Neuropathic symptoms with SARS-CoV-2 vaccination

Background and Objectives

Various peripheral neuropathies, particularly those with sensory and autonomic dysfunction may occur during or shortly after acute COVID-19 illnesses. These appear most likely to reflect immune dysregulation. If similar manifestations can occur with the vaccination remains unknown.

Results

In an observational study, we studied 23 patients (92% female; median age 40years) reporting new neuropathic symptoms beginning within 1 month after SARS-CoV-2 vaccination. 100% reported sensory symptoms comprising severe face and/or limb paresthesias, and 61% had orthostasis, heat intolerance and palpitations. Autonomic testing in 12 identified seven with reduced distal sweat production and six with positional orthostatic tachycardia syndrome. Among 16 with lower-leg skin biopsies, 31% had diagnostic/subthreshold epidermal neurite densities (≤5%), 13% were borderline (5.01-10%) and 19% showed abnormal axonal swelling. Biopsies from randomly selected five patients that were evaluated for immune complexes showed deposition of complement C4d in endothelial cells. Electrodiagnostic test results were normal in 94% (16/17). Together, 52% (12/23) of patients had objective evidence of small-fiber peripheral neuropathy. 58% patients (7/12) treated with oral corticosteroids had complete or near-complete improvement after two weeks as compared to 9% (1/11) of patients who did not receive immunotherapy having full recovery at 12 weeks. At 5-9 months post-symptom onset, 3 non-recovering patients received intravenous immunoglobulin with symptom resolution within two weeks.

Conclusions

This observational study suggests that a variety of neuropathic symptoms may manifest after SARS-CoV-2 vaccinations and in some patients might be an immune-mediated process.

Connectivity-based risk ranking of infectious salmon anaemia virus (ISAv) outbreaks for targeted surveillance planning in Canada and the USA

Infectious salmon anaemia (ISA) can be a serious viral disease of farmed Atlantic salmon (Salmo salar). A tool to rank susceptible farms based on the risk of ISA virus (ISAv) infection spread from infectious farms after initial incursion or re-occurrence in an endemic area, can help guide monitoring and surveillance activities. Such a tool could also support the response strategy to contain virus spread, given available resources. We developed a tool to rank ISAv infection risks using seaway distance and hydrodynamic information separately and combined. The models were validated using 2002-2004 ISAv outbreak data for 30 farms (24 in New Brunswick, Canada and 6 in Maine, United States). Time sequence of infection spread was determined from the outbreak data that included monthly infection status of the cages on these farms. The first infected farm was considered as the index site for potential spread of ISAv to all other farms. To assess the risk of ISAv spreading to susceptible farms, the second and subsequent infected farms were identified using the farm status in the given time period and all infected farms from the previous time periods. Using the three models (hydrodynamic only, seaway-distance, and combined hydrodynamic-seaway-distance based models), we ranked susceptible farms within each time interval by adding the transmission risks from surrounding infected farms and sorting them from highest to lowest. To explore the potential efficiency of targeted sampling, we converted rankings to percentiles and assessed the model's predictive performance by comparing farms identified as high risk based on the rank with those that were infected during the next time interval as observed in the outbreak data. The overall predictive ability of the models was compared using area under the ROC curve (AUC). Farms that become infected in the next period were always within the top 65% of the rank predicted by our models. The overall predictive ability of the combined (hydrodynamic-seaway-distance based model) model (AUC = 0.833) was similar to the model that only used seaway distance (AUC = 0.827). Such models can aid in effective surveillance planning by balancing coverage (number of farms included in surveillance) against the desired level of confidence of including all farms that become infected in the next time period. Our results suggest that 100% of the farms that become infected in the next time period could be targeted in a surveillance program, although at a significant cost of including many false positives.

Area contact networks and the spatio-temporal spread of infectious salmon anemia virus (ISAV) in Chile

Area management, the coordination of production and biosecurity practices across neighboring farms, is an important disease control strategy in aquaculture. Area management in aquaculture escalated in prominence in response to outbreaks of infectious salmon anemia (ISA) internationally. Successes in disease control have been attributed to the separation achieved through area-level synchronized stocking, fallowing, movement restrictions, and fomite or pest control. Area management, however, is costly; often demanding extra biosecurity, lengthy or inconveniently timed fallows, and localization of equipment, personnel, and services. Yet, this higher-order organizational structure has received limited epidemiologic attention. Chile's National Fisheries and Aquaculture Service instigated area management practices in response to the 2007 emergence of ISA virus (ISAV). Longitudinal data simultaneously collected allowed retrospective evaluation of the impact of component tenets on virus control. Spatiotemporal analyses identified hydrographic linkages, shared ports, and fish transfers from areas with recent occurrence of ISAV as the strongest predictors of virus spread between areas, though specifics varied by ISAV type (here categorized as HPR0 for the non-virulent genotypes, and HPRv otherwise). Hydrographic linkages were most predictive in the period before implementation of enhanced biosecurity and fallowing regulations, suggesting that viral load can impact spread dynamics. HPR0 arose late in the study period, so few HPRv events were available by which to explore the hypothesis of HPR0 as progenitor of outbreaks. However, spatiotemporal patterns in HPRv occurrence were predictive of subsequent patterns in HPR0 detection, suggesting a parallel, or dependent, means of spread. Better data precision, breadth and consistency, common challenges for retrospective studies, could improve model fit; and, for HPR0, specification of diagnostic test accuracy would improve interpretation.

