CCRG-01. KAT5 ACTIVITY REGULATES G0-LIKE STATES IN HUMAN GLIOMAS

Glioblastoma, the most aggressive type of primary brain cancer, benefits little from standard of care therapy. Over the past few decades not much advancement has been made in improving the recurrence-free survival after treatment, with a median survival period of 15 month from diagnostic. G0-like states are thought to act a reservoir for tumor recurrence after treatment in glioblastoma. Targeting G0 states in glioblastoma poses an attractive therapeutic approach, however, little progress has been made in the field, likely due to poorly understood mechanisms that regulate G0 ingress and egress. To find regulators of G0 states, we performed a genome-wide CRISPR-Cas9 screen of patient-derived glioblastoma stem cells. We identified KAT5, a histone acetyltransferase coding gene which is the catalytic subunit of the histone acetyltransferase complex NuA4, as an important candidate for regulating G0 ingress and egress. We found that in primary gliomas, KAT5-low cells display G0-like properties, while overall KAT5 activity increases from low to high grade tumors. To study G0 states in glioblastoma, we have engineered an inducible KAT5 system that functions as a fully tunable model system, where we can control expression of KAT5 and, therefore, effectively control glioma cell entry and exit from G0-like states. We provide evidence that G0-like states are characterized by hypoacetylated histones and low protein synthesis rates, which remarkably induces shifts in cell state reminiscent of dedifferentiation and acquisition of stem-like behavior. Our work demonstrates that regulation of G0 like states may be coupled to the generation of tumor heterogeneity and, more importantly, suggests a potential strategy whereby inhibiting KAT5 activity could effectively "down grade" GBM tumors by lengthening residence time in G0-like states, significantly increasing survival times. For these studies we will present a variety of techniques, including single cell RNA-seq to characterize cellular subpopulations in tumors and GBM stem-like cell cultures.

Global and context-specific transcriptional consequences of oncogenic Fbw7 mutations

The Fbw7 ubiquitin ligase targets many proteins for proteasomal degradation, which include oncogenic transcription factors (TFs) (e.g., c-Myc, c-Jun, and Notch). Fbw7 is a tumor suppressor and tumors often contain mutations in FBXW7, the gene that encodes Fbw7. The complexity of its substrate network has obscured the mechanisms of Fbw7-associated tumorigenesis, yet this understanding is needed for developing therapies. We used an integrated approach employing RNA-Seq and high-resolution mapping (cleavage under target and release using nuclease) of histone modifications and TF occupancy (c-Jun and c-Myc) to examine the combinatorial effects of misregulated Fbw7 substrates in colorectal cancer (CRC) cells with engineered tumor-associated FBXW7 null or missense mutations. Both Fbw7 mutations caused widespread transcriptional changes associated with active chromatin and altered TF occupancy: some were common to both Fbw7 mutant cell lines, whereas others were mutation specific. We identified loci where both Jun and Myc were coregulated by Fbw7, suggesting that substrates may have synergistic effects. One coregulated gene was CIITA, the master regulator of MHC Class II gene expression. Fbw7 loss increased MHC Class II expression and Fbw7 mutations were correlated with increased CIITA expression in TCGA colorectal tumors and cell lines, which may have immunotherapeutic implications for Fbw7-associated cancers. Analogous studies in neural stem cells in which FBXW7 had been acutely deleted closely mirrored the results in CRC cells. Gene set enrichment analyses revealed Fbw7-associated pathways that were conserved across both cell types that may reflect fundamental Fbw7 functions. These analyses provide a framework for understanding normal and neoplastic context-specific Fbw7 functions.

CBIO-12. KAT5 ACTIVITY CONTROLS GLIOBLASTOMA CELL CYCLE DYNAMICS AND TUMOR GROWTH

Current standard of care therapy for glioblastoma (GB) includes cytoreduction followed by ablative therapies that target rapidly dividing cell types. However, non-cycling, quiescent-like states (G0 phase cells) are present in both normal tissue and tumors and play important roles in maintaining heterogeneity and cellular hierarchies. The presence of quiescent-like/G0 states therefore represents a natural reservoir of tumor cells that are resistant to current treatments. Quiescence or G0 phase is a reversible state of “stasis” cells enter in response to developmental or environmental cues. However, it remains largely unclear to what degree or by what mechanisms tumor cells enter into or exit from quiescent-like states. To gain insight into how GB cells might regulate G0-like states, we performed a genome-wide CRISPR-Cas9 screen in patient-derived GB stem-like cells (GSCs) harboring a G0 reporter construct, which is stabilized when cells enter a G0-like state. Among the top screen hits were members of the Tip60/KAT5 histone acetyltransferase complex, including KAT5 itself. Remarkably, we show that knockout of KAT5 in vitro and in vivo dramatically increases G0 subpopulations in GSC cultures and GSC-induced tumors. Using genetically engineered GSC harboring KAT5 under the control of a Doxycyclin-titratable promoter, we establish that incrementally down regulating KAT5 activity is sufficient to slow cell cycle dynamics causing a build-up G0-like cells; and that partial inhibition of KAT5 leads to extended (mouse) patient survival. Further, in primary tumors, cell-based KAT5 activity assays revealed that high grade tumors harbor larger cell subpopulations with higher KAT5 activity than lower grade tumors. In summary, our results suggest that Tip60/KAT5 activity plays key roles in G0 ingress/egress for GBM tumors, may contribute to tumor progression, and may provide novel therapeutic opportunities.

