Neuropsychological Markers for Cognitve Performance (Symposium or Panel)

Chair: Dr. Norey Nigro (USA)

Discussant Prof. dr. Arthur Freeman (USA)

Panelists: Prof. dr. Andrzej Kokoszka (Poland)

Prof. dr. Daniel David (Romania)

Dr. Corey Nigro (USA)

The Patient that we Love to Hate: Cognitive Behavioral Treatment of the Narcissistic Personality Disorder (mini workshop)

The patient with a narcissistic personality disorder may be among the most difficult patients in the clinician's caseload to treat. They may take more time in therapy, more of the theraapist's energy, and overwhelm the therapist's ability to dea;l with the countertransference. Given their self-serving and demanding style, they are more frequently "sent" to therapy than electing to come for treatment. Thus the morivation for therapy and for change is severely limited. The patient's ability to establish a working therapeutic bond is also limited by the very nature of their disorder. Given all of this they can be treated. The active, directive, structred, and problem oriented facets of Cognitive Behavior Therapy make this model an ideal treatment modality. Helping the patient to examine what is in their best personal interest, the therapy proceeds by examining the patienbt's thoughts, feelings, and behaviors.

An investigation of a workplace-based return-to-work program for shoulder injuries

The purpose of this study was to investigate and evaluate the current workplace management of rotator cuff injuries in a manufacturing plant. The secondary aims were to examine the impact of the company's return-to-work processes, compare outcomes to current industry standards for work (re)entry and to identify the components that characterized this workplace-based return-to-work (RTW) program. This investigation involved a case study approach comprised of an examination of the program context using interviews, onsite visits, a document review and a retrospective analysis of the RTW experiences of 184 workers with shoulder injuries. Findings revealed that the workplace-based RTW program was consistent with and shaped by the organizational culture of problem solving, knowledge exchange and equitable participation of workers, supervisors and health professionals. These components contributed to the program in achieving the following outcomes for workers with shoulder injuries. One-third of workers were placed on modified duties within three days, 56% of workers who engaged in an early RTW program returned to work within one month. Overall, 87.8% of workers with rotator cuff injuries successfully returned to pre-injury work. The implications of developing capacity for workplace-based programs to manage injuries at work are discussed.

Frequency of risk factors for foot ulceration in individuals with chronic kidney disease

BACKGROUND

Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This pilot study was designed to investigate the risk factors for foot ulceration in individuals with CKD who do not have diabetes. The aims of this study were to establish the risk status for foot ulceration in individuals with CKD and to identify the particular foot ulcer risk factors most prevalent in this group.

METHODS

One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (i) control: neither diabetes nor CKD, (ii) diabetes alone, (iii) coexisting CKD and diabetes and (iv) CKD alone. All participants were assessed for past/current foot ulcers, peripheral neuropathy, vascular insufficiency, structural deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors.

RESULTS

Participants with CKD who did not have diabetes displayed no significant differences in risk factor presentation from those with diabetes alone. Of the participants with CKD and no diabetes, 36% had peripheral neuropathy, 20% had vascular insufficiency and 24% had the copresentation of peripheral neuropathy and structural deformity. Overall, participants with both CKD and diabetes had the highest presentation of past/current foot ulcers, peripheral neuropathy and vascular insufficiency, all significantly more frequent in this group than in controls (P < 0.05). Eight of the total 10 participants found to have a past/current foot ulcer were in end-stage kidney failure.

CONCLUSION

Individuals with CKD frequently display risk factors for foot ulceration. Risk factors are more prevalent in individuals who also have diabetes and foot ulcers become more frequent with progression to end-stage kidney failure. Risk assessment and patient awareness strategies should therefore be extended to include all patients with CKD so as to reduce future foot ulcer development.

Hypomethylation of WNT5A, CRIP1 and S100P in prostate cancer

Oligoarray analysis of a matched pair of prostate cancer and normal cell lines derived from the same radical prostatectomy specimen identified 113 candidate hypomethylated genes that were overexpressed in the cancer cells and contained CpG islands. Hypomethylation of wingless-related MMTV integration site 5A (WNT5A), S100 calcium-binding protein P (S100P) and cysteine-rich protein 1(CRIP1) was confirmed in the cancer cells by bisulfite sequencing. Treatment of the corresponding normal prostate epithelial cells 1542-NPTX with the DNA methyltransferase inhibitor 5-Aza-2'-deoxycytidine (5-aza-CdR) induced higher levels of mRNA expression and partial loss of methylation on these genes. Primary prostate cancers were tested using methylation-specific polymerase chain reaction. WNT5A was hypomethylated in 11/17 (65%) tumors, S100P in 8/16 (50%) and CRIP1 in 13/20 (65%). Bisulfite sequencing of a section of the 5' untranslated region (UTR) of WNT5A revealed that three CpG sites (15, 24 and 35) were consistently methylated (93%) in the normal cell line and normal tissues, but not in the prostate cancer cell line and eight primary prostate cancers. Multiple putative binding sites for the transcription factors SP1 and AP-2 were found adjacent to CpG sites 15 and 24. A putative c-Myb binding site was located within the CpG site 35. Anti-c-Myb antibody co-precipitation with WNT5A was methylation-sensitive in 1542-NPTX cells. It is likely that an epigenetic mechanism regulates WNT5A expression in prostate cancer.