Enteric outbreak surveillance in British Columbia, 2009-2013

BACKGROUND

Understanding enteric disease outbreak sources, burden of illness, mode of transmission and use of interventions informs planning, policy development and prevention programs.

OBJECTIVE

To describe trends in enteric disease outbreaks investigated in British Columbia (BC) between 2009 and 2013.

METHODS

An analysis was conducted of enteric disease outbreaks that had been entered into a national, secure web-enabled outbreak reporting system using the Canadian Network for Public Health Intelligence (CNPHI) and investigated in BC between January 1, 2009 and December 31, 2013. The data included information on pathogen, number of cases, hospitalizations, deaths, setting, mode of transmission, source, factors that contributed to the outbreak and interventions. Residential facility-based viral outbreaks and outbreaks associated with international travel were excluded.

RESULTS

There were 104 outbreaks investigated in BC between 2009 and 2013. Ninety-three were reported by BC organizations and 11 were national outbreak investigations reported by the Public Health Agency of Canada (PHAC). There was an average of 21 outbreaks per year. Overall, the annual rate of foodborne outbreaks in BC was 2.8 per one million population. Seventy-nine (76%) outbreaks had a pathogen identified, most commonly norovirus, Salmonella and E. coli. There was a total of 108 hospitalizations (3.8% of all cases) and two deaths (0.1% of all cases); one caused by botulism, the other by E. coli O157. Food service establishments were the most common setting (33.7%), followed by the community (24.0%) and private functions (12.5%). The food types most often reported were fruits and vegetables, meat and seafood. The data showed a pathogen-food source combination between Salmonella and eggs.

CONCLUSION

This is the first publication summarizing trends in enteric disease outbreaks in BC including assessing sources, burden and interventions. Ongoing reporting and analysis of outbreak data in BC will allow for improved assessment of trends in sources and pathogens over time and further understanding of the effectiveness of interventions associated with outbreaks.

Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study

BACKGROUND

There is an evident need for improved management of elderly patients with trauma in order to avoid common and troublesome complications such as delirium. The aim of this study was to investigate whether an implementation of a multi-factorial program including intensified pre-hospital and perioperative treatment and care could reduce the incidence of delirium in elderly patients with hip fracture, cognitively intact at admission to the hospital. In addition, we explored the factors that characterize patients who developed delirium.

METHODS

A prospective, quasi-experimental design was used. A total of 263 patients with hip fracture (> or = 65 years), cognitively intact at admission, were consecutively included between April 2003 and April 2004. On 1 October 2003, a new program was introduced. All patients were screened for cognitive impairment within 30 min after admission to the emergency department using The Short Portable Mental Status Questionnaire (SPMSQ). To screen for delirium, patients were tested within 4 h of admission and thereafter daily, using the Organic Brain Syndrome scale.

RESULTS

The number of patients who developed delirium during hospitalization was 74 (28.1%), with a decrease from 34% (45 of 132) in the control group to 22% (29 of 131) in the intervention group (P=0.031). Patients who developed delirium were statistically older, more often had > 4 prescribed drugs at admission and scored less well in the SPMSQ test.

CONCLUSION

The use of a multi-factorial intervention program in elderly hip fracture patients, lucid at admission, reduced the incidence of delirium during hospitalization by 35%.

Physostigmine and tetrahydroaminoacridine treatment of Alzheimer's disease

The cholinergic hypothesis of Alzheimer's disease (AD) was tested in two doubleblind crossover studies. Physostigmine given intravenously to 10 AD patients for two hours caused improvement of reaction time and EEG and increased regional cerebral blood flow (rCBF) in the temporoparietal cortex. 17 AD patients (mean age 62.6 +/- 6.8 years) obtained three types of treatment: tetrahydroaminoacridine (THA), THA + lecithin and placebo in randomized order. Each treatment period was 6 weeks. The mean THA dose was 104 +/- 20 mg/day. There were differences in outcome between groups of patients over the total 26 weeks treatment period. The subclassification in responders, unchanged and deteriorated was supported by rCBF, EEG and psychometric testing.

ADHD in adult psychiatry. Minimum rates and clinical presentation in general psychiatry outpatients

The objective of the study was to determine the prevalence and comorbidity of persisting attention-deficit hyperactivity disorder (ADHD) in adult psychiatric outpatients. Consecutive patients, first visits excluded, at a general psychiatric outpatient clinic were offered a screening for childhood ADHD with the Wender Utah Rating Scale (WURS). One hundred and forty-one patients out of 398 (35%) completed and returned the scale. Patients above or near cut-off for ADHD (n=57) were offered an extensive clinical evaluation with psychiatric as well as neuropsychological examination. The attrition was analysed regarding age, sex and clinical diagnoses. Out of the screened sample, 40% had scores indicating possible childhood ADHD. These 57 patients were invited to the clinical part of the study, but 10 declined assessment, leaving 47 (37 women and 10 men) who were actually examined. Thirty of these (21 women and nine men) met diagnostic criteria for ADHD at the time of examination. Among the patients with ADHD, affective disorders were the most common psychiatric diagnoses. The rate of alcohol and/or substance abuse, as noted in the medical records, was also high in the ADHD group. In the WURS-screened group, 22% (30 patients assessed as part of this study and one person with ADHD previously clinically diagnosed) were shown to have persisting ADHD. Therefore, it is clearly relevant for psychiatrists working in general adult psychiatry to have ADHD in mind as a diagnostic option, either as the patient's main problem or as a functional impairment predisposing for other psychiatric disorders.

