Mail and Telephone Outreach from Electronic Health Records for Research Participation on Cognitive Health and Aging

OBJECTIVES

This report describes the efficacy and utility of recruiting older individuals by mail to participate in research on cognitive health and aging using Electronic Health Records (EHR).

METHODS

Individuals age 65 or older identified by EHR in the Mount Sinai Health System as likely to have Mild Cognitive Impairment (MCI) were sent a general recruitment letter (N=12,951). A comparison group of individuals with comparable age and matched for gender also received the letter (N=3,001).

RESULTS

Of the 15,952 individuals who received the mailing, 953 (6.0%) responded. 215 (1.3%) declined further contact. Overall rate of expression of interest was 4.6%. Of the 738 individuals who responded positively to further contact, 321 indicated preference for further contact by telephone. Follow-up of these individuals yielded 30 enrollments (0.2% of 15,952). No differences in response rate were noted between MCI and comparison groups, but the comparison group yielded higher enrollment. 6 individuals who were not the intended recipients of mailing but nevertheless contacted our study were also enrolled.

CONCLUSIONS

Mailings to individuals identified through a trusted source, such as a medical center from which they have received clinical care, may be a viable means of reaching individuals within this age group as this effort yielded a low rejection rate. However, EHR information did not enhance study enrollment. Implications for improving recruitment are discussed.

Daylight photodynamic therapy is an option for the treatment of actinic keratosis in patients with xeroderma pigmentosum in Africa

BACKGROUND

Xeroderma pigmentosum (XP) is a very rare and severe genetic disorder with a DNA repair defect of ultraviolet (UV)-induced damage. Photodynamic therapy (PDT) has been successfully used in XP patients to treat actinic keratosis (AK) and daylight PDT (DL-PDT) has demonstrated similar efficacy to conventional PDT (C-PDT) for AK.

OBJECTIVES

To assess DL-PDT for the treatment of AK in patients with XP.

METHODS

Patients with XP were evaluated by a group of Spanish and African dermatologists. Clinical characteristics of the patients were assessed and divided in mild, severe or moderate affectation of AK in the face. A topical photosensitizer was extended on the patients' faces and after two hours of indoor light exposure, fluorescence was assessed and the cream was removed. Patients were examined two and seven days later to assess the reaction to PDT and followed up three months later.

RESULTS

A total of 13 patients were treated on the whole face. Three were classified as severe AK, six as moderate AK and four as mild AK. Fluorescence assessment showed a soft yellow-green colour and a pink-color delineating the AK. Two days after treatment patients presented a scaly reaction. After one week the reaction healed, there was improvement and after three months no adverse events were noticed.

CONCLUSIONS

PDT is an option for treatment of AK in patients with XP.

Characterizing cognitive deficits and dementia in an aging urban population in India

Rapid rise in the population of older adults in India will lead to the need for increased health care services related to diagnosis, management, and long-term care for those with dementia and cognitive impairment. A direct approach for service provision through memory clinics can be an effective, successful, and sustaining means of delivering specialized health care services. We have established a memory clinic in Mumbai, India by employing the diverse clinical skills available in Indian academic institutions, diagnostic and research expertise of clinicians and psychologists, and the support of the U.S. National Institutes of Health. Our project involved recruitment of patients, clinical and neuropsychological assessment, and standardized diagnostic procedures, demonstrating the feasibility of using research methods to develop a memory clinic. In this paper, we describe the development of a community-based memory clinic in urban India, including linguistic and cultural factors and present detailed results, including diagnostic characterization, on 194 subjects with various stages of cognitive deficits. Our findings support the feasibility of developing a memory clinic in a public hospital and successful use of research diagnostic criteria to categorize cognitive deficits observed in this population, which may be used to inform the development of other such clinics.

