the groin and one via iliac conduit within 1 week of presentation (five < 24 h). Technical success was 90.90% (10/11) and 3/11 (27%) died within 30 days (two ARDS, one a persistent leak and rupture at 48 h). One patient developed transient paraplegia; three haemothoraces required chest drains, one of which subsequently required empyema drainage. In survivors, CT scans were satisfactory, with no further intervention required at 32.5 (6–66) months of median follow-up. In conclusion, endovascular management of acute PTAU appears effective and durable with mortality rates that are likely to be better than for open surgery. However, haemodynamic compromise at presentation remains a robust denominator of over-all survival.

The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation

OBJECTIVES

To assess whether open angle glaucoma (OAG) screening meets the UK National Screening Committee criteria, to compare screening strategies with case finding, to estimate test parameters, to model estimates of cost and cost-effectiveness, and to identify areas for future research.

DATA SOURCES

Major electronic databases were searched up to December 2005.

REVIEW METHODS

Screening strategies were developed by wide consultation. Markov submodels were developed to represent screening strategies. Parameter estimates were determined by systematic reviews of epidemiology, economic evaluations of screening, and effectiveness (test accuracy, screening and treatment). Tailored highly sensitive electronic searches were undertaken.

RESULTS

Most potential screening tests reviewed had an estimated specificity of 85% or higher. No test was clearly most accurate, with only a few, heterogeneous studies for each test. No randomised controlled trials (RCTs) of screening were identified. Based on two treatment RCTs, early treatment reduces the risk of progression. Extrapolating from this, and assuming accelerated progression with advancing disease severity, without treatment the mean time to blindness in at least one eye was approximately 23 years, compared to 35 years with treatment. Prevalence would have to be about 3-4% in 40 year olds with a screening interval of 10 years to approach cost-effectiveness. It is predicted that screening might be cost-effective in a 50-year-old cohort at a prevalence of 4% with a 10-year screening interval. General population screening at any age, thus, appears not to be cost-effective. Selective screening of groups with higher prevalence (family history, black ethnicity) might be worthwhile, although this would only cover 6% of the population. Extension to include other at-risk cohorts (e.g. myopia and diabetes) would include 37% of the general population, but the prevalence is then too low for screening to be considered cost-effective. Screening using a test with initial automated classification followed by assessment by a specialised optometrist, for test positives, was more cost-effective than initial specialised optometric assessment. The cost-effectiveness of the screening programme was highly sensitive to the perspective on costs (NHS or societal). In the base-case model, the NHS costs of visual impairment were estimated as 669 pounds. If annual societal costs were 8800 pounds, then screening might be considered cost-effective for a 40-year-old cohort with 1% OAG prevalence assuming a willingness to pay of 30,000 pounds per quality-adjusted life-year. Of lesser importance were changes to estimates of attendance for sight tests, incidence of OAG, rate of progression and utility values for each stage of OAG severity. Cost-effectiveness was not particularly sensitive to the accuracy of screening tests within the ranges observed. However, a highly specific test is required to reduce large numbers of false-positive referrals. The findings that population screening is unlikely to be cost-effective are based on an economic model whose parameter estimates have considerable uncertainty. In particular, if rate of progression and/or costs of visual impairment are higher than estimated then screening could be cost-effective.

CONCLUSIONS

While population screening is not cost-effective, the targeted screening of high-risk groups may be. Procedures for identifying those at risk, for quality assuring the programme, as well as adequate service provision for those screened positive would all be needed. Glaucoma detection can be improved by increasing attendance for eye examination, and improving the performance of current testing by either refining practice or adding in a technology-based first assessment, the latter being the more cost-effective option. This has implications for any future organisational changes in community eye-care services. Further research should aim to develop and provide quality data to populate the economic model, by conducting a feasibility study of interventions to improve detection, by obtaining further data on costs of blindness, risk of progression and health outcomes, and by conducting an RCT of interventions to improve the uptake of glaucoma testing.