Estimating diagnostic test accuracy for infectious salmon anaemia virus in Maine, USA

Infectious salmon anaemia virus (ISAV) is a pathogen of consequence to farmed Atlantic salmon, Salmo salar L. ISA control centres on active surveillance for early detection by reverse transcription polymerase chain reaction (RT-PCR), indirect fluorescent antibody assay (IFAT) and virus isolation. Because diagnostic test performance varies among populations and laboratories, the Office International des Epizooties (OIE) recommends an evaluation of test accuracy in each region of use. This is complicated in Maine, USA by the co-existence of ISAV genotypes homologous to North American (NA) and European (EU) isolates. While NA ISAV genotypes isolated in Maine are characterized by high morbidity and mortality, the single EU genotype in Maine has not yet been linked to disease or isolated by cell culture. Consequently, distinguishing among genotypes is critical to infection response. Accuracy in NA genotype detection was estimated from ISA surveillance data using latent class models. Results suggested that RT-PCR is an excellent screening test for NA ISAV genotypes in Maine, although probably with reduced specificity in the presence of EU genotypes. IFAT, in contrast, was a poor screening test for detection of ISAV in Maine, although it may be useful in confirmation of NA genotypes during disease outbreaks.

Attempts to improve absolute quantification of cerebral blood flow in dynamic susceptibility contrast magnetic resonance imaging: a simplified T1-weighted steady-state cerebral blood volume approach

BACKGROUND

Attempts to retrieve absolute values of cerebral blood flow (CBF) by dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) have typically resulted in overestimations.

PURPOSE

To improve DSC-MRI CBF estimates by calibrating the DSC-MRI-based cerebral blood volume (CBV) with a corresponding T1-weighted (T1W) steady-state (ss) CBV estimate.

MATERIAL AND METHODS

17 volunteers were investigated by DSC-MRI and 133Xe SPECT. Steady-state CBV calculation, assuming no water exchange, was accomplished using signal values from blood and tissue, before and after contrast agent, obtained by T1W spin-echo imaging. Using steady-state and DSC-MRI CBV estimates, a calibration factor K = CBV(ss)/CBV(DSC) was obtained for each individual. Average whole-brain CBF(DSC) was calculated, and the corrected MRI-based CBF estimate was given by CBF(ss) = K x CBF(DSC).

RESULTS

Average whole-brain SPECT CBF was 40.1+/-6.9 ml/min x 100 g, while the corresponding uncorrected DSC-MRI-based value was 69.2+/-13.8 ml/min x 100 g. After correction with the calibration factor, a CBF(ss) of 42.7+/-14.0 ml/min x 100 g was obtained. The linear fit to CBF(ss)-versus-CBF(SPECT) data was close to proportionality (R = 0.52).

CONCLUSION

Calibration by steady-state CBV reduced the population average CBF to a reasonable level, and a modest linear correlation with the reference 133Xe SPECT technique was observed. Possible explanations for the limited accuracy are, for example, large-vessel partial-volume effects, low post-contrast signal enhancement in T1W images, and water-exchange effects.

Spatial and non-spatial risk factors associated with cage-level distribution of infectious salmon anaemia at three Atlantic salmon, Salmo salar L., farms in Maine, USA

The distribution of infectious salmon anaemia (ISA) was examined among 80 cages from three Atlantic salmon grow-out farms in Maine, USA that were stocked with smolts from a single hatchery. Cage-level disease was broadly defined as one or more moribund fish testing positive for infectious salmon anaemia virus (ISAV) by RT-PCR and a second confirmatory test (IFAT, culture or genotype sequence). Spatio-temporal and cage-level risks were explored using logistic regression and survival analysis. Non-spatial risk factors associated with ISA, or shortened survival time to disease, included increased predation, trucking company choice for smolt transfers, a finely-sedimented benthic substrate, and smaller average size of smolts at stocking. Univariable analysis identified the time-dependent spatial factor 'adjacency to newly infected cages' to be predictive of new infection in neighbouring cages 11-12 weeks later. However, none of the spatial factors, or their lags retained relevance in multiple-variable models. The results suggest a diffuse distribution of virus exposure throughout infected sites, with host-susceptibility factors probably influencing disease manifestation in individual cages. The narrow focus of the current study may limit application of the findings to other sites and year-classes. However, these data support the relevance of husbandry efforts to optimize fish health in regions affected by ISAV.

Efficacy of emamectin benzoate against sea lice infestations of Atlantic salmon, Salmo salar L.: evaluation in the absence of an untreated contemporary control

The efficacy of emamectin benzoate (SLICE) against sea lice infestations of Atlantic salmon, Salmo salar L., is typically assessed using untreated fish, or fish treated with alternative therapeutants, as controls. The State of Maine, USA, is currently under active management for the OIE-notifiable pathogen, infectious salmon anaemia virus (ISAV); consequently, neither control group is feasible in this region. Untreated salmon risk extensive damage from the ectoparasites, and threaten to increase vector-borne exposure or susceptibility of farms to ISAV; and the only treatment presently available in Maine is SLICE. However, because sea lice infestations are unlikely to resolve spontaneously, and response to treatment occurs within weeks, use of a pretreatment baseline is a reasonable alternative for confirmatory studies. We evaluated SLICE efficacy on Atlantic salmon farms in Cobscook Bay 2002-2005, in the absence of untreated controls, using pretreatment lice loads as a reference for calculation. Maximum efficacy ranged from 68% to 100% reduction from initial levels. Time-to-maximum efficacy ranged from 1 to 8 weeks after treatment initiation. Efficacy duration, measured between first reduction and first progressive rise in counts, ranged from 4 to 16 weeks.