CBIO-19. LOW GLOBAL HISTONE H4 ACETYLATION LEVELS REVEAL CANDIDATE QUIESCENT CELL POPULATIONS IN GLIOMA AND DISTINGUISH TUMORS BY GRADE

Current standard of care therapy for glioblastoma (GBM) includes cytoreduction followed by ablative therapies that target rapidly dividing cell types. However, the presence of quiescent-like/G0 states, therefore, represents a natural reservoir of tumor cells that are resistant to current treatments. Quiescence or G0 phase is a reversible state of “stasis” cells enter in response to developmental or environmental cues. To gain insight into how glioblastoma cells might regulate G0-like states, we performed a genome-wide CRISPR-Cas9 screen in patient-derived GBM stem-like cells (GSCs) harboring a G0-reporter to identify genes that when inhibited trap GSCs in G0-like states. Among the top screen hits were members of the Tip60/KAT5 histone acetyltransferase complex, which targets both histones (e.g., H4) and non-histone proteins for acetylation. NuA4 functions as a transcriptional activator, whose activities are coordinated with MYC in certain contexts, and also participates in DNA double-strand break repair by facilitating chromatin opening. However, currently little is known about the roles for NuA4 complex in GBM biology. Through modeling KAT5 function in GSC in vitro cultures and in vivo tumors, we find that KAT5 inhibition causes cells to arrest in a G0-like state with high p27 levels, G1-phase DNA content, low protein synthesis rates, low rRNA rates, lower metabolic rate, suppression of cell cycle gene expression, and low histone H4 acetylation. Interestingly, partial inhibition of KAT5 activity slows highly aggressive tumor growth, while increasing p27hi H4-aclow populations. Remarkably, we that low grade gliomas have significantly higher H4-aclow subpopulations and generally lower H4-ac levels than aggressive grade IV tumors. Taken together, our results suggest that NuA4/KAT5 activity may play a key role in quiescence ingress/egress in glioma and that targeting its activity in high grade tumors may effectively “down grade” them, thus, increase patient survival.

Histone deposition pathways determine the chromatin landscapes of H3.1 and H3.3 K27M oncohistones

Lysine 27-to-methionine (K27M) mutations in the H3.1 or H3.3 histone genes are characteristic of pediatric diffuse midline gliomas (DMGs). These oncohistone mutations dominantly inhibit histone H3K27 trimethylation and silencing, but it is unknown how oncohistone type affects gliomagenesis. We show that the genomic distributions of H3.1 and H3.3 oncohistones in human patient-derived DMG cells are consistent with the DNAreplication-coupled deposition of histone H3.1 and the predominant replication-independent deposition of histone H3.3. Although H3K27 trimethylation is reduced for both oncohistone types, H3.3K27M-bearing cells retain some domains, and only H3.1K27M-bearing cells lack H3K27 trimethylation. Neither oncohistone interferes with PRC2 binding. Using Drosophila as a model, we demonstrate that inhibition of H3K27 trimethylation occurs only when H3K27M oncohistones are deposited into chromatin and only when expressed in cycling cells. We propose that oncohistones inhibit the H3K27 methyltransferase as chromatin patterns are being duplicated in proliferating cells, predisposing them to tumorigenesis.

GENE-10. A SIMPLE AND EFFICIENT METHOD FOR GENERATING MULTI-ALLELIC INSERTION-DELETION MUTATIONS AND PRECISE DELETIONS IN PRIMARY HUMAN CELL CULTURES

CRISPR-Cas9-based technologies have revolutionized experimental manipulation of the human genome by enabling generation of site-specific genetic alterations, such as insertion-deletion (indel) mutations. None-the-less, limitations of the delivery and efficacy of these technologies restrict their application in primary human cells. Here, we present a simple and effective method for fast and penetrant induction of multi-allelic indels and near-precise deletions (ranging from ~50bp to >50kbp) in primary human neural stem/progenitor cell (NPC) and brain tumor-derived stem-like cell cultures using the CRISPR-Cas9 system. We report that mono-, bi-, or multi-allelic (depending on ploidy) indel efficiencies of >90% can be routinely achieved within 3 days, without the need for pre-engineering cells to express Cas9 or isolating clones. As a result, this method enables the quick generation of a series of knockouts at different genomic loci, which we illustrate by successively targeting TP53, CDKN2A, PTEN, and NF1 in human NPC populations, where ³95% loss of protein expression is observed. RNA-seq analysis of these NPC knockout pools confirmed gene expression changes including p53 transcriptional and Rb-axis targets, as well as NF1-dependent repression of major histocompatibility complex class II gene expression. Given its simplicity, this method is readily adaptable to other primary mammalian cell types.