Final results from a phase II trial of systemic chemotherapy in a small cell urothelial cancer: Evidence supporting neoadjuvant chemotherapy from the M.D. Anderson Cancer Center

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Background: Previously reported retrospective data supported a potential role for neoadjuvant chemotherapy in small cell urothelial cancer (SCUC). We now report final results from a phase II clinical trial in SCUC. Methods: Since 2001, 30 patients with biopsy proven SCUC received alternating doublet chemotherapy with Ifosfamide + Doxorubicin, and Etoposide + Cisplatin. Patients with surgically resectable disease (<=cT4aN0M0) received a total of 4 cycles followed by cystectomy, while those with unresectable disease (>=cT4b, N+, or M+) received 2 cycles beyond maximal response. Results: Neoadjuvant chemotherapy was given in 18 patients (cT2:14, cT3:4), while 12 patients were treated for metastatic SCUC. For those receiving neoadjuvant therapy, the median OS is 58 months, with a 5-year survival of 48%; 8 remain alive and NED beyond 2.5 years. There have been only 5 deaths for the neoadjuvant group (3 SCUC, 1 post-op infection, 1 AML). For those with metastatic disease, the median OS is 14 months. Two were rendered resectable with chemotherapy (cT4b:1,N+:1); 1 died of recurrent SCUC, while the other is currently undergoing therapy for TCC of the ureter. Brain metastases developed in 7 patients (cT3b:2, initial M+:5). Chemotherapy has been well-tolerated with only 2 G4 toxicities (catheter infection and neutropenia). The most frequent G3 toxicities include transfusion (10), neutropenic fever (7), infection (5), and vomiting (3). There was only one post-surgical death; a case of sepsis in a patient with diverticulitis and abscess requiring sigmoid colon resection. Conclusions: These prospective results, which are consistent with our previously reported retrospective review, provide additional support for 4 cycles of neoadjuvant chemotherapy in the setting of SCUC. Unfortunately, once metastases are present, the prognosis remains poor with few long-term survivors. These results may also predict a patient subset for which prophylactic cranial irradiation may be potentially beneficial.

No significant financial relationships to disclose.

Age, gender, and education norms on the CERAD neuropsychological battery in the oldest old

OBJECTIVE

To evaluate the performance of nondemented subjects 85 years and older on the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery, and to assess its relationship with sociodemographic variables.

METHODS

We studied 196 subjects enrolled in an Alzheimer's Disease Research Center study who had a complete CERAD neuropsychological assessment. We used multiple regression analysis to predict performance on the neuropsychological tests from age, education, and sex. Eight representative hypothetical individuals were created (for example, an 87-year-old man, with high education). For each test, estimates of performance at the 10th, 25th, 50th, and 75th percentiles were reported for the eight representative hypothetical individuals.

RESULTS

Mean age was 89.2 years (SD = 3.2), mean years of education was 14.9 (SD = 3.2), and 66% of the sample were women. For 11 of the 14 neuropsychological tests, there was a significant multiple regression model using education, age, and sex as predictors. Neither the models nor the predictors used individually were significant for Delayed Recall, Savings, or correct Recognition. Among the significant results, seven had education as the strongest predictor. Lower age and higher education were associated with better performance. Women performed better than men in three of four tests with significant results for sex.

CONCLUSIONS

In a sample of oldest old whose primary language is English, neuropsychological testing is influenced mainly by education and age. Cutoff scores based on younger populations and applied to the oldest old might lead to increased false-positive misclassifications.

Early-onset substance abuse and community violence by outpatients with chronic mental illness

OBJECTIVE

This study examined the relationship between violence and substance abuse among patients with chronic mental illness living in the community.

METHODS

All referrals over a one-year period to an urban assertive community treatment team were evaluated systematically with a standardized intake protocol. Thirty-seven patients with a history of violence in the community were compared with 27 patients without such a history on a variety of clinical and demographic variables.

RESULTS

More than half of the patients (58 percent) had a history of violence in the community. The only significant differences between those with a history of violence and those without involved alcohol or drug use. The single best predictor of violence was the onset of alcohol or drug abuse in late childhood or early adolescence.

CONCLUSIONS

In this sample, very early onset of substance abuse among people who developed mental illness was associated with the greatest risk of community violence. Thus at least some of the causal determinants of violence in this sample may precede the onset of adult mental illness.