Plasma homocysteine and markers of bone metabolism in psychogeriatric patients

OBJECTIVE

In recent studies high plasma total homocysteine (tHcy) levels were reported to be associated with increased risk of osteoporotic fractures. In elderly psychogeriatric patients there is a high frequency of elevated plasma tHcy concentration. The present study therefore investigates the association between plasma tHcy concentration and markers of bone metabolism in psychogeriatric patients.

MATERIAL AND METHODS

A total of 152 psychogeriatric patients were investigated and plasma tHcy and its major determinants (serum folate, serum cobalamin and renal function) were measured. Osteocalcin and crosslaps were chosen as markers of bone metabolism.

RESULTS

Bone markers (crosslaps and osteocalcin) were increased in elderly patients with dementia compared to patients without dementia. Stepwise multiple regression analysis showed that plasma tHcy concentration made only a small contribution to the prediction of crosslaps in serum, whereas plasma tHcy concentration was not an independent predictor of serum osteocalcin.

CONCLUSIONS

The present study does not provide support for the hypothesis that a moderately increased plasma tHcy concentration is a risk factor for impaired bone metabolism.

Dementia in first-degree relatives of patients with frontotemporal dementia. A family history study

Several studies have found a clustering of dementia in relatives of patients with frontotemporal dementia (FTD). This study analysed the familial aggregation of FTD specifically as well as the occurrence of dementia in general in first-degree relatives of patients with FTD. A family history study was carried out on 478 first-degree relatives of 74 index patients suffering from FTD. Cases of organic dementia and of FTD were diagnosed according to internationally accepted diagnostic criteria. Age- and sex-specific incidences of organic dementia and of FTD were calculated as was the proportion of FTD in relation to organic dementia in general; comparisons with clinical and population studies were made. There was a tenfold increase in the incidence of FTD in the first-degree relatives of FTD patients compared with the incidence of FTD in a population study. The proportion of FTD in relation to all types of organic dementia was much higher in relatives of FTD patients compared to the corresponding proportions in clinical and population-based studies. There was a small, non-significant difference between the present family history study and the population studies as regards the incidence of organic dementia. The findings suggest that hereditary and/or shared environmental factors are strongly involved in the aetiology of FTD. There were no indications of familial clustering of organic dementia in general in relatives of FTD patients.

Blood pressure and drug treatment in clinically diagnosed Lewy body dementia and Alzheimer's disease

The aim of the study was to investigate arterial blood pressure (BP) and the use of pharmacological treatment in patients with Lewy body dementia (cLBD) and Alzheimer's disease (cAD) diagnosed on clinical grounds. BP and pharmacological treatment was analysed based on the medical records of 200 deceased dementia patients. Forty-eight cases with LBD and 45 AD were diagnosed using clinical criteria. The patients, who died between 1985 and 1994, were part of a prospective longitudinal dementia project. The majority of the cases were examined and cared for at the psychogeriatric and psychiatric departments. BP levels were very similar at an early stage of dementia but there was a marked decrease during the course of dementia in cAD and cLBD. The cLBD cases became hypotensive during the course of dementia to a significantly greater extent and also had a more pronounced drop in systolic BP at orthostatic testing compared to the cAD cases. cLBD and cAD were prescribed neuroleptics and medication potentially associated with hypotension to the same extent. The total number of these drugs was however higher in cLBD than in cAD. Antiparkinsonian treatment was, as expected, more common in cLBD compared to cAD. The findings suggest that insufficient BP regulation and drug treatment could affect the clinical picture of dementia, particularly in cLBD patients.

Five-year outcome of cholinergic treatment of Alzheimer's disease: early response predicts prolonged time until nursing home placement, but does not alter life expectancy

Fifty consecutive outpatients with Alzheimer's disease (AD) received treatment with the cholinesterase inhibitor tacrine in an open longitudinal study. Assessments using Mini-Mental State Examination, Alzheimer's Disease Assessment Scale - cognitive subscale, and a global rating were made at baseline and at 6, 12, 24, 36, 48 and 60 months. Three outcome groups were characterized: responders, unchanged and deteriorated. Additional outcome measures were time until nursing home placement, and mortality rate. At 6 months -75%, at 12 months -42%, at 24 months -20%, and after that 10% of the patients still on medication had improved or remained stable. The mortality rate did not differ between the outcome groups. Response to tacrine treatment at 6 or 12 months was found to predict a prolonged time until nursing home placement. No predictors for a positive treatment response could be identified at baseline.

Subjective experience of memory deficits related to clinical and neuroimaging findings

The aim of this study was to evaluate cognitive impairment, psychiatric symptoms and cerebral blood flow (CBF) patterns in middle-aged (35-64 years) and younger old patients (65-74 years) with subjective experience of memory deficits. The study group was heterogeneous with patients fulfilling criteria for dementia, as well as patients with mild cognitive impairment (MCI) and with non-verified cognitive impairment (non-MCI). Seventy per cent of the non-MCI patients reported long-lasting experiences of psychosocial stress tentatively causing the memory problems. The MCI patients were subdivided into two groups: MCI type 1 included patients with isolated memory impairment, while MCI type 2 included patients with memory impairment together with slight verbal and/or visuospatial impairments. CBF measurements comparing the two MCI groups with the non-MCI group were performed. The MCI type 2 showed reduced CBF in the left anterior medial temporal lobe as well as in parts of the posterior cingulate gyrus. The CBF pattern in MCI type 2 concurs with the pathophysiological process of Alzheimer's disease. The results indicate that it is important to make a subdivision of MCI patients regarding the presence of isolated memory impairments or memory impairments together with other slight cognitive deficits.

