Pharmacogenetic interactions between beta-blocker therapy and the angiotensin-converting enzyme deletion polymorphism in patients with congestive heart failure

BACKGROUND

Activation of the renin-angiotensin and sympathetic nervous systems adversely affect heart failure progression. The ACE deletion allele (ACE D) is associated with increased renin-angiotensin activation; however, its influence on patient outcomes remains uncertain, and the pharmacogenetic interactions with beta-blocker therapy have not been previously evaluated.

METHODS AND RESULTS

We prospectively followed 328 patients (age, 56.1+/-11.9 years) with systolic dysfunction (left ventricular ejection fraction, 0.24+/-0.08) to assess the impact of the ACE D allele on transplant-free survival (median follow-up, 21 months). Transplant-free survival was compared by genotype for the whole cohort and separately in patients with (n=120) and those without beta-blocker therapy (n=208) at the time of entry. Transplant-free survival was significantly poorer for patients with the D: allele (1-year percent survival II/ID/DD=94/77/75; 2-year=78/65/60; ordered log-rank test, P:=0.044). In patients not treated with beta-blockers, the adverse impact of ACE D allele was dramatically increased (1-year percent survival II/ID/DD=95/75/67; 2-year=81/61/48; P:=0.005). In contrast, in patients receiving beta-blocker therapy, no influence of ACE genotype on transplant-free survival was evident (1-year percent survival II/ID/DD=91/80/86; 2-year=70/71/77; P:=0.73).

CONCLUSIONS

In a cohort of patients with systolic dysfunction, the ACE D allele was associated with a significantly poorer transplant-free survival. This effect was primarily evident in patients not treated with beta-blockers and was not seen in patients receiving therapy. These findings suggest a potential pharmacogenetic interaction between the ACE D/I polymorphism and therapy with beta-blockers in the determination of heart failure survival.

Pyrido[2,3-d]pyrimidin-7-one inhibitors of cyclin-dependent kinases

The identification of 8-ethyl-2-phenylamino-8H-pyrido[2, 3-d]pyrimidin-7-one (1) as an inhibitor of Cdk4 led to the initiation of a program to evaluate related pyrido[2, 3-d]pyrimidin-7-ones for inhibition of cyclin-dependent kinases (Cdks). Analysis of more than 60 analogues has identified some clear SAR trends that may be exploited in the design of more potent Cdk inhibitors. The most potent Cdk4 inhibitors reported in this study inhibit Cdk4 with IC(50) = 0.004 microM ([ATP] = 25 microM). X-ray crystallographic analysis of representative compounds bound to the related kinase, Cdk2, reveals that they occupy the ATP binding site. Modest selectivity between Cdks is exhibited by some compounds, and Cdk4-selective inhibitors block pRb(+) cells in the G(1)-phase of the cell division cycle.

True eminectomy for internal derangement of the temporomandibular joint

We carried out a prospective study to assess the short- and long-term outcomes of true eminectomy in 20 consecutive patients with type III or IV anteriorly displaced discs in whom conventional conservative treatment had failed to resolve the symptoms. Maximum opening was measured preoperatively, 3-6 months postoperatively and at one year postoperatively. Each patient filled out a Mandibular Functional Impairment Questionnaire [MFIQ] and Clinical Dysfunctional Index both preoperatively and one year postoperatively. Imaging records included preoperative and one year postoperative orthopantomograph (OPG) and magnetic resonance imaging (MRI). Maximum mouth opening one year postoperatively had increased in 95% of patients (range 5-20 mm, mean 12 mm). There was an improvement in symptoms, using the MFIQ, in 85% of patients. The Clinical Dysfunctional Index was reduced to Type I in most patients. MRI showed increase in rotation and translatory movement of the condylar head. We conclude that true eminectomy may be used to successfully treat type III and type IV anteriorly displaced discs in patients who have failed to respond to conventional conservative treatment.

Expression of proinflammatory cytokines in the failing human heart: comparison of recent-onset and end-stage congestive heart failure

BACKGROUND

Plasma levels of proinflammatory cytokines, including tumor necrosis factor (TNF)-alpha and interleukin (IL)-6, are elevated in patients with congestive heart failure (CHF). Recent studies suggest that the failing human heart is a source of proinflammatory cytokines in the end-stage failing heart. However, the relevance of plasma levels to those of the myocardium remains undefined. We sought to compare cytokine expression in early and end-stage CHF, and to evaluate the correlation of tissue expression to plasma levels.