CBMT-42. A GENOME-WIDE CRISPR-Cas9 SCREEN FOR GENES REGULATING QUIESCENT-LIKE STATES IN GLIOBLASTOMA

Current standard of care therapy for glioblastoma (GBM) includes cytoreduction followed by ablative therapies that target rapidly dividing cell types. However, non-cycling, quiescent-like states (G0 phase cells) are present in both normal tissue and tumors and play important roles in maintaining heterogeneity and cellular hierarchies. The presence of quiescent-like/G0 states therefore represents a natural reservoir of tumor cells that are resistant to current treatments. Quiescence or G0 phase is a reversible state of “stasis” cells enter in response to developmental or environmental cues. However, it remains largely unclear to what degree or by what mechanisms tumor cells enter into or exit from quiescent-like states. To gain insight into how glioblastoma cells might regulate G0-like states, we performed a genome-wide CRISPR-Cas9 screen in patient-derived GBM stem-like cells (GSCs) harboring a p27-mVenus reporter construct, which is stabilized when cells enter a G0-like state. By assaying p27 reporteractivity, we were able to identify sgRNAs enriched in p27hipopulations and, which upon retest, trigger a G0-like arrest in GSCs. Among the top screen hits were members of the Tip60/KAT5 histone acetyltransferase complex, including KAT5 itself. Remarkably, we show that downregulation of KAT5 in vitro and in vivo dramatically increases the pool of cells in G0-like states in GSC cultures and GSC-induced tumors. Using single cell RNA-sequencing, we show that this cell state is characterized by gene expression signatures similar to those found in non-dividing subpopulations of GBM tumors and quiescent neural stem cells. In addition, we perform in-depth molecular and phenotypic characterization of these induced G0-like states, including epigenetic and metabolic profiles. These suggest a key role for KAT5 in regulating genes related to protein synthesis. In summary, our results suggest that Tip60/KAT5 activity plays key roles in G0 ingress/egress for GBM tumors and may provide novel therapeutic opportunities.

STEM-05. NEURAL G0: A NOVEL QUIESCENT-LIKE STATE IN PROLIFERATING HUMAN NEURAL STEM AND GLIOBLASTOMA TUMOR CELLS

Single cell (sc) genomic technologies are rapidly transforming our understanding of cellular states in normal and diseased tissues. Here, we applied scRNA-seq to cultures of proliferating human neural stem cells (NSCs) to better understand the relationship between cell cycle dynamics and developmental gene expression. This analysis revealed both conventional cell cycle states (S, G2, M) and novel G1 and G0-like states. Of note, we identified a Neural G0 phase representing a subpopulation enriched for expression of genes associated with adult quiescent NSCs, including CLU, HOPX, ID3, OLIG2, PTN, SYT11, S100B, SOX9, PTPRZ1, and TTYH1. Remarkably, by applying our hNSC cell cycle phase classifier to human glioblastoma (GBM) tumors, we found that Neural G0 subpopulations as a prominent tumor-specific cellular subclass of GBM tumors, which, similar to NSCs, does not overlap with proliferative cell cycle phases. We further identified modulators of Neural G0 via CRISPR-Cas9 screens, revealing highly significant enrichment for tumor suppressor genes associated with brain tumors. In depth analysis of five of these Neural G0 modulatory genes, including CREBBP, NF2, PTPN14, TAOK1, or TP53, revealed that they promote compartmentalization of G0/G1 phase and expression of genes associated with Neural G0. Our results suggest that Neural G0 is a dynamic cell state in mammalian NSCs, that a subset of GBM cells maintain and is modulated by genes commonly found altered in GBM.

Evaluation of anaerobic digestion post-treatment options using an integrated model-based approach

The objective of this paper is to present the main results of an engineering-research project dealing with model-based evaluation of waste streams treatment from a biotech company. This has been extensively done in domestic treatment systems, but is equally important, and with different challenges in industrial wastewater treatment. A new set of biological (activated sludge, anaerobic digestion), physicochemical (aqueous phase, precipitation, mass transfer) process models and model interfaces are required to describe removal of organics in an upflow anaerobic sludge blanket (UASB) reactor plus either traditional nitrification/denitrification (A₁) or partial nitritation (PN)/anammox (ANX) (A₂) processes. Model-based analysis shows that option A₁ requires a decrease in digestion energy recovery (E_recovery) in order to have enough organic substrate for subsequent post NO₃ reduction treatment (95 kWh.kg N^-1). In contrast, A₂ in an aerobic granular sludge reactor allows for higher UASB conversion since N removal is carried out autotrophically. The study also reveals that the addition of an aerated pre-treatment unit prior to the PN/ANX (A₂) reactor promotes COD and H₂S oxidation, CO₂ and CH₄ stripping, a pH increase (up to 8.5) and a reduction of the risk of intra-granular precipitation as well as sulfide inhibition. Simulations indicate clear differences regarding the microbial distribution/abundance within the biofilm in A₂ when comparing the two operational modes. Final results show the effects of different loading and operational conditions; dissolved oxygen (DO), Total Suspended Solids (TSS_op), energy recovery (E_recovery); on the overall process performance; N removal, aeration energy (E_aeration), net energy production (E_recovery); using response surfaces, highlighting the need of integrated approaches to avoid sub-optimal outcomes. The study shows the benefits of virtual plant simulation and demonstrates the potential of model-based evaluation when process engineers in industry have to decide between competing options.

Assessing the effects of intra-granule precipitation in a full-scale industrial anaerobic digester

In this paper, a multi-scale model is used to assess the multiple mineral precipitation potential in a full-scale anaerobic granular sludge system. Reactor behaviour is analysed under different operational conditions (addition/no addition of reject water from dewatering of lime-stabilized biomass) and periods of time (short/long term). Model predictions suggest that a higher contribution of reject water promotes the risk of intra-granule CaCO₃ formation as a result of the increased quantity of calcium arriving with that stream combined with strong pH gradients within the biofilm. The distribution of these precipitates depends on: (i) reactor height; and (ii) granule size. The study also exposes the potential undesirable effects of the long-term addition of reject water (a decrease in energy recovery of 20% over a 100-day period), caused by loss in biomass activity (due to microbial displacement), and the reduced buffer capacity. This demonstrates how both short-term and long-term operational conditions may affect the formation of precipitates within anaerobic granules, and how it may influence methane production and consequently energy recovery.