Predictors of mortality in frontotemporal dementia: a retrospective study of the prognostic influence of pre-diagnostic features

OBJECTIVES

To find associations between predictors and survival in frontotemporal dementia (FTD).

METHODS

96 patients with FTD, here defined as Dementia in Pick's disease, were studied. The predictors included psychiatric/behavioural features, language impairment and neurological deficits present up to the time of diagnosis. The influence on mortality was studied by means of Cox regression analyses.

RESULTS

Most of the behavioural/psychiatric features were associated with longer survival. Among these features, anxiety and suicidal ideation were associated with a statistically significant decreased mortality. Semi-mutism/mutism and neurological deficits were associated with a statistically significant increased mortality. Analyses of the dementia-specific mortality strengthened the already significant results and revealed dysphagia as significantly related to increased mortality.

CONCLUSIONS

Two groups of predictors with different influence on survival were identified in FTD. Most behavioural/psychiatric features were associated with longer survival. These features may indicate a slower disease progress and a better preserved cerebral function. By contrast, semi-mutism/mutism, neurological deficits and dysphagia were associated with shorter survival, indicating an aggressive, degenerative process.

Evaluation of predictors of mortality in frontotemporal dementia-methodological aspects

OBJECTIVES

To retrospectively evaluate pre-diagnostic clinical features (predictors) of mortality in frontotemporal dementia (FTD). The main aim was to investigate if there were indications against interpreting missing data as signs of absence.

MATERIAL AND METHODS

96 cases with FTD, here defined as Dementia in Pick's disease according to ICD-10. The predictors were behavioural/psychiatric features, language impairment and neurological deficits up to the date of diagnosis. Each predictor was rated as present (Yes), absent (No) or not recorded (Missing), and evaluated according to its distribution and mortality pattern: if a feature was not recorded because it was absent, the mortality of the Missing and the No-category should hypothetically be close. Statistical methods included Kaplan-Meier survival curves and Cox regression analyses.

RESULTS

Neurological deficits and language impairments were frequently recorded as present or absent, while non-recordings were more prevalent among the behavioural/psychiatric features. Some features were excluded as predictors because they showed too little variation. Analyses of the survival pattern indicated that in some features, the observations of the Missing-category could be interpreted as absence of the symptoms. In other features these observations had to be regarded as truly missing.

CONCLUSIONS

In the retrospective evaluation of predictors of mortality a method for treating missing data was applied. The interpretation of non-recordings as signs of absence was supported by the analyses of the survival patterns in some of the studied features. However, the study underscores the importance of systematic estimations of pre-diagnostic clinical features in dementia.

Role of impaired renal function as a cause of elevated plasma homocysteine concentration in psychogeriatric patients

In previous studies a high frequency of elevated plasma tHcy concentrations has been observed in psychogeriatric patients (40-50%), but the main cause of these increased concentrations could not be established with certainty. Impaired renal function could partly contribute to elevated plasma tHcy concentrations in psychogeriatric patients. Therefore, in the present study, cystatin C was used as a sensitive marker for glomerular filtration. A linear regression analysis including age, blood folate, serum cobalamin, serum cystatin C and serum creatinine showed that only serum creatinine (p<0.001) and blood folate (p<0.001) independently predicted plasma tHcy concentration. However, about 44% of the patients with elevated plasma tHcy concentrations had signs of reduced glomerular filtration rate, as judged by increased serum cystatin C, whereas only about 13% of the patients with normal concentrations of plasma tHcy had signs of reduced glomerular filtration rate. This finding indicates that renal impairment may to some extent contribute to the elevated plasma tHcy concentration, even though serum cystatin C did not independently predict plasma tHcy concentration.

Contributions of other brain pathologies in dementia with lewy bodies

The clinical picture with its pathological correlate was analysed in 16 patients fulfilling consensus criteria for dementia with Lewy bodies (DLB). The cases were part of a larger cohort (n = 200) of patients within a prospective longitudinal study of dementing disorders. Six cases exhibited not only Lewy bodies (LBs) but also other brain pathologies such as Alzheimer changes, multiple infarcts or complete and incomplete white matter infarcts. Degeneration of the nucleus basalis of Meynert and substantia nigra was also seen. The 10 cases without LBs all had Alzheimer changes. In 7 cases, these changes were combined with mainly incomplete frontal white matter infarcts. However, the degeneration of brain stem nuclei was less pronounced in these cases. Symptoms such as fluctuations in cognition, falls and episodic confusion appeared in association with arterial hypotension, which developed during the course of dementia in almost all the 16 cases. The majority of the cases were treated with neuroleptics and other potentially hypotensive medication. This study shows that multiple and different pathological features may contribute to a clinical symptom constellation as in DLB. The case study approach reveals the complexity of the clinico-pathological relationships in dementia that might otherwise be lost in the analysis of larger group data.

Barriers to the use of electroconvulsive therapy in the elderly: a European survey

A postal survey was carried out to determine the clinical and legal guidelines governing the use of electroconvulsive therapy (ECT) in the countries of the wider Europe. Respondents from 23 of the 33 countries returned completed questionnaires. Considerable variation was found in the availability of ECT, the frequency of its use and associated legal procedures. However, there was a broad consensus with regard to the clinical indications. Access to the treatment was most frequently limited by financial or other resource constraints, political or legal restrictions.

