Assessment of cognition in advanced AD: The test for severe impairment

Article abstract The Test for Severe Impairment (TSI) was compared with the Mini-Mental State Examination (MMSE) and a modified MMSE (mMMSE) in a multisite, longitudinal study of AD. The TSI correlated highly with the MMSE (r = 0.83) and the mMMSE (r = 0.82), but was not redundant. There was a wide range of scores on the TSI among those scoring in the severely impaired range on the MMSE and mMMSE. The slope of cognitive change over time detected by the TSI was greater than that revealed by the MMSE or the mMMSE. Performance on the TSI was a significant predictor of survival. The TSI is a valid measure that is sensitive to cognitive change over time in severely demented patients with AD.

Effect of literacy on neuropsychological test performance in nondemented, education-matched elders

The current investigation compared neuropsychological test performance among nondemented literate and illiterate elders. The sample included participants in an epidemiological study of normal aging and dementia in the Northern Manhattan community. All participants were diagnosed as nondemented by a neurologist, and did not have history of Parkinson's disease, stroke, or head injury. Literacy level was determined by self-report. MANOVAs revealed a significant overall effect for literacy status (literate vs. illiterate) on neuropsychological test performance when groups were matched on years of education. The overall effect of literacy status remained significant after restricting the analyses to elders with no formal education, and after controlling for the effects of language of test administration. Specifically, illiterates obtained lower scores on measures of naming, comprehension, verbal abstraction, orientation, and figure matching and recognition. However tests of verbal list delayed recall, nonverbal abstraction, and category fluency were unaffected by literacy status, suggesting that these measures can be used to accurately detect cognitive decline among illiterate elders in this sample. Differences in organization of visuospatial information, lack of previous exposure to stimuli, and difficulties with interpretation of the logical functions of language are possible factors that contribute to our findings.

Cerebral tuberculomas in Northern Ireland

Two children presenting with very different clinical pictures were both found to have intracranial tuberculomas. This condition, although rare in developed countries, should be suspected in any child with enhancing cerebral lesions or cranial computed tomography.

Hourly care received by people with Alzheimer's disease: results from an urban, community survey

People with Alzheimer's disease living in a defined community in New York City were identified and assessed on two occasions to determine the number of hours of activities of daily living (ADL) care they received. Nearly half received all care hours from informal sources; however, a quarter received all ADL care hours from formal sources. The mean number of daily ADL hours in the sample was 9.7, of which 4.2 came from formal sources. This reflects the extensive use of Medicaid-based home care services in New York City. As dementia worsened, substitution of formal for informal care was rare, but formal care assumed a greater proportion of total care hours.

A randomized, placebo-controlled dose-comparison trial of haloperidol for psychosis and disruptive behaviors in Alzheimer's disease

OBJECTIVE

The goal of this study was to compare the efficacy and side effects of two doses of haloperidol and placebo in the treatment of psychosis and disruptive behaviors in patients with Alzheimer's disease.

METHOD

In a 6-week random-assignment, double-blind, placebo-controlled trial (phase A), haloperidol, 2-3 mg/day (standard dose), and haloperidol, 0.50-0.75 mg/day (low dose), were compared in 71 outpatients with Alzheimer's disease. For the subsequent 6-week double-blind crossover phase (phase B), patients taking standard- or low-dose haloperidol were switched to placebo, and patients taking placebo were randomly assigned to standard- or low-dose haloperidol.

RESULTS

For the 60 patients who completed phase A, standard-dose haloperidol was efficacious and superior to both low-dose haloperidol and placebo for scores on the Brief Psychiatric Rating Scale psychosis factor and on psychomotor agitation. Response rates according to three sets of criteria were greater with the standard dose (55%-60%) than the low dose (25%-35%) and placebo (25%-30%). The advantage of standard dose over low dose was replicated in phase B. In phase A, extrapyramidal signs tended to be greater with the standard dose than in the other two conditions, primarily because of a subgroup (20%) who developed moderate to severe signs. Low-dose haloperidol did not differ from placebo on any measure of efficacy or side effects.