Cognitive performance and regional brain volume in human immunodeficiency virus type 1 infection

BACKGROUND

Brain atrophy has been reported to occur in advancing human immunodeficiency virus (HIV) infection, particularly in patients with HIV-related dementia. Atrophy of the caudate region, as assessed by magnetic resonance imaging measures, has been reported to correlate with cognitive impairment in patients with HIV infection; however, differences in the severity of HIV-induced immunosuppression may have contributed to these findings.

OBJECTIVE

To determine the relationship between regional brain volumes and cognitive performance in individuals with HIV infection.

PATIENTS AND METHODS

We evaluated 11 patients with advanced HIV disease by using neuropsychologic tests and quantitative magnetic resonance imaging volume analysis.

SETTING

University hospital, involving patients from a clinical trial.

RESULTS

Caudate volume, expressed as a ratio of total intracranial volume, correlated with performance on the Trails A and Grooved Pegboard tests, but not with other tests of memory, motor speed, or mood (adjusted for age and education). Hippocampal volume did not correlate with any of the neuropsychologic tests.

CONCLUSIONS

Caudate volume in patients with advanced HIV disease is associated with poor performance on neuropsychologic tests of complex motor and sequencing skills. Hippocampal volume does not appear to be related to impairment on neuropsychologic tests. These findings are independent of the degree of immunosuppression and the overall extent of brain atrophy; however, these results must be interpreted with some caution, given the limited sample size.

Liver preservation with UW solution. I. Evidence that hydroxyethyl starch is not essential

Preservation of rat livers by simple ice-storage has been demonstrated after 24 hr using the University of Wisconsin (UW) solution. Equally good preservation could be obtained by substituting hydroxyethyl starch (HES) from another source or by omission of HES from the UW formulation. Survival, early and late function, and morphology at the end of a 3-month follow-up period were essentially similar for all three test groups. It is concluded that HES is not required for optimum preservation of the rat liver in this treatment model.

Vertex epidural hematomas

Four cases of vertex epidural hematomas are presented to illustrate the unique management problems which set them apart from their more common counterparts located over the temporal convexity. Diagnosis requires a high degree of suspicion as vertex epidural hematomas are often missed by conventional horizontal scanning. Coronal computed tomographic scanning should be undertaken in all suspected cases. Clinical symptoms exceeding the small volume of clot may be present due to venous obstruction and disruption of cerebrospinal fluid absorption. Evacuation of the clot usually leads to clinical improvement.

Tardive dyskinesia: a five year follow-up

A group of chronic schizophrenic patients receiving prolonged treatment with neuroleptics was assessed in 1978 at an outpatient clinic to determine the prevalence of Tardive Dyskinesia. Those with TD were reassessed after two and five years with regard to change in TD severity. The Smith scale was used every time and, on the last assessment, the AIMS scale and videotaped interviews were added. Because of the high attrition rate, results, though interesting, cannot be generalized.

The importance of the hepatic artery in rat liver transplantation

The hepatic artery is important in preventing biliary ischemia and obstruction after bile duct reconstruction or orthotopic liver transplantation in the rat. A technique of orthotopic liver transplantation in the rat with reestablishment of the arterial inflow is described, suitable for studies in immunology and preservation. Reestablishment of both venous and arterial inflow is required to minimize biliary complications. General survival, hepatic cellular function, and biliary drainage are all improved by rearterialization. In all these features, the rat illustrates characteristics applicable to human liver transplantation. The vital requirement of the adequacy of blood supply to the bile duct in liver transplantation surgery in all species is highlighted by these findings, which indicate clearly the importance of an arterial blood supply in rat liver transplantation and bile duct surgery.

Preoperative embolization in the treatment of osseous metastases from renal cell carcinoma

Metastatic lesions due to renal cell carcinoma are frequently hypervascular. This study reports the results of preoperative embolization of skeletal metastases from hypernephroma. Reported for the first time in the English literature is the use of this technique for preoperative devascularization of metastatic lesions to the spine in eight patients. Effective devascularization was achieved in all peripheral lesions. Blood loss for peripheral lesions averaged 940 cc and compared favorably to 20 nonembolized cases, in whom average blood loss was 1975 cc. Spinal embolization requires careful identification and preservation of any segmental arteries that supply the anterior spinal artery. Effective spinal devascularization was achieved in six of eight patients. In two patients significant bleeding occurred as a result of incomplete embolization. This series supports the growing evidence for the efficacy and safety of selective arterial embolization in the preoperative control of hemostasis in patients with metastatic hypernephroma. Embolization of spinal metastases, although technically demanding, has been effective in devascularizing these lesions without serious neurologic complications.