The accuracy of accredited glaucoma optometrists in the diagnosis and treatment recommendation for glaucoma

AIM

To compare the diagnostic performance of accredited glaucoma optometrists (AGO) for both the diagnosis of glaucoma and the decision to treat with that of routine hospital eye care, against a reference standard of expert opinion (a consultant ophthalmologist with a special interest in glaucoma).

METHODS

A directly comparative, masked, performance study was undertaken in Grampian, Scotland. Of 165 people invited to participate, 100 (61%) were examined. People suspected of having glaucoma underwent, within one month, a full ophthalmic assessment in both a newly established community optometry led glaucoma management scheme and a consultant led hospital eye service.

RESULTS

Agreement between the AGO and the consultant ophthalmologist in diagnosing glaucoma was substantial (89%; kappa = 0.703, SE = 0.083). Agreement over the need for treatment was also substantial (88%; kappa = 0.716, SE = 0.076). The agreement between the trainee ophthalmologists and the consultant ophthalmologist in the diagnosis of glaucoma and treatment recommendation was moderate (83%, kappa = 0.541, SE = 0.098, SE = 0.98; and 81%, kappa = 0.553, SE = 0.90, respectively). The diagnostic accuracy of the optometrists in detecting glaucoma in this population was high for specificity (0.93 (95% confidence interval, 0.85 to 0.97)) but lower for sensitivity (0.76 (0.57 to 0.89)). Performance was similar when accuracy was assessed for treatment recommendation (sensitivity 0.73 (0.57 to 0.85); specificity 0.96 (0.88 to 0.99)). The differences in sensitivity and specificity between AGO and junior ophthalmologist were not statistically significant.

CONCLUSIONS

Community optometrists trained in glaucoma provided satisfactory decisions regarding diagnosis and initiation of treatment for glaucoma. With such additional training in glaucoma, optometrists are at least as accurate as junior ophthalmologists but some cases of glaucoma are missed.

Social determinants of diagnostic labels in depression

The role of diagnostic labels in medicine is usually that of labelling an illness as a means of communication. Control over labelling processes in medicine is ordinarily imposed via medical schools, textbooks, education or by diagnostic manuals. Diagnostic labels often change following new discoveries in underlying pathology such as 'consumption' being relabelled as 'TB' or 'cancer'. Sub-types of broad diagnostic labels also often emerge from such discoveries e.g. 'lung cancer' or 'throat cancer'. In mental health, underlying pathology is the subject of ongoing debate spanning ideas including the brain as a faulty organ, faulty genetics and environmental problems. With controversy over pathology comes controversy over labels and the idea that labels may be used not just for communication, but as devices of social and professional control, arising out of a social process. This study explores the codification of the diagnostic label 'depression' which emerged in the twentieth-century and has proliferated with numerous sub-types over the last 40 years. The aim is to examine its social determinants and context. Medline is used as a data source for professional label usage. A range of depression sub-type labels in professional use was identified. This exercise revealed many official and 'unofficial' terms in professional use. Citation rate plots by year were then generated for these depression sub-type labels. The rise and fall of different labels are examined in relation to social determinants and context, including publication of diagnostic manuals DSM and ICD, power shifts in psychiatry, the discovery of psychiatric drugs and the shift from inpatient to community care. Exploring the changing use of official and unofficial labels over time in this way provides a novel historical perspective on the concept of depression in the late twentieth-century.

An oral carcinogenicity and toxicity study of senna (Tinnevelly senna fruits) in the rat