Markers for the functional availability of cobalamin/folate and their association with neuropsychiatric symptoms in the elderly

Cobalamin/folate deficiency is common in elderly subjects and may lead to psychiatric symptoms, but even more often it increases the severity of other organic and non-organic mental diseases. This paper reviews the literature relevant for markers of cobalamin/folate status and their relation to neuropsychiatric symptoms in the elderly. Plasma homocysteine, a marker of cobalamin/folate status, is frequently increased in psychogeriatric patients. Among markers of cobalamin/folate status, plasma homocysteine shows the best association with neuropsychiatric dysfunction.

[Harmonization of dementia diagnoses--a necessary quality assurance]

Classification and registration of diseases is necessary in order to monitor the proliferation of diseases in a population. Despite the presence of an international framework for classification of diseases (ICD 10) which has been approved by the Swedish authorities, the guidelines provided are not observed in the area of dementia diseases. Different diagnoses can be used to describe the same condition, and "dementia unspecified" is sometimes employed when a specified diagnosis could have been used. In order to refine consensus regarding the use of different diagnoses in the dementia field, representatives for the Swedish University hospitals and medical faculties propose a unified description of a limited number of dementia diagnoses.

Neuropathological correlates to clinically defined dementia with Lewy bodies

OBJECTIVES

To analyse the neuropathological changes behind clinically defined dementia with Lewy bodies (clinDLB) compared with clinically diagnosed Alzheimer's disease (clinAD).

METHODS

The prevalence of neuropathological findings in 48 clinDLB and 45 clinAD cases was compared. Sixteen clinDLB and 10 clinAD cases were reassessed with alpha-synuclein staining for Lewy bodies (LB).

RESULTS

Alzheimer pathology was found in 81% of the clinDLB and 93% of the clinAD cases. The clinDLB group had a higher prevalence of frontal white matter pathology, mostly of ischemic type, and a more severe degeneration of the substantia nigra compared with the clinAD group. In hematoxylin-eosin staining, LBs were identified in seven (15%) of the clinDLB and in four (9%) of the clinAD group. In alpha-synuclein staining, 38% of the clinDLB and 40% of the clinAD cases exhibited LBs. The cases without LBs, in the clinDLB group, had AD pathology in combination with frontal white matter disease. Vascular pathology of significant degree was prevalent in more than 40% of all the cases with verified LBs regardless of clinical diagnosis.

CONCLUSION

Consecutive dementia cases, fulfilling the clinical consensus criteria for DLB, may exhibit combinations of neuropathological changes which in themselves can explain the clinical picture of DLB even when LBs are absent.

Improvement of cognitive functions after cobalamin/folate supplementation in elderly patients with dementia and elevated plasma homocysteine

OBJECTIVES

To investigate the effect of cobalamin/folate supplementation on cognitive function in elderly patients with dementia.

METHOD

The cobalamin/folate status of the patients was evaluated by measuring plasma homocysteine, serum methylmalonic acid, serum cobalamin and blood folate. Thirty-three patients were studied and repeatedly assessed with the Mini-Mental State Examination (MMSE) and 'A short cognitive performance test for assessing memory and attention' (SKT) during vitamin substitution.

RESULTS

Patients with mild-moderate dementia and elevated plasma homocysteine levels improved clinically with increased test scores after vitamin substitution, while severely demented patients and patients with normal plasma homocysteine levels did not improve clinically.

CONCLUSIONS

Plasma homocysteine may be the best marker for detecting treatable cobalamin/folate deficiency in patients with dementia.

Acute confusional state in elderly orthopaedic patients: factors of importance for detection in nursing care

OBJECTIVES

The aims of this study were to identify factors of significance in the development of acute confusional state (ACS) and the differences between patients who developed ACS and those who did not.

METHOD AND RESULTS

Assessment, observations and interviews with 505 patients admitted to an orthopaedic clinic revealed that 51 patients developed ACS during their in-hospital stay. Patients admitted for hip fracture had a higher incidence of ACS (20.2%) than patients admitted for elective surgery for coxarthros or gonarthros (3.6%). The highest hazard ratio for ACS was several other physical diseases 15.94 (CI: 4.60-55.31 and p-value <0.00001) and the lowest was age 1.10 (CI: 1.04-1.15 and p-value <0.0002). The ACS lasted from 1 to 9 days, and patients had one (N=42), two (N=8) or three episodes (N=1) of confusion during their stay on the ward. More patients who developed ACS before surgery had two or more confusional episodes and emergency patients developed ACS more rapidly. The ACS lasted longer in patients with a higher score on the OBS scale at admittance and with rapid development of ACS.

CONCLUSIONS

Acuteness in the situation seems an important risk indication for ACS in the elderly. Awareness of factors associated with the development of ACS makes it possible to more systematically identify those at risk, for instance by systematic assessment in the first interview with the patient on admission to hospital.

[Homocysteine and methylmalonic acid as markers of cobalamin/folate status. The association to neuropsychiatric symptoms in the elderly is explored]

Cobalamin/folate deficiency in elderly subjects may lead to psychiatric symptoms. Most studies concerning the relation between mental disorders in the elderly and deficiencies of cobalamin and folate have used methods that determine the blood concentrations of these vitamins, which might not reflect vitamin status in the tissues. Two new markers, plasma homocysteine and serum methylmalonic acid, have attracted growing interest since they are considered to reflect the functional status of cobalamins and folates in the tissues. This review summarizes present findings concerning the different markers for cobalamin/folate deficiency as well as their association with functional parameters of the central nervous system such as cognitive and behavioral performance. Plasma homocysteine seems to be much more closely associated with neuropsychiatric dysfunction than is plasma methylmalonic acid.