CONCLUSIONS

The results indicated a favorable therapeutic profile for haloperidol in doses of 2-3 mg/day, although a subgroup developed moderate to severe extrapyramidal signs. A starting dose of 1 mg/day with gradual, upward dose titration is recommended. The narrow therapeutic window observed with haloperidol may also apply to other neuroleptics used in Alzheimer's disease patients with psychosis and disruptive behaviors.

Attachment and adolescent psychosocial functioning

To explore the meaning and function of attachment organization during adolescence, its relation to multiple domains of psychosocial functioning was examined in a sample of 131 moderately at-risk adolescents. Attachment organization was assessed using the Adult Attachment Interview; multiple measures of functioning were obtained from parents, adolescents, and their peers. Security displayed in adolescents' organization of discourse about attachment experiences was related to competence with peers (as reported by peers), lower levels of internalizing behaviors (as reported by adolescents), and lower levels of deviant behavior (as reported by peers and by mothers). Preoccupation with attachment experiences, seen in angry or diffuse and unfocused discussion of attachment experiences, was linked to higher levels of both internalizing and deviant behaviors. These relations generally remained even when other attachment-related constructs that had been previously related to adolescent functioning were covaried in analysis. Results are interpreted as suggesting an important role for attachment organization in a wide array of aspects of adolescent psychosocial development.

In vivo percutaneous absorption of boric acid, borax, and disodium octaborate tetrahydrate in humans compared to in vitro absorption in human skin from infinite and finite doses

Literature from the first half of this century report concern for toxicity from topical use of boric acid, but assessment of percutaneous absorption has been impaired by lack of analytical sensitivity. Analytical methods in this study included inductively coupled plasma-mass spectrometry which now allows quantitation of percutaneous absorption of 10B in 10B-enriched boric acid, borax, and disodium octaborate tetrahydrate (DOT) in biological matrices. This made it possible, in the presence of comparatively large natural dietary boron intakes for the in vivo segment of this study, to quantify the boron passing through skin. Human volunteers were dosed with 10B-enriched boric acid, 5.0%, borax, 5.0%, or disodium octaborate tetrahydrate, 10%, in aqueous solutions. Urinalysis, for boron and changes in boron isotope ratios, was used to measure absorption. Boric acid in vivo percutaneous absorption was 0.226 (SD = 0.125) mean percentage dose, with flux and permeability constant (Kp) calculated at 0.009 microgram/cm2/h and 1.9 x 10(-7) cm/h, respectively. Borax absorption was 0.210 (SD = 0.194) mean percentage of dose, with flux and Kp calculated at 0.009 microgram/cm2/h and 1.8 x 10(-7) cm/h, respectively. DOT absorption was 0.122 (SD = 0.108) mean percentage, with flux and Kp calculated at 0.01 microgram/cm2/h and 1.0 x 10(-7) cm/h, respectively. Pretreatment with the potential skin irritant 2% sodium lauryl sulfate had no effect on boron skin absorption. In vitro human skin percentage of doses of boric acid absorbed were 1.2 for a 0.05% solution, 0.28 for a 0.5% solution, and 0.70 for a 5.0% solution. These absorption amounts translated into flux values of, respectively, 0.25, 0.58, and 14.58 micrograms/cm2/h and permeability constants (Kp) of 5.0 x 10(-4), 1.2 x 10(-4), and 2.9 x 10(-4) cm/h for the 0.05, 0.5, and 5.0% solutions. The above in vitro doses were at infinite, 1000 microliters/cm2 volume. At 2 microliters/cm2 (the in vivo dosing volume), flux decreased some 200-fold to 0.07 microgram/cm2/h and Kp of 1.4 x 10(-6) cm/h, while percentage of dose absorbed was 1.75%. Borax dosed at 5.0%/1000 microliters/cm2 had 0.41% dose absorbed, flux at 8.5 micrograms/cm2/h, and Kp was 1.7 x 10(-4) cm/h. Disodium octaborate tetrahydrate (DOT) dosed at 10%/1000 microliters/cm2 was 0.19% dose absorbed, flux at 7.9 micrograms/cm2/h, and Kp was 0.8 x 10(-4) cm/h. These in vitro results from infinite doses (1000 microliters/cm2) were 1000-fold greater than those obtained in the companion in vivo study. The results from the finite (2 microliters/cm2) dosing were closer (10-fold difference) to the in vivo results. General application of infinite dose percutaneous absorption values for risk assessment is questioned by these results. These in vivo results show that percutaneous absorption of boron, as boric acid, borax, and disodium octaborate tetrahydrate, through intact human skin, is low and is significantly less than the average daily dietary intake. This very low boron skin absorption makes it apparent that, for the borates tested, the use of gloves to prevent systemic uptake is unnecessary. These findings do not apply to abraded or otherwise damaged skin.