METHODS

Two patient populations were studied: patients with recent-onset CHF, all with symptoms less than 6 months (n = 17, duration of symptoms 2.1 +/- 1.6 months, range of New York Heart Association (NYHA) 1 to 3), and end-stage heart-failure patients (n = 7) who underwent left-ventricular assist-device (LVAD) implantation (Duration of symptoms 47.1 +/- 28.0 months, all NYHA class 4). Plasma levels of TNF-alpha and IL-6 proteins were evaluated by an Enzyme-Linked Immuno-Sorbent Assay (ELISA), while myocardial levels of cytokine transcripts were assessed by ribonuclease (Rnase) protection assay.

RESULTS

In patients with end-stage heart failure, TNF-alpha and IL-6 were increased in the plasma as well as in the myocardium (plasma: TNF-alpha = 7.7 +/- 2.3 pg/ml, IL-6 = 45.0 +/- 47.1 pg/ml; myocardium: TNF-alpha = 0.31 +/- 0.15% of glyceraldehyde 3-phosphate dehydrogenase (GAPDH) expression, IL-6 = 1.56 +/- 1.54% ). In contrast, despite elevated plasma levels of TNF-alpha and IL-6, the myocardium of patients with the recent onset of symptoms demonstrated minimal expression of TNF-alpha and IL-6 messenger ribonucleic acid (mRNA) (plasma: TNF-alpha = 4.3 +/- 1.7 pg/ml, IL-6 = 3.3 +/- 1.8 pg/ml; myocardium: TNF-alpha = 0.13 +/- 0. 04%, IL-6 = 0.02 +/- 0.04%). Plasma levels of TNF-alpha were significantly correlated with those in the myocardium when both populations were combined. (r = 0.69, p < 0.001).

CONCLUSIONS

Cytokines are expressed in the myocardium in end-stage heart failure to a much greater degree than in patients with the recent-onset of symptoms. This suggests that induction of cytokines in the myocardium is a relatively late event in the pathogenesis of CHF. Furthermore, plasma levels of TNF-alpha correlates with mRNA expression in the myocardium and thus may serve as an appropriate marker of myocardial cytokine activation. Whether the production of cytokines in the failing human heart precedes the elevation of cytokines in the plasma remains undefined. Therefore, we studied expression of TNF-alpha and IL-6 in the myocardium as well as in the plasma in patients with early and end-stage CHF. The results have demonstrated that cytokines are expressed in the myocardium in end-stage heart failure to a much greater degree than in patients with the recent onset of symptoms. This suggests that induction of cytokines in the myocardium is a relatively late event in the pathogenesis of CHF.

Consensus guidelines: agreement and debate surrounding the optimal management of Helicobacter pylori infection

Helicobacter pylori is a recognized cause of a variety of gastroduodenal pathology. The high prevalence of both H pylori infection and related diseases within the community warrants its consideration as a public health care issue. The availability of reliable and safe noninvasive diagnostic techniques coupled with the development of effective and tolerable treatments has enabled primary health care personnel to manage this infection actively. The role of the primary care physician in the future management of H pylori infection is thus of central importance. The wealth of evidence produced by over 15 years of research into H pylori has expanded the list of disease associations and treatment benefits as well as elucidated the pathophysiological mechanisms involved. As a result, there has been a growing need to harmonize this information with clinical practice and to provide direction for the appropriate management by both specialists and general practitioners. Several national guidelines have been produced. The areas relating to H pylori infection that they considered and their recommendations vary. In 1994, the National Institutes of Health produced globally accepted recommendations for the management of H pylori-related peptic ulceration. The broader role of H pylori as a gastroduodenal pathogen and a public health care issue was not addressed. Recently, European and Canadian consensus guidelines have been published that identified overall management issues, including the role of primary and specialist care, and considered the appropriateness of employing eradication therapy for the spectrum of conditions in which H pylori has a direct or indirect association based on the available information. These guidelines, while in agreement regarding many issues, differ considerably in their recommendations for primary health care and regarding central issues such as the management of dyspepsia and gastric cancer. Some variations may reflect differing health care structures as well as the prevalence of both infection and associated diseases. However, the interpretation of evidence produced by recent research contributes to their conflicting statements.