Formation of double-walled microtubules and multilayered tubulin sheets by basic proteins

Some basic proteins enable microtubule protein to form special assembly products in vitro, known as double-walled microtubules. Using histones (H1, core histones) as well as the human encephalitogenic protein to induce the formation of double-walled microtubules, we made the following electron microscopic observations: (1) Double-walled microtubules consist of an "inner" microtubule which is covered by electron-dense material, apparently formed from the basic protein, and by a second tubulin wall. (2) The tubulin of the second wall seems to be arranged as protofilaments, surrounding the inner microtubule in a helical or ring-like manner. (3) The surface of double-walled microtubules lacks the projections of microtubule-associated proteins, usually found on microtubules. (4) In the case of protofilament ribbons (incomplete microtubules), H1 binds exclusively to their convex sides that correspond to the surface of microtubules. Zn2+-induced tubulin sheets, consisting in contrast to microtubules of alternately arranged protofilaments, are covered by H1 on both surfaces. Furthermore, multilayered sheet aggregates appeared. The results indicate that the basic proteins used interact only with that protofilament side which represents the microtubule surface. In accordance with this general principle, models on the structure of double-walled microtubules and multilayered tubulin sheets were derived.

Pathogenetic role of HIV infection in Kaposi's sarcoma of equatorial East Africa

Thirty residents of north-central Tanzania with various forms of Kaposi's sarcoma (KS) were evaluated. The absolute number of peripheral blood OKT4 lymphocytes in patients and Tanzanian control subjects tended to be low (in comparison with healthy young American adults), and many had inverted T4/T8 ratios. Plasma polyclonal beta- and gamma-globulin concentrations were increased in many patients with KS and in control patients in Tanzania with chronic dermatopathies, but not in African hospital employees and patients undergoing elective surgery. Three of nine patients with locally aggressive KS possessed antibodies to human T-cell lymphotropic virus type III/lyphadenopathy-associated virus (HIV), but none had evidence of the acquired immunodeficiency syndrome (AIDS) or the AIDS-related complex. Three patients with disseminated, rapidly progressive KS and high HIV-antibody titers had an immunologic and clinical picture consistent with AIDS. Two of 13 patients with the classic plaque/nodular form of KS had low plasma titers of HIV antibody, but the significance of these serologic findings is not known. The evidence suggests that HIV plays a role in the pathogenesis of some cases of KS in East Africa, but most patients with KS in East Africa have no evidence of overt immunologic deficiency or HIV infection.

Congenital scoliosis and urinary tract abnormalities: are intravenous pyelograms necessary?

One hundred patients with a diagnosis of congenital scoliosis were reviewed with regard to their urologic history, chemistries, and excretory urography. A 40% incidence of urologic abnormality was found in these asymptomatic patients. Twenty-five additional patients were evaluated by excretory urography and ultrasonography. Of six patients identified by ultrasonography as having abnormalities five had results confirmed by excretory urography. Urologic evaluation of all patients with congenital scoliosis is recommended; however, diagnostic ultrasonographic evaluations of the urinary tract have proven to be an acceptable alternative as an initial screening modality.

Subdural hematoma in systemic lupus erythematosus: report and review of the literature

A patient with systemic lupus erythematosus (SLE) and subdural hematoma is described. Pathophysiological concepts are discussed and a link between this lesion and active SLE is suggested. The disastrous consequences of failure to recognize subdural hematoma in this context is emphasized.