Cognitive test performance among nondemented elderly African Americans and whites

We examined the neuropsychological test performance of a randomly selected community sample of English-speaking non-Hispanic African American and white elders in northern Manhattan. All participants were diagnosed as nondemented by a neurologist, whose assessment was made independent of neuropsychological test scores. African American elders obtained significantly lower scores on measures of verbal and nonverbal learning and memory, abstract reasoning, language, and visuospatial skill than whites. After using a stratified random sampling technique to match groups on years of education, many of the discrepancies became nonsignificant; however, significant ethnic group differences on measures of figure memory, verbal abstraction, category fluency, and visuospatial skill remained. Discrepancies in test performance of education-matched African Americans and whites could not be accounted for by occupational attainment or history of medical conditions such as hypertension and diabetes. These findings emphasize the importance of using culturally appropriate norms when evaluating ethnically diverse elderly for dementia.

Prospective comparative study of the evolution of probable Alzheimer's disease and Parkinson's disease dementia

No previous comparison of test performance in probable Alzheimer's disease (pAD) and Parkinson's disease (PD) dementia has provided information about potential differences in the dementing process. This study compared the evolution of cognitive changes associated with these dementias. Generalized estimating equations (GEE) applied to regression analyses with repeated measures were used to evaluate cognitive changes over 1 to 3 years prior to the point when dementia was diagnosed in 40 matched pairs of patients with incident pAD and PD dementia. Both groups' performance declined on the Short Blessed, Selective Reminding Test (SRT; total recall, long-term retrieval, and delayed recall), Boston Naming Test, Category Fluency, and Similarities. The decline on naming and SRT delayed recall was more rapid in the PD dementia group, suggesting that these performance deficits emerge earlier in the development of pAD. The PD dementia group performed worse on Category Fluency throughout the follow-up period, suggesting either that dementia is overlaid on this preexisting performance deficit or that this type of executive deficit is an early manifestation of dementia in PD. The pAD group performed more poorly throughout the follow-up period on SRT delayed recognition, consistent with a pAD-specific encoding deficit. We conclude that while pAD and PD dementia are similar in many respects, differences in their evolution support previous observation of unique features in the 2 dementias and suggest different underlying pathologies.

Plasma esterase (ES) polymorphism in the tammar wallaby, Macropus eugenii

The major plasma esterase in the tammar wallaby was identified as a carboxylesterase by inhibition studies and polymorphism with six variants was observed by isoelectric focusing (pH 4.2-4.9), followed by staining for esterase activity. Family studies demonstrated an inheritance of six codominant alleles, ESA,B,C,D,E,F, and population studies revealed marked differences in the allele frequencies in five Australian populations of tammar wallabies.

The APOE-epsilon4 allele and the risk of Alzheimer disease among African Americans, whites, and Hispanics

CONTEXT

Although the association between Alzheimer disease (AD) and the apolipoprotein E epsilon4 (APOE-epsilon4) allele has been confirmed worldwide, it appears to be inconsistent among African Americans, Hispanics, and Nigerians.

OBJECTIVE

To investigate the association between the APOE-epsilon4 allele and AD in elderly African Americans, Hispanics, and whites.