Abstract 413: Emerging principles in synthetic lethality in glioblastoma

Synthetic lethality occurs when mutations in two otherwise nonessential genes are combined to cause lethality. Because cancer is a disease of genetic alteration, synthetic lethality has been heralded as a method to identity candidate therapeutic targets, e.g., where a target gene could be "synthetic lethal" with a cancer driver mutation. To define synthetic lethal relationships in glioblastoma (GBM), we have performed multiple focused-set and genome-wide CRISPR-Cas9 lethality screens in patient-derived GBM stem-like cells (GSCs) and nontransformed human neural progenitor cells. Because GSCs isolates likely represent a sub-clone of the original tumor and we can determine GSCs' genetic and epigenetic makeup, it is possible to address the concept of synthetic lethality for GBM. To this end, we recently performed comprehensive CRISPR-Cas9 retests of all scoring GBM lethal genes (>900) from screens in three patient isolates with different and overlapping genetic drivers. We then performed secondary retests of high-priority gene targets in 13 GSC harboring various alterations commonly found in GBMs, e.g., EGFRamp, NF1mut, PIK3CAmut, PTENloss/mut, TP53mut, etc. The results were surprising, first in what we did not find. We failed to find synthetic lethal targets for TP53loss/mut, RB1mut, or TERT expression, suggesting that synthetic lethal relationships for these alterations may not exist for GBM. Second, NF1mut interactors defined a broader class of synthetic lethal targets with general overactivity of the RTK/Ras pathway, which can arise from various activating lesions. Third, candidate synthetic lethal relationships can be observed, but, so far, only with EGFRamp, MYC/MYCNamp, and PTEN/PIK3CA alterations. Thus, in general our results suggest that the majority of synthetic lethal relationships in GBM arise from oncogenic activation of the RTK/Ras and PI-3 kinase pathway or amplification of MYC/MYCN. (Synthetic lethal targets will be revealed and discussed at the meeting.)

Citation Format: Pia Hoellerbauer, Sonali Arora, Megan Kufeld, Lucas Carter, Emily J. Girard, Heather Feldman, Philip Corrin, James M. Olson, Patrick J. Paddison. Emerging principles in synthetic lethality in glioblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 413.

Modelling an industrial anaerobic granular reactor using a multi-scale approach

The objective of this paper is to show the results of an industrial project dealing with modelling of anaerobic digesters. A multi-scale mathematical approach is developed to describe reactor hydrodynamics, granule growth/distribution and microbial competition/inhibition for substrate/space within the biofilm. The main biochemical and physico-chemical processes in the model are based on the Anaerobic Digestion Model No 1 (ADM1) extended with the fate of phosphorus (P), sulfur (S) and ethanol (Et-OH). Wastewater dynamic conditions are reproduced and data frequency increased using the Benchmark Simulation Model No 2 (BSM2) influent generator. All models are tested using two plant data sets corresponding to different operational periods (#D1, #D2). Simulation results reveal that the proposed approach can satisfactorily describe the transformation of organics, nutrients and minerals, the production of methane, carbon dioxide and sulfide and the potential formation of precipitates within the bulk (average deviation between computer simulations and measurements for both #D1, #D2 is around 10%). Model predictions suggest a stratified structure within the granule which is the result of: 1) applied loading rates, 2) mass transfer limitations and 3) specific (bacterial) affinity for substrate. Hence, inerts (X_I) and methanogens (X_ac) are situated in the inner zone, and this fraction lowers as the radius increases favouring the presence of acidogens (X_su,X_aa, X_fa) and acetogens (X_c4,X_pro). Additional simulations show the effects on the overall process performance when operational (pH) and loading (S:COD) conditions are modified. Lastly, the effect of intra-granular precipitation on the overall organic/inorganic distribution is assessed at: 1) different times; and, 2) reactor heights. Finally, the possibilities and opportunities offered by the proposed approach for conducting engineering optimization projects are discussed.

Abstract B14: Precision functional genomics for glioblastoma: Identifying molecular therapeutic targets using CRISPR-Cas9 and RNAi technologies in patient isolates

Glioblastoma (GBM) is the most aggressive and common form of adult brain cancer and is among the deadliest cancers, with a median survival of 15 months using standard-of-care therapies. Thus, improved treatments for GBM are desperately needed. To identify new GBM molecular therapeutic targets, our group has performed multiple functional genetic screens in patient-derived GBM stem-like cells (GSCs) and non-transformed human neural stem and progenitor cells (NPCs), which represent non-neoplastic controls. These screens, which have used both RNAi and CRISPR-Cas9 platforms, have led to the identification of several key molecular vulnerabilities in GSCs, including GBM-specific defects in: 3' splice site recognition, kinetochore function, and loss of redundancy between the kinase activities of PKMYT1 and WEE1. At this meeting we will present an overview of these studies, as well as our current efforts to: comprehensively retest all GBM-specific vulnerabilities scoring in these screens; address whether vulnerabilities arise from specific genetic alterations in patient samples (e.g. NF1 loss or PTEN loss); determine whether inhibition of specific molecular targets blocks tumor growth and/or maintenance; and demonstrate the mode of GBM-specific death for particular targets (e.g., cell cycle arrest, apoptosis, etc). In addition, we will highlight both strengths and limitations of applications of CRISPR-Cas9 technologies in patient samples. Collectively, our work illustrates the power of combining functional genetic technologies with the use of patient isolates to identify novel, patient-specific therapeutic strategies for GBM.