Photodynamic therapy using meso tetra hydroxy phenyl chlorin (mTHPC) in early prostate cancer

BACKGROUND AND OBJECTIVES

Prostate cancer is increasing in incidence, but current treatments including surgery and radiotherapy have significant side effects. This pilot study was designed to assess the potential of photodynamic therapy (PDT) using meso tetra hydroxy phenyl chlorin (mTHPC) for organ confined prostate cancer.

STUDY DESIGN/PATIENTS AND METHODS

Six men with organ confined prostate cancer were photosensitised with mTHPC (0.15 mg/kg). Between 2 and 5 days later, red light (652 nm) was delivered to areas of biopsy proven cancer via fibres inserted through transperineal needles (50-100 J per site).

RESULTS

After 8 of 10 PDT sessions, the prostate specific antigen (PSA) fell by up to 67%. Early MRI scans showed oedema and patchy necrosis, which resolved over 2 months. Biopsies of treated areas revealed necrosis and fibrosis at 1-2 months.

CONCLUSIONS

PDT for primary prostate cancer appears safe and can reduce PSA levels. As this was a phase I study, no attempt was made to treat the whole prostate; this or targeted tumour ablation could be attempted in a phase II study with an increased number of fibres. This technique merits further investigation in early prostate cancer.

The patient's view of need and caregiving consequences: a cross-sectional study of inpatients with severe mental illness

This cross-sectional study was conducted across inpatient facilities of a metropolitan mental health service in Sydney, Australia. Given shorter lengths of stay in acute inpatient facilities, it is important to ascertain differences between patients' and carers' perceptions of need and support in order to guide delivery of care in the community. The objectives were to: (1) assess the needs of patients recently admitted to hospital and ascertain the level of carer involvement while in hospital; (2) compare the degree of agreement between patients' and carers' perceptions of need and caregiver burden; and (3) determine the relationship between levels of need and carer burden prior to hospitalization. Over a 2-month period, consecutive patients (n = 200) were interviewed using the Camberwell Assessment of Need Short Appraisal Schedule and a modified version of the Involvement Evaluation Questionnaire to assess basic needs and patient perceptions of caregiver burden, respectively. Of the 200 patients interviewed, 68% (n = 135) identified a carer. Patients with schizophrenia had most met needs, those with affective disorders had most unmet needs and patients with other diagnoses recorded the lowest number of needs overall. The level of agreement between patient and carer perceptions of need was low, possibly because of confusion about the definition of need or different views about the support required to fulfil a need. Patients underestimated the consequences of caregiving, especially the impact of strained atmosphere, global burden, worrying about their future and encouragement to undertake an activity, indicating that carers were more burdened than patients perceived them to be.

Barriers to implementing a policy not to attempt resuscitation in acute medical admissions: prospective, cross sectional study of a successive cohort

OBJECTIVE

To establish whether acutely unwell patients admitted to hospital wish to participate in discussions about resuscitation.

DESIGN

Prospective, cross sectional study of a successive cohort of patients.

SETTING

Admission through the emergency department.

PARTICIPANTS

374 adult patients.

MAIN OUTCOME MEASURE

Whether acutely unwell patients wished to participate in discussions about resuscitation.

RESULTS

Of the total sample, 74 patients consented to take part in the study and provide full data. Of the remaining patients, 189 could not be approached for practical reasons and 111 did not wish to participate. Of the 74 patients who read the leaflet, 65 (88%) reported having little or no prior knowledge, 70 (96%) understood it, 56 (77.8%) preferred for resuscitation decisions to be discussed with them, and 55 (77.5%) did not mind discussing resuscitation within 24 hours of admission and overall showed a decline in their anxiety score.

CONCLUSION

Many patients admitted through the emergency department for medical reasons cannot participate in their decision not to attempt resuscitation within 24 hours of admission. Patients who were willing to participate rated the information leaflet that was provided positively.