DESIGN

Prospective, population-based, longitudinal study over a 5-year period (1991-1996).

SETTING

The Washington Heights-Inwood community of New York City.

PARTICIPANTS

A total of 1079 Medicare recipients without AD or a related disorder at baseline.

MAIN OUTCOME MEASURES

Risk of clinically diagnosed AD in the 3 ethnic groups and among individuals with and without an APOE-epsilon4 allele.

RESULTS

Compared with individuals with the APOE-epsilon3/epsilon3 genotype, the relative risk (RR) of AD associated with 1 or more copies of the APOE-epsilon4 allele was significantly increased among whites (RR, 2.5; 95% confidence interval [CI], 1.1-6.4), but not among African Americans (RR, 1.0; 95% CI, 0.6-1.6) or Hispanics (RR, 1.1; 95% CI, 0.7-1.6). In the absence of the APOE-epsilon4 allele, the cumulative risks of AD to age 90 years, adjusted for education and sex, were 4 times higher for African Americans (RR, 4.4; 95% CI, 2.3-8.6) and 2 times higher for Hispanics (RR, 2.3; 95% CI, 1.2-4.3) than for whites. In the presence of an APOE-epsilon4 allele, the cumulative risk of AD to age 90 years was similar for individuals in all 3 ethnic groups.

CONCLUSION

The presence of an APOE-epsilon4 allele is a determinant of AD risk in whites, but African Americans and Hispanics have an increased frequency of AD regardless of their APOE genotype. These results suggest that other genes or risk factors may contribute to the increased risk of AD in African Americans and Hispanics.

In vivo percutaneous absorption of boron as boric acid, borax, and disodium octaborate tetrahydrate in humans: a summary

Literature from the first half of this century reports concern for toxicity from topical use of boric acid, but assessment of percutaneous absorption has been impaired by lack of analytical sensitivity. Analytical methods in this study included inductively coupled plasma-mass spectrometry, which now allows quantitation of percutaneous absorption of 10B in 10B-enriched boric acid, borax, and disodium octaborate tetrahydrate (DOT) in biological matrices. This made it possible, in the presence of comparatively large natural dietary boron intakes for the in vivo segment of this study, to quantify the boron passing through skin. Human volunteers were dosed with 10B-enriched boric acid, 5.0%, borax, 5.0%, or disodium octaborate tetrahydrate, 10% in aqueous solutions. Urinalysis, for boron and changes in boron isotope ratios, was used to measure absorption. Boric acid in vivo percutaneous absorption was 0.226 (SD = 0.125) mean percent dose, with flux and permeability constant (Kp) calculated at 0.009 microg/cm2/h and 1.9 x 10(-7) cm/h, respectively. Borax absorption was 0.210 (SD = 0.194) mean percent dose, with flux and Kp calculated at 0.009 microg/cm2/h and 1.8 x 10(-7) cm/h, respectively. DOT absorption was 0.122 (SD = 0.108) mean percent, with flux and Kp calculated at 0.01 microg/cm2/h and 1.0 x 10(-7) cm/h, respectively. Pretreatment with the potential skin irritant 2% sodium lauryl sulfate had no effect on boron skin absorption. These in vivo results show that percutaneous absorption of boron, as boric acid, borax, and disodium octaborate tetrahydrate, through intact human skin is low and is significantly less than the average daily dietary intake. This very low boron skin absorption makes it apparent that, for the borates tested, the use of gloves to prevent systemic uptake is unnecessary. These findings do not apply to abraded or otherwise damaged skin.

Plasma protein polymorphisms in the tammar wallaby, Macropus eugenii

Five populations of the Australian tammar wallaby, Macropus eugenii, from Kangaroo Island, South Australia, and Garden, Abrolhos and Middle Islands and Perup, Western Australia, were examined for plasma protein polymorphisms. Select Kangaroo/Garden Island hybrids and backcross progeny were also included in the study. Vitamin D binding protein (GC), albumin (ALB), transferrin (TF), protease inhibitor (PI), haemopexin (HX), haptoglobin (HP) and immunoglobulin G (IgG) were identified by polyacrylamide gel electrophoresis, pH 7.9, isoelectric focusing, pH 4.2–4.9, and immunoblotting with rabbit antisera to human proteins. Five GC (A, B, C, D, E), two ALB (A, B), two TF (A, B) and five PI (I, J, L, M, P) variants were detected, and limited family studies demonstrated a codominant allelic inheritance for each of the systems.