Diagnostic imaging in pediatrics: the state of the art

The results of the study panels, both at national and international levels, have shown that much can be done to increase the efficiency and efficacy of diagnostic imaging in all areas of medical practice including pediatrics. Much remains to be done, however. The work that has been done must be expanded into a thorough investigation of the safety, yield, and cost of diagnostic imaging. It is the responsibility of all physicians to continue efforts toward more rational use of diagnostic imaging at all levels of society and to make sure that established guidelines are implemented. Flexibility in attitudes, cooperation between clinician and radiologist, and a willingness to learn and keep up with advances are essential to this process--not only to improve the benefits from diagnostic imaging, but to preserve the ability of society to pay for it. Those who would proclaim that this or that recommendation is the "last word" must realize that half of what is said today may well be proven false 10 years from now, and, further that we have no way of knowing what techniques and imaging approaches will comprise that half, nor should the imaging "standards" be self-serving. Guidelines drawn up in an academic vacuum where all imaging techniques are readily available may have little practical application in pediatric practice and impact on health care in areas of the world where diagnostic imaging, if available at all, will consist only of basic radiographic imaging. At the same time, experience gained in countries using all advanced imaging modalities must be shared with less fortunate nations: such knowledge may have important implications for even the most basic radiographic studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Imaging of neuroblastoma: an overview

This review article briefly describes the pathology, clinical features, prognosis, and treatment of neuroblastoma. The emphasis is on applications of newer diagnostic modalities (sonography, nuclear scintigraphy, computed tomography) for imaging and staging. The potential role of magnetic resonance imaging and spectroscopy is discussed.

Acute median nerve compression by haemorrhage from acute myelomonocytic leukaemia

A 61-year-old male receiving treatment for acute myelomonocytic leukaemia (AMML) developed weakness and sensory loss in the thumb, index and middle finger and half of the ring finger of the left hand as a result of a spontaneous haemorrhage into the carpal tunnel and forearm, an unusual cause of median nerve compression. These findings were confirmed by CT scanning and post-mortem examination. This is the first report of spontaneous haemorrhage occurring in a patient with AMML.

Extracranial cribside sonography in infants

In 29 real-time ultrasonic studies of infants in the intensive care nursery, the technique either accurately diagnosed or led directly to the correct diagnosis in 27 (93%). Twenty-four of these infants had suspected abnormality in the abdomen or pelvis, three had congestive heart failure and bruits, one had respiratory distress and an opacified hemithorax on chest roentgenogram, and one was a child with ambiguous genitalia in whom sonography identified a uterus. We suggest that portable, real-time ultrasonography is an ideal modality with which to study seriously ill infants whose medical condition precludes transport to the radiology department.

Use of computed tomography in pediatric oncology

Computed tomography (CT) has dramatically changed the imaging of pediatric oncologic disease. CT precisely displays and characterizes cross-sectional anatomic pathology. This provides important information for diagnosing and staging tumors in infants and children. The principles, techniques, and indications for computed tomography in the evaluation of pediatric extracranial tumors are reviewed in this article. Selected applications of computed tomography for pediatric tumors of the mediastinum, chest wall, lung parenchyma, abdomen, pelvis, and extremities are discussed and illustrated.

Congenital saccular anterior urethral diverticulum

Congenital saccular diverticulum is an uncommon abnormality of the anterior urethra in the male. In seven cases (6 infants and an 8-year-old boy) the diverticulum was well demonstrated by voiding cystourethrography and/or retrograde urethrography. In patients with saccular anterior urethral diverticulum, contrast material fills an oval outpouching of the ventral aspect of the anterior urethra. The clinical presentation, unique radiologic appearance, and differential diagnostic considerations are reviewed.

Localization of the site of urinary tract infections with the bladder washout test

The data from 100 bladder washout studies on pediatric patients have been analyzed to derive criteria for interpretation of this test and to define the limitations of this procedure in localization of the site of urinary tract infections. Using the bladder washout test, infection of the upper urinary tract is characterized by an abrupt increase in the concentration of bacteria in urinary specimens collected following urinary bladder sterilization. Infection limited to the lower urinary tract is characterized by scant if any bacterial growth in the specimens of urine collected following bladder sterilization. The site of infection may be incorrectly localized to the lower urinary tract or classified as not determined in patients with scant or intermittent renal bacteriuria.