Frontotemporal dementia can be distinguished from Alzheimer's disease and subcortical white matter dementia by an anterior-to-posterior rCBF-SPET ratio

Sixteen patients with frontotemporal dementia (FTD), 27 with early-onset Alzheimer's disease, 25 with late-onset Alzheimer's disease, 19 with subcortical white matter dementia (SWD) and 28 normal controls underwent semiquantitative regional cerebral blood flow measurement (rCBF) using single-photon emission tomography (SPET; (99m)Tc-HMPAO) and either computerized tomography (CT) or magnetic resonance imaging (MRI) of the brain. An anterior-to-posterior rCBF-SPET ratio (mesial superior frontal gyrus/medial temporal lobes) was calculated, which significantly separated the FTD group from the other dementia groups and controls with a sensitivity of 87.5% and a specificity of at least 78.6%. CT/MRI was found to be helpful in the differential diagnosis between FTD and SWD. In FTD patients, the mesial superior frontal gyrus, near the polus frontalis, was found to be the region with the most reduced rCBF values.

[Inventory of geriatric psychiatry in Sweden. In short supply where demand does not determine resource allocation]

In 1999 The Swedish Society for Old Age Psychiatry conducted an investigation in all Swedish counties in order to survey existing organizations and resources for medical services intended for elderly people with psychiatric complaints. In some counties there were no out-patient units specifically aimed at elderly people with psychiatric diseases, while more than half had no out-patient units for the large group of elderly with psychiatric ailments other than dementia. The total number of beds was far less than international recommendations. Less than 5 per cent of the total number of Swedish psychiatrists and geriatricians hold positions exclusively for geriatric psychiatry. Access to geriatric psychiatry resources appears to be unevenly distributed, and may be found mainly in or near university cities.

Treatment of cobalamin deficiency in dementia, evaluated clinically and with cerebral blood flow measurements

We investigated the relation between cobalamin deficiency, clinical changes and brain function in dementia patients. On admittance to the clinic, 24 patients had cobalamin deficiency, and dementia with additional symptoms of delirium. During cobalamin supplementation, the patients underwent repeated regional cerebral blood flow (rCBF) studies, psychiatric evaluations, and in some cases assessment with MMSE and the Organic Brain Syndrome scale. Fifteen patients who showed mild to moderate dementia improved clinically, and also showed a concomitant increase in their general CBF after treatment. In contrast, 9 patients who were severely demented showed no obvious clinical improvement, and no general blood flow change, although some regional flow increases were seen in sensory motor areas. We conclude that symptoms which probably indicated superimposed delirium such as clouding of consciousness, disorientation and clinical fluctuation, responded to the vitamin B12 supplementation, while the underlying dementia condition remained basically unchanged. The clinical improvement was also mirrored in general and focal rCBF changes.

The plasma homocysteine concentration is better than that of serum methylmalonic acid as a marker for sociopsychological performance in a psychogeriatric population

BACKGROUND

Cobalamin/folate deficiency in elderly subjects may lead to psychiatric symptoms, but more often it increases the severity of various organic and nonorganic mental diseases. A major clinical problem, however, is the uncertainty and controversy concerning biochemical markers of cobalamin/folate deficiency to be used in the diagnostic evaluation of suspected cobalamin/folate deficiency.

METHODS

We measured plasma homocysteine (tHcy), blood folate, serum methylmalonic acid, and serum cobalamin in 80 psychogeriatric patients (age, 77.3 +/- 8.6 years) and 50 controls (age, 76.1 +/- 8. 0 years). We assessed associations of these tests with measures of cognitive and behavior performance by use of regression analyses.

RESULTS

Plasma tHcy was increased in 45% of the psychogeriatric population (mean, 20.5 +/- 9.2 micromol/L vs 15.3 +/- 4.7 micromol/L for controls; P <0.01). Plasma tHcy correlated with severity of dementia (r = 0.36; P <0.01), the Katz ADL index (r = 0.29; P <0.05), the Berger scale (r = 0.29; P <0.05), and the score of symptoms (r = 0.39; P <0.001) in the psychogeriatric population. Similarly, blood folate was significantly correlated with these measures, but the concentrations of serum cobalamin and methylmalonic acid were not. In a stepwise multiple regression analysis including the biochemical markers, tHcy was the only significant predictor of the severity of dementia (r(2) = 0.11; P <0.01) and the score of symptoms (r(2) = 0.16; P <0.001).

CONCLUSION

Plasma tHcy is the best marker of those measured to investigate suspected tissue deficiency of cobalamin/folate.

Magnetic resonance imaging and histopathology in dementia, clinically of frontotemporal type

The magnetic resonance imaging (MRI) and computed tomography findings in 28 patients with the clinical diagnosis of frontotemporal dementia (FTD) were compared with the findings in a control group of 76 individuals without dementia or stroke. A pattern of frontal and temporal atrophy with predominantly frontal white matter changes was found in the FTD patients, and this was significantly different from the radiological findings in the control group. Six of the FTD patients have undergone autopsy. Histopathological evaluation showed a primary cortical degenerative disease (frontal lobe degeneration of non-Alzheimer type) in 3 of them, and primary white matter disorder, mainly frontal, of basically ischemic type (selective incomplete white matter infarction) in 3 of them. MRI could be a helpful tool to support the clinical diagnosis FTD, especially in young patients. MRI may also be helpful for the differentiation of a primary neurodegenerative from a mainly ischemic-vascular type of dementia.