Intravenous immune globulin in the therapy of peripartum cardiomyopathy

OBJECTIVES

We sought to evaluate the effect of therapy with intravenous immune globulin on recovery of left ventricular function in women presenting with peripartum cardiomyopathy.

BACKGROUND

Peripartum cardiomyopathy is a rare complication of pregnancy that results in significant morbidity and mortality in women of childbearing age. Intravenous immune globulin has been reported to improve left ventricular systolic function in patients with acute dilated cardiomyopathy and myocarditis, but its effectiveness in peripartum cardiomyopathy is unknown.

METHODS

In this retrospective study, we compared the clinical outcomes of six women with peripartum cardiomyopathy treated with intravenous immune globulin (2 g/kg) with those of 11 recent historical control subjects. All women in the study were referred between 1991 and 1998 with class II to IV heart failure and a left ventricular ejection fraction of <0.40. Left ventricular ejection was reassessed during early follow-up (6.1+/-2.9 months).

RESULTS

The two groups did not differ in terms of baseline left ventricular ejection fraction, left ventricular end-diastolic diameter, months to presentation, age or multiparity. The improvement in left ventricular ejection fraction in patients treated with immune globulin was significantly greater than in the conventionally treated group (increase of 26+/-8 ejection fraction units vs. 13+/-13, p = 0.042).

CONCLUSIONS

In this small retrospective study of women with peripartum cardiomyopathy, patients treated with immune globulin had a greater improvement in ejection fraction during early follow-up than patients treated conventionally. Given the poor prognosis of women with peripartum cardiomyopathy who do not improve, this therapy merits further study.

Gastro-oesophageal reflux disease and Helicobacter pylori: an intricate relation

Heartburn is a common symptom affecting 21-44% of the adult population on a monthly basis. Oesophagitis is less common, affecting 2% of individuals. Epidemiological studies have shown that patients with gastro-oesophageal reflux disease (GORD) have similar incidence rates of Helicobacter pylori infection as do controls. Some groups have reported that there is a lower incidence, deducing that infection does not cause, and in some way confers protection against GORD. Additional supportive evidence is available from reports of GORD development following successful H pylori eradication. The mechanisms involved are complicated. Individuals with H pylori induced pangastritis and subsequent hypochlorhydria may be protected whereas those with an antral predominant gastritis, as in duodenal ulcer disease, with an increased acid output may be prone to development of GORD. Recent evidence has linked H pylori infection with the development of inflammation of the gastric cardia---carditis. Reports are available which show that carditis is a frequent finding in patients with GORD. The incidence of both cardia and oesophageal carcinoma is increasing. The relation between GORD, carditis, intestinal metaplasia, and cardia carcinoma is unclear. Intestinal metaplasia may result from multifocal atrophic gastritis, linked to H pylori infection or from GORD and the development of Barrett's oesophagus. Long term follow up studies will be required to assess the malignant potential of these histological entities and whether or not H pylori infection has an aetiological role.

HpSA: assessment of a new non-invasive diagnostic assay for Helicobacter pylori infection in an Irish population

BACKGROUND

The diagnosis of Helicobacter pylori is an essential element in the management of many common gastrointestinal pathologies. Previously diagnosis was dependent on the availability of endoscopic biopsy samples. The advent of non invasive assays such as the C13Urea breath test and Elisa serology have enabled diagnosis and treatment to be undertaken in the primary care setting. The isolation of Helicobacter pylori antigen from stool has led to the development of a new non-invasive test.

AIM

A prospective study was designed to assess and compare the performance of Premier Platinum HpSA with current gold standard tests.

METHODS

Consecutive patients undergoing a gastroscopy for investigation of dyspepsia at the Meath and Adelaide hospitals were enrolled. At endoscopy gastric biopsies were taken for histology, microbiology and rapid urease testing. In addition all subjects had C13UBT, serology and stool tests performed. Individuals who were H. pylori positive received standard proton pump inhibitor based triple therapy. Following treatment all tests, apart from serology were repeated.

RESULTS

54 patients were enrolled, 46 per cent were H. pylori positive. HpSA had a sensitivity and specificity and positive and negative predicted values of 96 per cent, 75 per cent and 80.6 per cent, 75.8 per cent respectively and compared favourably with all other tests. The sensitivity and specificities of the other tests were, histology 79.2 per cent and 100 per cent, culture 68 per cent and 100 per cent, rapid urease test 75 per cent and 100 per cent, serology 75 per cent and 96 per cent and C13 urea breath test 100 per cent and 96.6 per cent.