Decreasing striatal 6-FDOPA uptake with increasing duration of cocaine withdrawal

It has been hypothesized that a decrease in dopaminergic presynaptic activity during abstinence or withdrawal is related to relapse in cocaine-dependent subjects (Dackis and Gold 1985; Markou and Koob 1991). This study measured striatal 6-fluorodopa (6-FDOPA) uptake, an index of dopaminergic presynaptic activity, using positron emission tomography (PET) in 11 drug-free cocaine addicts compared to eight normal subjects. Middle abstinence cocaine addicts (n = 5, off cocaine 11-30 days) had significantly lower striatal 6-FDOPA uptake compared to normal controls or early abstinence cocaine addicts (n = 6, off cocaine 1-10 days). The cocaine-dependent subjects (n = 11) showed a significant negative correlation between days off cocaine and striatal 6-FDOPA uptake. The results suggest that during abstinence from cocaine there is a delayed decrease in dopamine terminal activity in the striatum.

Bartholin's gland hyperplasia in a postmenopausal woman

BACKGROUND

Benign solid tumors of Bartholin's gland are rare, with only six cases reported in the English language literature since 1966. Bartholin's gland hyperplasia has not been described.

CASE

A postmenopausal woman with painless bilateral vulvar masses underwent surgical removal of one of the masses, which revealed a well-circumscribed, nonencapsulated tumor composed of mucous glands and ducts within a dense fibrous stroma, most consistent with hyperplasia of Bartholin's gland.

CONCLUSION

Hyperplasia represents a new etiology for the enlarged Bartholin's gland. Whether the hyperplastic gland forms in response to a stimulus is unclear. However, it appears to share some features with Bartholin's gland hamartoma or adenoma.

Large scale manufacturing of TXU(anti-CD7)-pokeweed antiviral protein (PAP) immunoconjugate for clinical trials

We have conjugated the murine monoclonal anti-CD7 antibody TXU to the plant hemitoxin pokeweed antiviral protein (PAP) to construct an effective immunotoxin against CD7 antigen positive hematologic malignancies. The scaled-up production and purification of TXU antibody, PAP toxin, and TXU-PAP immunotoxin permitted the manufacturing of a highly purified clinical-grade TXU-PAP preparation. In clonogenic assays, TXU-PAP elicited selective and potent cytotoxicity against CD7 antigen positive human leukemia cells and killed primary clonogenic leukemic cells from T-lineage acute lymphoblastic leukemia (ALL) patients. To our knowledge, this pre-IND work represents the first effort of producing a clinical-grade PAP immunotoxin for treatment of T-lineage ALL. Since the CD7 antigen is also expressed on AML cells, TXU-PAP could also be useful for the treatment of CD7 positive acute myeloid leukemia (AML) patients.

Genetic polymorphism of cat (Felis catus) plasma orosomucoid

Genetic polymorphism of orosomucoid (ORM) was observed in 22 breeds of cats (Felis catus) using isoelectric focusing (pH 4.0-6.5) of desialylated plasmas followed by immunoblotting with rabbit antiserum to human ORM. From a total of 943 plasma samples examined, 15 phenotypes were identified and family studies demonstrated an inheritance of five codominant alleles, ORMA, ORMB, ORMC, ORMD, and ORME, at a single locus.