Citation Format: Pia Hoellerbauer, Heather Feldman, Sonali Arora, Lucas Carter, Emily J. Girard, Philip Corrin, James M. Olson, Eric C. Holland, Patrick J. Paddison. Precision functional genomics for glioblastoma: Identifying molecular therapeutic targets using CRISPR-Cas9 and RNAi technologies in patient isolates [abstract]. In: Proceedings of the AACR Precision Medicine Series: Opportunities and Challenges of Exploiting Synthetic Lethality in Cancer; Jan 4-7, 2017; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2017;16(10 Suppl):Abstract nr B14.

Re-Engineering Alzheimer Clinical Trials: Global Alzheimer's Platform Network

Alzheimer's disease (AD) drug development is costly, time-consuming, and inefficient. Trial site functions, trial design, and patient recruitment for trials all require improvement. The Global Alzheimer Platform (GAP) was initiated in response to these challenges. Four GAP work streams evolved in the US to address different trial challenges: 1) registry-to-cohort web-based recruitment; 2) clinical trial site activation and site network construction (GAP-NET); 3) adaptive proof-of-concept clinical trial design; and 4) finance and fund raising. GAP-NET proposes to establish a standardized network of continuously funded trial sites that are highly qualified to perform trials (with established clinical, biomarker, imaging capability; certified raters; sophisticated management system. GAP-NET will conduct trials for academic and biopharma industry partners using standardized instrument versions and administration. Collaboration with the Innovative Medicines Initiative (IMI) European Prevention of Alzheimer's Disease (EPAD) program, the Canadian Consortium on Neurodegeneration in Aging (CCNA) and other similar international initiatives will allow conduct of global trials. GAP-NET aims to increase trial efficiency and quality, decrease trial redundancy, accelerate cohort development and trial recruitment, and decrease trial costs. The value proposition for sites includes stable funding and uniform training and trial execution; the value to trial sponsors is decreased trial costs, reduced time to execute trials, and enhanced data quality. The value for patients and society is the more rapid availability of new treatments for AD.

A refined risk stratification scheme for clinical stage 1 NSGCT based on evaluation of both embryonal predominance and lymphovascular invasion

BACKGROUND

Active surveillance is an increasingly accepted approach for managing patients with germ-cell tumors (GCTs) after an orchiectomy. Here we investigate a time-to-relapse stratification scheme for clinical stage 1 (CS1) nonseminoma GCT (NSGCT) patients according to factors associated with relapse and identify a group of patients with a lower frequency and longer time-to-relapse who may require an alternative surveillance strategy.

PATIENTS AND METHODS

We analyzed 266 CS1 GCT patients from the IRB-approved DFCI GCT database that exclusively underwent surveillance following orchiectomy from 1997 to 2013. We stratified NSGCT patients according to predominance of embryonal carcinoma (EmbP) and lymphovascular invasion (LVI), using a 0, 1, and 2 scoring system. Cox regression and conditional risk analysis were used to compare each NSGCT group to patients in the seminomatous germ-cell tumor (SGCT) category. Median time-to-relapse values were then calculated among those patients who underwent relapse. Relapse-free survival curves were generated using the Kaplan-Meier method.

RESULTS

Fifty (37%) NSGCT and 20 (15%) SGCT patients relapsed. The median time-to-relapse was 11.5 versus 6.3 months for the SGCT and NSGCT groups, respectively. For NSGCT patients, relapse rates were higher and median time-to-relapse faster with increasing number of risk factors (RFs). Relapse rates (%) and median time-to-relapse (months) were 25%/8.5 months, 41%/6.8 months and 78%/3.8 months for RF0, RF1 and RF2, respectively. We found a statistically significant difference between SGCT and patients with one or two RFs (P < 0.001) but not between SGCT and NSGCT RF0 (P = 0.108).

CONCLUSION

NSGCT patients grouped by a risk score system based on EmbP and LVI yielded three groups with distinct relapse patterns -and patients with neither EmbP nor LVI appear to behave similar to SGCT.

Cognitive and adaptive functioning after liver transplantation for maple syrup urine disease: a case series

MSUD is a complex metabolic disorder that has been associated with central nervous system damage, developmental delays, and neurocognitive deficits. Although liver transplantation provides a metabolic cure for MSUD, changes in cognitive and adaptive functioning following transplantation have not been investigated. In this report, we present data from 14 patients who completed cognitive and adaptive functioning testing pre- and one yr and/or three yr post-liver transplantation. Findings show either no significant change (n=8) or improvement (n=5) in IQ scores pre- to post-liver transplantation. Greater variability was observed in adaptive functioning scores, but the majority of patients evidenced no significant change (n=8) in adaptive scores. In general, findings indicate that liver transplantation minimizes the likelihood of additional central nervous system damage, providing an opportunity for possible stabilization or improvement in neurocognitive functioning.

Safety and efficacy of galantamine in subjects with mild cognitive impairment

OBJECTIVE

To assess the safety of galantamine in subjects with mild cognitive impairment (MCI), the ability of galantamine to benefit cognition and global functioning in subjects with MCI, and the ability of galantamine to delay conversion to dementia.

METHODS

In two studies, 2,048 subjects, 990 in Study 1 and 1,058 in Study 2, with a Clinical Dementia Rating (CDR) = 0.5, CDR memory score > or =0.5, without dementia were randomized to double-blind galantamine (16-24 mg/day) or placebo for 24 months. Primary efficacy endpoint at month 24 was number (%) of subjects who converted from MCI to dementia (CDR > or = 1.0).