CONCLUSION

The detection of H. pylori antigen in stool by means of a HpSA assay is a new and effective non-invasive means of diagnosis which can be performed in a routine laboratory setting. It is simple to perform and has possible advantages over other non-invasive tests, detecting actual antigen indicating current active infection.

Effects of central and peripheral nicotinic blockade on human nicotine discrimination

Nicotine produces interoceptive stimulus effects in humans, which may be critical in understanding tobacco use. It has not yet clearly been demonstrated that discrimination of nicotine, or any drug, in humans is due to its central effects. We compared effects of mecamylamine (10 mg p.o.), a central and peripheral nicotine antagonist, on nicotine discrimination with those of trimethaphan (10-40 microg/kg per min i.v.), a peripheral nicotine antagonist only, and placebo. Smokers (n = 6) were first trained to reliably discriminate 0 versus 20 microg/kg nicotine by nasal spray and then tested on generalization of this discrimination across a range of nicotine doses (0, 3, 6, 12, 20 microg/kg) following antagonist/placebo pretreatment. Nicotine self-administration was also assessed after generalization testing by having participants intermittently choose between nicotine versus placebo spray. Compared with responding following placebo pre-treatment, discrimination of the highest dose of nicotine was significantly attenuated following mecamylamine but not trimethaphan. Similar results were observed for some subjective responses to nicotine. Mecamylamine also tended to increase nicotine self-administration. Consistent with previous animal studies, these results suggest that discriminative stimulus effects of nicotine in humans are mediated at least in part by its central effects.

Helicobacter pylori and gastric cancer

Gastric cancer despite a declining incidence remains a significant cause of morbidity and mortality world wide. There is strong epidemiological and histological evidence to associate Helicobacter pylori infection with the subsequent development of gastric cancer. The exact pathophysiological mechanisms involved remain to be elucidated. There is evidence to relate Helicobacter pylori infection and subsequent inflammation with an increase in gastric epithelial cell proliferation and with the induction of apoptosis. Such alterations in cellular dynamics may promote the development of mitogenic cell lines by inducing DNA damage. Studies have shown that following successful treatment, proliferation rates return to normal. At what histological stage, eradication is of benefit is less clear. It is likely that following the development of atrophy or intestinal metaplasia eradication will only slow progression. It would, therefore, seem logical, that to establish any benefit for a population, treatment should be employed at an earlier stage. As yet, an at risk group has not been identified, and as such population screening cannot be advised, mainly as a result of financial implications and the risk of promoting the development of resistant strains. Recent studies have explored the rules of bacterial factors, CagA and VacA status, host factors, HLA type, and environmental factors as determinants of outcome. Results have been variable. The establishment of an at risk group would enable selective screening and treatment, and thus prevent the development of gastric carcinoma as a result of Helicobacter pylori infection in the long-term.

Predicting short-term outcome in severely ill heart failure patients: implications regarding listing for urgent cardiac transplantation and patient selection for temporary ventricular assist device support

BACKGROUND

The purpose of this study was to determine which patients on a cardiac transplantation list required a ventricular assist device.

METHODS AND RESULTS

In a preliminary study, 26 patients with decompensated severe New York Heart Association class IV chronic heart failure were studied. Blood levels for sodium, hemoglobin, cytokines, neurohormones, and hemodynamics were obtained. During short-term follow-up of 40 days, 12 patients had undergone emergent implantation of a ventricular assist device (range 1-27 days, mean 5 days), 4 died (range 14-38 days, mean 26 days), and 5 were alive and receiving only medical therapy while waiting for a transplantation. In addition, five patients had undergone transplantation (range 5-29 days, mean 18 days, excluded from further analysis). Survival curves were constructed by comparing the incidence of death and the implantation of an emergent ventricular assist device in patients with values of a variable above or below the mean value (or median for nonnormally distributed data). There was a significantly greater incidence of death or need for a ventricular assist device in patients with higher levels of tumor necrosis factor-alpha (P = .008), lower levels of serum sodium and hemoglobin (P = .02 and P = .03, respectively), higher heart rates (P = .03), and higher plasma norepinephrine levels (P = .01). The Cox proportional hazards model demonstrated that only serum sodium (P = .03) independently predicted those patients who died or who required emergent left ventricular assist device.