Clinical Lewy body dementia and the impact of vascular components

OBJECTIVE

To study the prevalence of patients fulfilling the clinical consensus criteria for dementia with Lewy bodies (DLB) in a dementia population followed up with postmortem examination. To compare the clinical and neuropathological findings in the clinical Lewy body dementia (LBD) group with findings in a clinically defined group with Alzheimer's disease (AD).

DESIGN

Medical records from 200 patients were studied retrospectively. Clinical consensus criteria for DLB and clinical criteria for other dementias were applied.

SETTING

The majority of the cases were examined and cared for in psychogeriatric and psychiatric departments.

PATIENTS

The patients, who died between 1985 and 1994, were part of a longitudinal dementia project. Each case was neuropathologically examined. Main outcome measures Prevalence of clinical signs and neuropathology was compared between the clinical groups.

RESULTS

Forty-eight (24%) patients fulfilled the clinical criteria for DLB while 45 (22%) fulfilled the clinical criteria for Alzheimer's disease. The clinical LBD group had a higher Hachinski score compared to the clinical AD group. They also showed a tendency towards a 'frontal profile' with disinhibition, confusion, personality change and vocally disruptive behaviour. More than 80% of the AD and LBD groups respectively exhibited Alzheimer pathology. The LBD group had frontal white matter pathology and degeneration of the substantia nigra more often than the clinical AD group. Both LBD and AD groups showed a progressive and marked increase in severity of dementia and decrease in ADL capacity according to an evaluation based on the Berger scale and Katz index. The condition of the LBD group was significantly worse earlier in dementia.

CONCLUSION

The results of this study indicate that patients fulfilling the clinical criteria for DLB also exhibit clinical features of possible vascular origin and a frontal profile. Subcortical vascular pathology, nigral degeneration and AD pathology in this group could partly explain the clinical features used to define DLB.

Plasma homocysteine is a sensitive marker for tissue deficiency of both cobalamines and folates in a psychogeriatric population

The concentration of blood folates was decreased and the concentration of plasma homocysteine was increased in a psychogeriatric population, whereas the concentrations of methylmalonic acid or serum cobalamins were not changed compared with healthy subjects. The highest frequency of abnormal values was shown by plasma homocysteine concentration, which was increased in 88 of 168 patients. In 29 of these 88 patients increased concentration of plasma homocysteine could possibly be attributed to tissue cobalamin deficiency. One patient had only a lowered concentration of blood folate. Thirteen patients had elevated concentrations of serum creatinine which could explain increased plasma homocysteine concentration. Even if the remaining patients (n = 45) had normal vitamin levels in circulation, the increased plasma homocysteine concentration in most cases must be attributed to tissue deficiency of cobalamins and/or folates. Thus, many patients with increased plasma homocysteine concentrations need further vitamin supplementation despite their normal vitamin levels in serum and blood. Copyrightz1999S.KargerAG,Basel

Brain function in spider phobia

Measurements of regional cerebral blood flow (rCBF) were performed in 16 women suffering from spider phobia. The non-invasive 133Xe inhalation method, giving information about the blood flow of superficial areas, was used. The subjects were studied under three conditions: during resting, when exposed to a videotape showing nature scenery, and finally when watching a video with living spiders. During the rCBF measurements the subjects' behaviour was registered systematically and respiration, blood pressure, Pco2, and heart rate were monitored. Eight subjects who showed and reported severe panic during the spider exposure had marked rCBF decreases in frontal areas, especially in the right hemisphere. The remaining eight subjects displayed a more efficient control of their emotions and became frightened, but not panic-stricken, during the spider exposure. These showed a consistent rCBF increase in the right frontal area compared to neutral stimulation. Thus, results revealed significant functional changes in the frontal cortex in subjects with spider phobia during phobogenic exposure. It seems likely that these frontal changes are related to the experience and control of phobic anxiety.

Frontotemporal lobar degeneration: a consensus on clinical diagnostic criteria

OBJECTIVE

To improve clinical recognition and provide research diagnostic criteria for three clinical syndromes associated with frontotemporal lobar degeneration.

METHODS

Consensus criteria for the three prototypic syndromes-frontotemporal dementia, progressive nonfluent aphasia, and semantic dementia-were developed by members of an international workshop on frontotemporal lobar degeneration. These criteria build on earlier published clinical diagnostic guidelines for frontotemporal dementia produced by some of the workshop members.

RESULTS

The consensus criteria specify core and supportive features for each of the three prototypic clinical syndromes and provide broad inclusion and exclusion criteria for the generic entity of frontotemporal lobar degeneration. The criteria are presented in lists, and operational definitions for features are provided in the text.

CONCLUSIONS

The criteria ought to provide the foundation for research work into the neuropsychology, neuropathology, genetics, molecular biology, and epidemiology of these important clinical disorders that account for a substantial proportion of cases of primary degenerative dementia occurring before the age of 65 years.

No impaired cognitive function in treated patients with mild-moderate hypertension compared to normotensive controls

Hypertension is a predictor for impaired cognitive function and dementia in several prospective studies. It is currently under debate whether treatment of hypertension, and thus blood pressure lowering, is another risk factor for cognitive decline. We recruited a sample of 123 treated hypertensive patients and 76 normotensive controls, from a population-based study in primary health care, for screening of blood pressure, metabolic variables and cognitive function, as measured by the Mini-Mental State Examination (MMSE). Treated hypertensives had higher blood pressure but did not differ in cognitive function from the normotensives. Neither educational level nor metabolic variables confounded the findings. In conclusion, treated hypertensives did not differ in cognitive function from normotensive controls. This does not support the notion that pharmacological blood pressure reduction impairs cognitive function.