Genome-wide screening for genetic changes in a matched pair of benign and prostate cancer cell lines using array CGH

Copy number alterations in a matched pair of benign epithelial and prostate cancer cell lines derived from the same patient were assessed using array-based comparative genomic hybridisation (aCGH). The cancer cell line showed a gain of chromosome 7, deletion of chromosome 8, gains (including high level) and losses on chromosome 11, loss of 18p and gain of 20q. Deletions on chromosome 8 were confirmed with microsatellite markers. The aCGH results were compared to gene expression data obtained using DNA microarrays and suggested the involvement of caspases and ICEBERG on 11q and E2F1 on chromosome 20q.

Channeling and adherence with alendronate and risedronate among chronic glucocorticoid users

INTRODUCTION

Despite the efficacy of bisphosphonates to reduce fractures in high risk populations, bisphosphonate adherence among chronic glucocorticoid users has received limited attention. Moreover, perceived differences in GI tolerability may lead physicians to preferentially prescribe particular bisphosphonates.

METHODS

Among chronic glucocorticoid users (>60 days of therapy) enrolled in managed care, we identified individuals initiating therapy with alendronate or risedronate during 2001-2004. Multivariable logistic regression and proportional hazards models were used to examine factors associated with channeling patients to risedronate (versus alendronate) and with discontinuation (>3-month gap without refill). The Medication Possession Ratio (MPR) was calculated as the filled days of medication divided by the interval of time between prescriptions.

RESULTS

Of 1,158 glucocorticoid users initiating bisphosphonate therapy, demographic characteristics of alendronate users (n=754) and risedronate users (n=404) were similar for age (mean 53 years) and gender (approximately 80% female). Past history of a GI symptom or event was associated with risedronate receipt (OR=2.24, 95% CI 1.15-4.35). After multivariable adjustment, rates of discontinuation (mean time to discontinuation approximately 18 months) and adherence (mean MPR=73%) were similar between users of the two bisphosphonates. Younger age, greater medical comorbidity, and lack of BMD testing were significantly associated with discontinuation.

CONCLUSIONS

Overall persistence rates were suboptimal for bisphosphonate use among chronic glucocorticoids users and did not differ significantly by drug. Newer strategies to promote long-term adherence are needed to improve osteoporosis therapeutic effectiveness.

Randomized, double-blind, placebo-controlled, short-term trial of ropinirole in restless legs syndrome

BACKGROUND AND PURPOSE

Restless legs syndrome (RLS) is a condition characterized by an urge to move the legs, usually accompanied by lower limb paresthesias. These symptoms worsen at rest, are relieved by activity, and are worse at night. Previous studies have suggested that dopaminergic drugs such as L-dopa and dopamine agonists, as well as benzodiazepines and opioids, can treat RLS successfully. The purpose of this study was to test the clinical efficacy of ropinirole, a D2/D3 agonist, in the treatment of RLS in a double-blind, short-term, placebo-controlled clinical trial.

PATIENTS AND METHODS

After undergoing successful open-label titration and dose adjustments with ropinirole for RLS symptoms over a period of 4 weeks, 22 RLS patients (mean age=50.8; mean duration of symptoms=26.1 years) were randomized to receive either placebo (n=13) or ropinirole (n=9) for 2 additional weeks. Outcome measures included assessment of periodic leg movements in sleep (PLMS) recorded with nocturnal polysomnography and RLS symptoms as assessed with the International Restless Legs Syndrome Study Group (IRLSSG) Rating Scale. Secondary outcomes included sleep macroarchitecture.

RESULTS

Results indicated that relative to placebo, ropinirole, at a mean dose of 1.4mg HS significantly decreased PLMS and RLS symptoms. Sleep macroarchitecture did not change. Side effects were typical of all dopamine agonists and were dose related. The majority of patients elected to continue treatment with ropinirole upon study completion.

CONCLUSIONS

Ropinirole successfully treated long-standing RLS and can be considered a viable short-term treatment for this condition.

Bladder necrosis presenting with hematuria in a patient with sickle-cell disease

We present an interesting case of bladder necrosis in an 11-year-old boy with sickle-cell disease. The patient initially presented with sudden onset of abdominal pain and went on to have gross hematuria with clots and severe dysuria. Cysto-urethroscopy revealed global hemorrhagic cystitis and a suprapubic catheter was inserted percutaneously during cystoscopy. The symptoms spontaneously resolved over several weeks and the child voids normally at last follow-up. Multiple bladder biopsies were taken and all were completely necrotic.

Metastatic intramammary lymph nodes as the primary presenting sign of breast cancer

Intramammary lymph nodes (IMLNs) are not uncommon, and are likely to be more frequently identified with the wider use of mammography and breast ultrasound. IMLNs could be invaded by breast cancer influencing the prognosis and the management of patients. The aim of this study is to present the very rare phenomenon of metastatic involvement of these nodes from an occult breast cancer.