CONCLUSION

Numerous variables, particularly serum sodium, need to be considered when evaluating which patients on the transplant list require early assist device implantation or urgent transplantation. These preliminary observations merit confirmation in a larger patient population.

Effects of tumor necrosis factor gene polymorphisms on patients with congestive heart failure. VEST Investigators for TNF Genotype Analysis. Vesnarinone Survival Trial

BACKGROUND

Tumor necrosis factor-alpha (TNF-alpha) is known to be elevated in patients with congestive heart failure (CHF). Two biallelic polymorphisms have been identified in the TNF gene locus: one in the promoter region of TNF-alpha (TNFA1/2), and the other in the first intron of TNF-beta (TNFB1/2). Both TNFA2 and TNFB2 alleles are associated with high TNF-alpha production in vitro and susceptibility to inflammatory diseases. Given the importance of TNF-alpha in the pathogenesis of CHF, we studied the prevalence of TNF gene polymorphisms in CHF patients and the correlation of genotypes to in vivo TNF-alpha levels.

METHODS AND RESULTS

TNFA and TNFB genotypes were determined by the polymerase chain reaction-restriction fragment length polymorphism technique. There were no differences in the TNF allele frequencies between CHF (n=229; TNFA1/2=0.84/0.16, TNFB1/2=0.33/0.67) and control subjects (n=139; TNFA1/2=0.84/0.16, TNFB1/2=0.32/0.68). In 211 patients with CHF, circulating levels of TNF-alpha and the soluble receptors type I and type II were measured by ELISA: 6.18+/-3.59 pg/mL, 1768+/-761 pg/mL, and 4484+/-1750 pg/mL, respectively. There were no correlations between TNFA or TNFB genotypes and circulating levels of TNF-alpha or its soluble receptors in the CHF patients.

CONCLUSIONS

Despite their association with other inflammatory diseases, neither TNFA nor TNFB polymorphisms are related to the presence of CHF or the elevation of circulating TNF-alpha. Thus, other factors may be more important in determining the circulating levels of TNF-alpha in CHF.

Treatment of patients admitted to the hospital with congestive heart failure: specialty-related disparities in practice patterns and outcomes

OBJECTIVES

This study sought to define specialty-related differences in the care and outcome of patients admitted to the hospital with congestive heart failure (CHF).

BACKGROUND

Congestive heart failure is the leading diagnosis-related group (DRG) discharge diagnosis in the United States and accounts for an estimated annual hospital cost in excess of $7 billion. The clinical impact of aggressive CHF management and the importance of the subspecialist in guiding this care have not been evaluated.

METHODS

To define differences in physician practice patterns, we performed a chart review of consecutive patients admitted to a university teaching hospital with a primary DRG discharge diagnosis of CHF. We compared treatment and outcome of patients cared for by a generalist (n = 160) and those whose care was guided by a cardiologist (n = 138) during their index hospital period with CHF and over the next 6 months.

RESULTS

At our institution, > 50% of patients admitted to the hospital with CHF cared for by generalists alone had minimal (New York Heart Association functional class I or II) symptoms, compared with < 15% of those cared for by a cardiologist (p < 0.01). Although generalists' patients underwent significantly fewer in-hospital diagnostic tests and had shorter lengths of stay, they had a 1.7-fold increased risk of readmission for CHF within 6 months (p < 0.05). Six-month cardiac and all-cause mortality were not significantly different between the groups. The type of physician caring for the patient and a history of diabetes, previous CHF or myocardial infarction were independent predictors of readmission for CHF.

CONCLUSIONS

Involvement of a cardiologist in the care of patients admitted to the hospital with CHF is associated with increased use of diagnostic testing, longer hospital stays and improved clinical outcome. These results substantiate practice guidelines that suggest a role for cardiologists in the care of symptomatic patients with CHF.

Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy

BACKGROUND

Although an autoimmune pathogenesis has been postulated for dilated cardiomyopathy, immunosuppressive therapy has not been shown to be effective in clinical trials. Immune modulatory therapy with immune globulin is an effective therapy for Kawasaki disease in children, and recent data suggest that it improves ventricular function in children with new-onset dilated cardiomyopathies. The role of immune globulin therapy in adults with this disorder has not previously been evaluated.