RESULTS

There were no differences between galantamine and placebo in 24-month conversion rates (Study 1: 22.9% [galantamine] vs 22.6% [placebo], p = 0.146; Study 2: 25.4% [galantamine] vs 31.2% [placebo], p = 0.619). Mean CDR-sum of boxes declined less with galantamine than placebo at 12 and 24 months in Study 1 (p = 0.024 [12 months] and p = 0.028 [24 months]), but not in Study 2 (p = 0.662 [12 months] and p = 0.056 [24 months]). Digit Symbol Substitution Test scores improved with galantamine in Study 1 at 12 months and in Study 2 at 24 months (Study 1: p = 0.009 [month 12] and p = 0.079 [Month 24]; Study 2: p = 0.154 [month 12] and p = 0.020 [month 24]). The most frequently reported adverse event was nausea (galantamine, 29%; placebo, 10%). Serious AEs occurred in 19% of each group. Mortality of the cohort after retrospectively determining the status of subjects (98.3%) at 24 months was 1.4% (galantamine) and 0.3% (placebo); RR (95% CI), 1.70 (1.00, 2.90).

CONCLUSIONS

Galantamine failed to significantly influence conversion to dementia. Galantamine was generally well tolerated. Whereas recorded mortality was greater in the galantamine group than in the placebo group in the original per-protocol assessment, a post hoc analysis of the cohort was consistent with no increased risk.

Behavioural measures in frontotemporal lobar dementia and other dementias: the utility of the frontal behavioural inventory and the neuropsychiatric inventory in a national cohort study

BACKGROUND

Distinguishing between patients with frontotemporal lobar dementia (FTLD) and other dementing illnesses remains a difficult task for many clinicians. In this study, we aimed to provide further evidence for the construct validity of the frontal behavioural inventory (FBI) and assess its utility in differentiating FTLD patients from other groups using data from the Canadian Collaborative Cohort of Related Dementias (ACCORD) study.

METHOD

Baseline scores on the FBI and neuropsychiatric inventory (NPI) were compared among several clinical groups (n = 177).

RESULTS

The FBI discriminated a higher percentage of FTLD patients (>75% correct classification) from Alzheimer's disease and other groups compared to the NPI (54.2%).

CONCLUSION

This study provides good evidence for convergent validity between the FBI and NPI (r = 0.72), indicating that both measures capture similar psychopathology in this nationwide cohort.

Gallium-67 scintigraphy in polymyalgia rheumatica

A patient with atypical presentation of polymyalgia rheumatica is presented. Her major symptoms were mild weakness, pain on passive movement of the shoulder and hip girdles, with mild tenderness but no joint stiffness. Muscle enzymes were within the normal range. The diagnostic work-up included gallium-67 scintigraphy, which showed intense uptake in both shoulders, with remarkable improvement following steroid treatment. A prospective study may delineate the possible role of this imaging modality in establishing a diagnosis of polymyalgia rheumatica.

A randomized trial of teaching clinical skills using virtual and live standardized patients

BACKGROUND

We developed computer-based virtual patient (VP) cases to complement an interactive continuing medical education (CME) course that emphasizes skills practice using standardized patients (SP). Virtual patient simulations have the significant advantages of requiring fewer personnel and resources, being accessible at any time, and being highly standardized. Little is known about the educational effectiveness of these new resources. We conducted a randomized trial to assess the educational effectiveness of VPs and SPs in teaching clinical skills.

OBJECTIVE

To determine the effectiveness of VP cases when compared with live SP cases in improving clinical skills and knowledge.

DESIGN

Randomized trial.

PARTICIPANTS

Fifty-five health care providers (registered nurses 45%, physicians 15%, other provider types 40%) who attended a CME program.

INTERVENTIONS

Participants were randomized to receive either 4 live cases (n=32) or 2 live and 2 virtual cases (n=23). Other aspects of the course were identical for both groups.

RESULTS

Participants in both groups were equivalent with respect to pre-post workshop improvement in comfort level (P=.66) and preparedness to respond (P=.61), to screen (P=.79), and to care (P=.055) for patients using the skills taught. There was no difference in subjective ratings of effectiveness of the VPs and SPs by participants who experienced both (P=.79). Improvement in diagnostic abilities were equivalent in groups who experienced cases either live or virtually.

CONCLUSIONS

Improvements in performance and diagnostic ability were equivalent between the groups and participants rated VP and SP cases equally. Including well-designed VPs has a potentially powerful and efficient place in clinical skills training for practicing health care workers.

Treating vascular risk factors and maintaining vascular health: is this the way towards successful cognitive ageing and preventing cognitive decline?

Dementia is a progressive disorder that typically worsens with time and from which recovery is unlikely. The incidence of dementia increases exponentially with ageing and is an important public health challenge. There is now growing evidence for the role of vascular factors in Alzheimer's disease, mixed dementia (Alzheimer's disease with cerebrovascular disease), and of course vascular dementia. With the rising prevalence of vascular disease, there are increasing numbers of people who are identified to be at risk of cognitive impairment. By changing modifiable vascular risk factors, there is emerging evidence that it may be possible to prevent or delay the expression and progression of dementia.

Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium

The dementia with Lewy bodies (DLB) Consortium has revised criteria for the clinical and pathologic diagnosis of DLB incorporating new information about the core clinical features and suggesting improved methods to assess them. REM sleep behavior disorder, severe neuroleptic sensitivity, and reduced striatal dopamine transporter activity on functional neuroimaging are given greater diagnostic weighting as features suggestive of a DLB diagnosis. The 1-year rule distinguishing between DLB and Parkinson disease with dementia may be difficult to apply in clinical settings and in such cases the term most appropriate to each individual patient should be used. Generic terms such as Lewy body (LB) disease are often helpful. The authors propose a new scheme for the pathologic assessment of LBs and Lewy neurites (LN) using alpha-synuclein immunohistochemistry and semiquantitative grading of lesion density, with the pattern of regional involvement being more important than total LB count. The new criteria take into account both Lewy-related and Alzheimer disease (AD)-type pathology to allocate a probability that these are associated with the clinical DLB syndrome. Finally, the authors suggest patient management guidelines including the need for accurate diagnosis, a target symptom approach, and use of appropriate outcome measures. There is limited evidence about specific interventions but available data suggest only a partial response of motor symptoms to levodopa: severe sensitivity to typical and atypical antipsychotics in approximately 50%, and improvements in attention, visual hallucinations, and sleep disorders with cholinesterase inhibitors.