Predicting length of stay of substance-using pregnant and postpartum women in day treatment

Pregnant and postpartum substance-using women are a special population whose needs do not reflect those of the general substance-using communities. This study examined length of stay in a federally funded day treatment demonstration program in order to identify predictor variables that may help identify pregnant and postpartum substance-using women at high risk for dropping out of treatment. Variables from intake and exit questionnaires on a sample of 163 women were analyzed using multiple regression on both days in treatment and the logarithmic transformation of days in treatment. Few predictor variables were identified, although findings suggest that if a women is younger and self-referred, she may leave treatment sooner. As one of the first sets of published data on pregnant and postpartum women and retention in treatment, this study lays the groundwork for future research on the retention of pregnant and postpartum women in treatment, thereby facilitating the success of these women in overcoming their addiction.

The absence of an apolipoprotein epsilon4 allele is associated with a more aggressive form of Alzheimer's disease

We investigated the relationship between APOE genotype and rate of disease progression and survival in 99 patients with probable Alzheimer's disease (AD) who were followed biannually for up to 6 years. Patients were stratified into two groups, those with and without at least one APOE epsilon4 allele. The rate of decline in modified Mini-Mental State Examination scores was slower, the presence of extrapyramidal signs was decreased, and the development of myoclonus occurred later among patients with APOE epsilon4 alleles compared with patients with other genotypes. Compared with patients without an APOE epsilon4 allele, the risk of mortality was also decreased in patients with at least one epsilon4 allele (RR = 0.38; CI = 0.17-0.84, p < 0.02). Because the decline in mental ability as well as the development of myoclonus and extrapyramidal signs are consistent manifestations of disease progression, our results imply that APOE epsilon4 is associated with a less aggressive form of AD.

Genetical and physical assignments of equine microsatellites--first integration of anchored markers in horse genome mapping

Twenty equine microsatellites were isolated from a genomic phage library, and their genetical and physical localization was sought by linkage mapping and fluorescent in situ hybridization (FISH). Nineteen of the markers were found to be polymorphic with, in most cases, heterozygosities exceeding 50%. The markers were mapped in a Swedish reference family for gene mapping, comprising eight half-sib families from Standardbred and Icelandic horse sires. Segregation was analyzed against a set of 35 other markers typed in the pedigree. Thirteen of the microsatellites showed linkage to at least one other marker, with a total of 21 markers being involved in these linkages. In parallel, 18 of the microsatellites could be assigned to their chromosomal region by FISH. These assignments involved eight equine autosomes: ECA1, 2, 4, 6, 9, 10, 15, and 16. The genetical and physical mappings revealed by this study represent a significant extension of the current knowledge of the equine genome map.

Predicting time to nursing home care and death in individuals with Alzheimer disease

OBJECTIVE

To develop and validate an approach that uses clinical features that can be determined in a standard patient visit to estimate the length of time before an individual patient with Alzheimer disease (AD) requires care equivalent to nursing home placement or dies.

DESIGN

Prospective cohort study of 236 patients, followed up semiannually for up to 7 years. A second validation cohort of 105 patients was also followed.

SETTING

Three AD research centers.

PATIENTS

All patients met National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria for probable AD and had mild dementia at the initial visit.

INTERVENTION

Predictive features, ascertained at the initial visit, were sex, duration of illness, age at onset, modified Mini-Mental State Examination (mMMS) score, and the presence or absence of extrapyramidal signs or psychotic features.

MAIN OUTCOME MEASURES

(1) Requiring the equivalent of nursing home placement and (2) death.

RESULTS

Prediction algorithms were constructed for the 2 outcomes based on Cox proportional hazard models. For each algorithm, a predictor index is calculated based on the status of each predictive feature at the initial visit. A table that specifies the number of months in which 25%, 50%, and 75% of patients with any specific predictor index value are likely to reach the end point is then consulted. Survival curves for time to need for care equivalent to nursing home placement and for time to death derived from the algorithms for selected predictor indexes fell within the 95% confidence bands of actual survival curves for patients. When the predictor variables from the initial visit for the validation cohort patients were entered into the algorithm, the predicted survival curves for time to death fell within the 95% confidence bands of actual survival curves for the patients.

CONCLUSIONS

The prediction algorithms are a first but promising step toward providing specific prognoses to patients, families, and practitioners. This approach also has clear implications for the design and interpretation of clinical trials in patients with AD.