METHODS AND RESULTS

Ten patients were treated with high-dose intravenous immune globulin infusions (2 g/kg). All were hospitalized with NYHA class III to IV heart failure, left ventricular ejection fraction (LVEF) < 0.40, and symptoms for < 6 months at the time of presentation. One patient died before the completion of therapy. The remaining 9 were discharged, and LVEF was reassessed 12 months after therapy. LVEF improved from 0.24 +/- 0.02 (mean +/- SEM) at baseline to 0.41 +/- 0.04 at follow-up (P = .003). All 9 patients improved functionally to NYHA class I to II, and there have been no subsequent hospitalizations for heart failure during the course of follow-up.

CONCLUSIONS

In this series of patients with new-onset dilated cardiomyopathy treated with high-dose immune globulin, LVEF improved 17 EF units. The effectiveness of intravenous immune globulin therapy in this disorder should be evaluated in a randomized, multicenter trial.

Cryptogenic organising pneumonitis in association with acute viral hepatitis

Case history of a 54 yr old lady with acute viral hepatitis who developed cryptogenic organising pneumonitis. The patient was receiving corticosteroids at the time of onset of symptoms.

Left ventricular dysfunction after heart transplantation: incidence and role of enhanced immunosuppression

BACKGROUND

The purpose of this study was to examine the incidence, natural history, and outcome of left ventricular dysfunction in 102 consecutive heart transplant recipients. Left ventricular dysfunction (defined as a decline in the echocardiographic ejection fraction to < 0.45) occurred in 16 of 102 transplant recipients (16%) at a mean of 9.7 +/- 8.6 (standard deviation) months after transplantation.

METHODS

Diagnostic evaluation included right heart catheterization and endomyocardial biopsy in all patients and coronary angiography in 13 patients.

RESULTS

Four patients were found to have moderate cellular rejection (International Society for Heart and Lung Transplantation grade 2 or higher) and were treated with enhanced immunosuppression. Two patients had angiographically apparent coronary allograft vasculopathy; both died of electromechanical dissociation within 4 months. The remaining ten patients had no or mild cellular rejection (International Society for Heart and Lung Transplantation grade 0 or 1). Therapy in these ten patients included corticosteroids (n = 8). OKT3 (n = 5), and plasmapheresis (n = 2). Three patients died within 2 months of diagnosis, two from undetected severe coronary allograft vasculopathy and one from unrecognized constrictive pericarditis. The echocardiographic ejection fraction improved in the surviving patients after enhanced immunosuppressive therapy (0.33 to 0.53, p < 0.005). With the benefit of long-term clinical follow-up and autopsy data, the origins of left ventricular dysfunction in the 16 patients included moderate cellular rejection (n = 4), vascular rejection (n = 1), coronary allograft vasculopathy (n = 3), intercurrent cytomegalovirus infection (n = 1), constrictive pericarditis (n = 1), and either mild or no evident rejection (n = 6). Survival of the 16 patients with left ventricular dysfunction was similar to that of the 86 patients without left ventricular dysfunction.

CONCLUSIONS

The cause of left ventricular dysfunction after heart transplantation includes cellular rejection, vascular rejection, coronary allograft vasculopathy, cytomegalovirus infection, constrictive pericarditis, and unexplained mechanisms. Given the improvement in left ventricular function observed after empiric therapy with enhanced immunosuppression in patients with left ventricular dysfunction, immune-mediated phenomena may play an important pathogenic role.

Comparisons between SPECT and quantitative EEG measures of cortical impairment in mild to moderate Alzheimer's disease

This study aimed at examining correlations between quantitative REM sleep EEG, regional cerebral blood flow measured by single photon emission computerized tomography (SPECT) and global cognitive functioning in nine patients with mild to moderate Alzheimer's disease. REM sleep EEG was not correlated with SPECT measures in any of the 6 regions studied. However, degrees of interhemispheric asymmetry calculated by both measures were concordant for the parieto-occipital region. Mini-mental state score correlated with REM sleep EEG slowing for left frontal, left and right parieto-occipital and left temporal regions but was not correlated with SPECT measures for any of the six regions. These results suggest that quantitative REM sleep EEG would be more useful than SPECT for evaluating cerebral dysfunctions in mild to moderate Alzheimer's disease.