The Biomolecular Interaction Network Database and related tools 2005 update

The Biomolecular Interaction Network Database (BIND) (http://bind.ca) archives biomolecular interaction, reaction, complex and pathway information. Our aim is to curate the details about molecular interactions that arise from published experimental research and to provide this information, as well as tools to enable data analysis, freely to researchers worldwide. BIND data are curated into a comprehensive machine-readable archive of computable information and provides users with methods to discover interactions and molecular mechanisms. BIND has worked to develop new methods for visualization that amplify the underlying annotation of genes and proteins to facilitate the study of molecular interaction networks. BIND has maintained an open database policy since its inception in 1999. Data growth has proceeded at a tremendous rate, approaching over 100 000 records. New services provided include a new BIND Query and Submission interface, a Standard Object Access Protocol service and the Small Molecule Interaction Database (http://smid.blueprint.org) that allows users to determine probable small molecule binding sites of new sequences and examine conserved binding residues.

Economic evaluation of donepezil in moderate to severe Alzheimer disease

OBJECTIVE

To investigate the costs to society of Alzheimer disease (AD) care in a multinational, randomized, placebo-controlled trial of donepezil in patients with moderate to severe AD.

METHODS

A total of 290 patients with AD (screening standardized Mini-Mental State Examination score 5 to 17) were randomized to receive either donepezil (n = 144; 5 mg/day for 28 days, followed by 10 mg/day as per clinician's judgment) or placebo (n = 146) for 24 weeks. The authors collected data on patient and caregiver health resource utilization prospectively using the Canadian Utilization of Services Tracking questionnaire. Costs were calculated for patients and caregivers in each group based on resource utilization multiplied by the unit prices for each resource. A cost (the average Ontario minimum wage for 1998 [Can 6.85 dollars per hour]) was assigned to unpaid time that caregivers spent assisting the patient with activities of daily living (ADL).

RESULTS

Patient and caregiver demographics at baseline were similar across the two groups. After adjusting for baseline total cost per patient, the mean total societal cost per patient for the 24-week period was donepezil, Can 9,904 dollars (US 6,686 dollars) and placebo, Can 10,236 dollars (US 6,910 dollars). This net cost saving of Can 332 dollars (US 224 dollars) included the average 24-week cost of donepezil treatment. Most of the cost-saving with donepezil treatment was due to less use of residential care by patients, and caregivers spending less time assisting patients with ADL.

CONCLUSION

This cost-consequence analysis reveals economic benefits of treatment of moderate to severe AD with donepezil.

Behavioral symptoms in mild cognitive impairment

The authors investigated neuropsychiatric symptoms in mild cognitive impairment (MCI) from baseline data of the Investigation in the Delay to Diagnosis of AD with Exelon (InDDEx) study (n = 1,010). Neuropsychiatric symptoms were reported in 59% of subjects (Neuropsychiatric Inventory [NPI]). NPI+ subjects had significantly greater impairment on global, cognitive, and functional scores than NPI- subjects. The presence of neuropsychiatric symptoms appears to be a marker of MCI severity.

Neurofilament inclusion body disease with early onset frontotemporal dementia and primary lateral sclerosis

A small number of patients have recently been described with a sporadic neurodegenerative disease, associated with the neuropathological finding of neurofilament-immunoreactive neuronal inclusions. The clinical and pathological spectrum of this new disease entity has yet to be fully defined. We describe an additional case of "neurofilament inclusion body disease" (NIBD) with several unusual features. This young woman, who suffered from rapidly progressive frontotemporal dementia (FTD) and features of primary lateral sclerosis (PLS), died at age 29. Neuropathological examination disclosed numerous neuronal cytoplasmic inclusions in many regions of the central nervous system. The inclusions varied in morphology with some being immunoreactive for ubiquitin while others showed strong positivity for neurofilament proteins. Intranuclear neuronal inclusions were also present. There was no significant tau or alpha-synuclein pathology. There was severe degeneration of the corticospinal tracts but lower motor neurons were normal in number and morphology. This case confirms that NIBD should be considered in the differential diagnosis of FTD, particularly in young patients. In addition, it extends the clinical phenotype of NIBD to include PLS and better defines the anatomical distribution and morphology of the pathological lesions.