Pulmonary sarcoidosis in childhood

Clinical and radiologic characteristics of pulmonary sarcoidosis in 26 children are presented. Initial nonspecific symptomatology and decreased pulmonary function are almost invariably accompanied by radiologic evidence of pulmonary disease. Bilateral hilar lymphadenopathy frequently associated with bilateral paratracheal adenopathy is characteristic. Other mediastinal lymphadenopathy (subcarinal, anterior, and posterior) is sporadically present, and is invariably associated with the more specific bilateral patterns of thoracic adenopathy. Pulmonary parenchymal involvement is common and predominantly appears radiographically as small irregular densities. Pleural effusion, pneumothorax, and cardiomegaly are unusual findings. Extrathoracic radiographic manifestations are uncommon. Lytic lesions of the tubular bones of the hands and feet are rare in childhood.

The dietary chloride deficiency syndrome

Chronic depletion of body chloride developed in a group of infants ingesting a diet consisting almost exclusively of chloride deficient Neo-Mull-Soy. Ten of the 12 infants were on this diet three to five months before loss of appetite, failure to thrive, muscle weakness, and lethargy led to a diagnostic evaluation. The outstanding laboratory features were severe hypokalemic metabolic alkalosis, low urinary chloride concentrations (< 10 mEq/liter), and erythrocyturia. There was marked decrease in weight for age in all 12 infants. Head circumference for age had decreased in five of six and length for age in five of ten infants for whom earlier measurements were available. The biochemical abnormalities reverted to normal following dietary supplementation with either sodium or potassium chloride. Appetite, affect, and muscle strength improved, and weight gain resumed. Head circumference for age has moved toward the percentile level present prior to starting Neo-Mull-Soy in all instances. With one exception, length measurements show a similar pattern. The erythrocyturia has decreased or vanished. Chloride deficiency led to contraction of the extracellular volume and the substitution of poorly reabsorbable anions for readily reabsorbable chloride. These alterations caused development of the negative hydrogen ion and potassium balances which led to the hypokalemic metabolic alkalosis.

Ultrasonic diagnosis of obstructed renal duplication and ureterocele

The diagnoses of complete obstruction in a duplicated renal collecting system and ureterocele can be made with a high degree of confidence by ultrasound. Two children presenting with abdominal masses were examined by gray scale ultrasonography which demonstrated large cystic masses dorsal to and displacing the lower pole of the kidney ventrally and laterally. In one patient the dilated ureter terminated in a ureterocele. Ultrasonography is the appropriate imaging modality for this disease process, though it generally becomes the complementary study to excretory urography in the diagnosis of an obstructed duplicated system. The dilated pelvis and ureter can be imaged to ultrasonography even when their presence is only implied on an excretory urogram. Finally, the cystic nature of a ureterocele, as well as its relationship to the ureter and bladder, makes ultrasonography an ideal technic for evaluating this anomaly.

Radiological observations during transpyloric tube feeding in infants of low birth weight. Perforation of the duodenum and variations in normal duodenal anatomy

Perforation of the duodenum is a serious complication of transpyloric tube feeding in infants of low birth weight. Polyvinyl chloride and (less commonly) silicone tubes have been implicated. Altered radiographic configuration of the tube in the region of the superior or inferior flexure, associated with clinical deterioration, pneumoperitoneum, peritonitis, or a retroperitoneal fistula, is diagnostic of duodenal perforation. The configuration of the tube may vary during uncomplicated transpyloric alimentation and is frequently incompatible with the expected anatomical course. Contrast examination may demonstrate normal anatomy or mobility of the distal duodenal loop as an adaptation to rigidity of the tube. The possibility of perforation appears to be increased at or adjacent to the flexures.

Integrated imaging for the evaluation of the urologic diseases of childhood

The rational selection of imaging modalities for the diagnosis of renal and adrenal masses in children is discussed with a view toward obtaining an accurate assessment of pathologic changes with the least amount of stress and expense to the patient. The integration of the results of these tests in specific clinical settings is also described.