Senna (Tinnevelly senna fruits), a known laxative derived from plants, was administered by gavage to Sprague-Dawley (Crl:CD (SD) BR) rats once daily at dose levels of 0, 25, 100 and 300 mg/kg/day for up to 104 consecutive weeks. Based upon clinical signs related to the laxation effect of senna, the highest dose (300 mg/kg/day) was considered to be a maximum tolerated dose. Sixty animals per sex were assigned to the control and dose groups. Assessments included clinical chemistry, hematology, full histology (control and high-dose groups; in addition, low and mid dose: intestinal tract, adrenals, liver, kidneys, brain and gross lesions) and toxicokinetics. The primary treatment-related clinical observation was mucoid feces seen at 300 mg/kg/day. When compared to controls, animals administered 300 mg/kg/day had slightly reduced body weights, increased water consumption and notable changes in electrolytes in serum (increases in potassium and chloride) and urine (decreases in sodium, potassium and chloride). The changes in electrolytes are most likely physiologic adaptations to the laxative effect of senna. At necropsy, dark discoloration of the kidneys was observed in animals in all treated groups. Histological changes were seen in the kidneys of animals from all treated groups and included slight to moderate tubular basophilia and tubular pigment deposits. In addition, for all treated groups, minimal to slight hyperplasia was evident in the colon and cecum. These histological changes, together with the changes seen in the evaluation of clinical chemistry and urine parameters, have been shown to be reversible in a previous 13-week rat study of senna. No treatment-related neoplastic changes were observed in any of the examined organs. Based upon these data, it is concluded that senna is not carcinogenic even after daily administration for 2 years at dosages of up to 300 mg/kg/day in Sprague-Dawley rats.

The effectiveness of psychological treatments for treatment-resistant depression: a systematic review

OBJECTIVE

A systematic review of all studies (controlled and uncontrolled) to evaluate psychological interventions with treatment-resistant depression.

METHOD

A systematic search to identify studies evaluating a psychological intervention with adults with a diagnosis of major depressive disorder who had not responded to at least one course of antidepressant medication.

RESULTS

Twelve studies met inclusion criteria, of which four were controlled and eight uncontrolled. Treatment effect sizes were computable for four studies and ranged from 1.23 to 3.10 with a number of better quality studies demonstrating some improvements in patients following a psychological intervention.

CONCLUSION

Psychological treatments for depression are commonly delivered and often recommended following the failure of medication. The paucity of evidence for their effectiveness in these situations is a significant problem. There is a need for studies with a strong controlled design investigating the effectiveness of psychological treatments for patients with treatment-resistant depression.

SENSITIVITY AND SPECIFICITY OF FINGER TAPPING TEST SCORES FOR THE DETECTION OF SUSPECT EFFORT

Past studies indicate that patients with incentive to fake neuropsychological symptoms are likely to have lower finger tapping scores than credible patients. The present study builds upon past research by investigating finger tapping performance for seven groups: (a) noncredible patients (as determined by failed psychometric and behavioral criteria), and patients with (b) closed head injury, (c) dementia, (d) mental retardation, (e) psychosis, or (f) depression, and (g) healthy older controls. Results showed that men tapped faster than women, requiring that groups be divided by gender. Noncredible male and female patients tapped slower than their comparison group counterparts. Dominant hand score proved to be more sensitive to noncredible performance than other scores (nondominant, sum of both hands, difference between dominant and nondominant), especially for women. Sensitivity, specificity, and positive and negative predictive value tables are presented. With specificity set at 90% for the comparison groups combined, a dominant hand cutoff score of </=35 for men yielded 50% sensitivity, while a score of </=28 yielded 61% sensitivity for women. Specificity values for specific cutoff scores varied significantly across the comparison groups, indicating that cutoffs should be adjusted for the particular differential diagnosis. In conclusion, results indicate that when using finger tapping scores to detect noncredible performance: (a) Dominant hand performance is more sensitive, and (b) cutoffs should be selected based on gender and claimed diagnosis.

Acute hepatitis C in a nursing home resident

Elderly patients commonly present with jaundice from a multitude of causes. We present an unusual case of acute hepatitis C in an elderly nursing home resident who had no risk factors. Possible causes and treatment are discussed.

Relational integration and executive function in Alzheimer's disease

Executive functions depend on the ability to represent relations between objects and events, and the prefrontal cortex provides the neural substrate for this capacity. Patients with probable Alzheimer's disease (AD) and control participants were administered measures of working memory and reasoning that varied systematically in their relational complexity. AD patients showed impairment on reasoning measures that required the online integration of relations but performed as well as control participants on nonrelational items and items requiring the processing of only single relations. When AD patients were divided into subgroups based on their performance on relational reasoning measures, the subgroup that showed significant impairment on relational integration measures exhibited a neuropsychological profile consistent with prefrontal cortical dysfunction.