[Results of the international hemodialysis study DOPPS in Spain and Europe]

The Dialysis Outcomes and Practice Pattern Study (DOPPS) is an international observational study of treatment conditions and medical outcomes in hemodialysis patients. Prospective sampling has yielded long-term observational data from randomly selected groups of patients receiving treatment at representative, randomly selected hemodialysis units in each country. The data shown were collected at 20 hemodialysis units/centers in Spain. The data pertaining to Spain--Sp--refers to 575 patients and their comparison with those of the Euro-DOPPS countries--Eu--(Germany, France, United Kingdom, Italy and Spain), which encompass 3,038 patients, represent the formal goal of this paper. Diabetes mellitus, at 21.5% in Eu and 21.7% in Sp, was the most common cause of renal insufficiency in dialysis and coronariopathy, as a concomitant disease, was present in 67.8% in Eu as opposed to 75.8% in Sp. Differences were observed in the incident of hypertension (73.4% in Eu vs 77.4% in Sp), hepatitis C (11.6% vs 19.5%), depression (12.7 vs 16.2%) and left ventricular hypertrophy (54.9% vs 62.3%). The patterns of vascular access were similar (79% vs 81% AV fistulas in Eu and Sp, and 10% synthetic grafts for both) and the mean applied dose of dialysis--Kt/V--smaller (1.19) in Sp than in Eu (1.24); likewise the duration of the dialysis (in minutes) was shorter (234 in Eu vs 217 in Sp) and the % of synthetic membranes used was smaller (60% in Eu vs 52% in Sp). There were no differences between the groups in the figures for urea, creatinine, albumin, nPCR, calcium, phosphate or PTH. There were also no differences in the mean values of Hb (10.7 for Eu vs 10.8 for Sp), given that the values of ferritin were noticeably lower in Sp (288 vs 355) and the dose of EPO/kg/week was higher to in Sp (115 vs 102); s.c. route was used in similar proportions (69% in Eu vs 67% in Sp). The level of medical care, understood as contact with the physician at all or almost all treatments, was noticeably better in Sp (90%) that in Eu (66%), whereas the number of patients per hour of specialized personnel and % of specialized staff, were smaller. Mortality (death/100 patients-years) was one point lower in Sp than in Eu (15.4 vs 16.3). These data suggest that an increment in dialysis time and in the percentage of synthetic membranes used, as well as in the supply of intravenous iron, would be justified.

A Canadian cohort study of cognitive impairment and related dementias (ACCORD): study methods and baseline results

The overall objective of the Canadian Collaborative Cohort of Related Dementias (ACCORD) study is to describe the diagnostic distribution, natural history and treatment outcomes of individuals referred from the community to dementia clinics in Canada. Between 1997 and 1999, an inception cohort of 1,136 subjects entered into this longitudinal study. At the baseline assessment, 10.9% of the subjects were classified as "not cognitively impaired" (NCI), 30.1% as "cognitively impaired not demented" (CIND), and 59% as demented. A subclassification of CIND included amnestic 25.1%, vascular cognitive impairment 18.1%, psychiatric 17.2%, neurologic 7.3%, medical/toxic metabolic 3.5%, mixed 7.6% and not specified 19.0%. The percentage of the cohort referred with dementia increased progressively each decade, while the proportions of CIND and NCI decreased. Within the dementia group, Alzheimer's disease accounted for 47.2% of the subjects, mixed dementias 33.7%, vascular dementia 8.7%, frontotemporal degenerations 5.4%, dementia with Lewy bodies 2.5%, and unclassifiable 1.8%. The ACCORD cohort will allow a detailed study of the longitudinal course of CIND, and the longer-term outcomes of both treated and untreated dementia subjects.

Indomethacin for the treatment of Alzheimer's disease patients

BACKGROUND

Inflammatory processes involving cytokines, prostaglandins, free radicals and glial cells have been implicated in the pathogenesis of Alzheimer's disease. Non-steroidal anti-inflammatory drugs such as indomethacin attenuate inflammatory reactions. Hence, there may be a role for some of these drugs in the treatment of Alzheimer's disease.

OBJECTIVES

To examine the efficacy of indomethacin in the treatment of patients suffering from Alzheimer's disease.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (which contains records from many different medical and trials databases) on 14 June 2001 using the terms indomethacin and indome* and NSAIDS. In addition two independent reviewers systematically searched relevant computerized databases and Internet sites. This was supplemented by hand searching and additional references sought from selected papers.

SELECTION CRITERIA

Single or multi-centre placebo-controlled randomized trials examining the efficacy of indomethacin in patients diagnosed with Alzheimer's disease were eligible for selection for this review. Using a standard extraction form, inclusion/exclusion criteria were set to ensure design quality and lack of bias of all trials included.

DATA COLLECTION AND ANALYSIS

Data were collected independently by two reviewers and any discrepancies were subject to discussion. Corresponding authors were contacted for any missing data needed for statistical analysis.

MAIN RESULTS

Only one study was selected for this review (~~Rogers 1993~~). We detected no statistically significant difference between indomethacin treatment and placebo for the individual cognitive tests, Mini Mental State Examination (MMSE), Alzheimer's Disease Assessment Scale ( ADAS), Boston Naming Test (BNT) and Token Test (TK). Dropouts and death rate were the only reported results that were amenable to evaluation. The dropout rate was higher in the indomethacin group (10/24) than in the control group (6/20). Gastrointestinal adverse events were more prevalent in the treatment group (5/24 compared with 1/20 in control group). There was no statistically significant difference in death rate between the two groups (p=0.9).

REVIEWER'S CONCLUSIONS

On the basis of this one trial and subsequent analysis of data as reported by the authors, indomethacin cannot be recommended for the treatment of mild to moderate severity Alzheimer's disease. At doses of 100-150 mg daily, serious side effects will limit its use.

Functional, cognitive and behavioral effects of donepezil in patients with moderate Alzheimer's disease

OBJECTIVE

To investigate the efficacy and safety of donepezil in a subgroup of patients with Alzheimer's disease (AD) of moderate severity from a previous trial.

METHODS

Two hundred and seven patients with moderate AD (standardized Mini-Mental State Examination [sMMSE] score 10-17) were randomized to treatment in this 24-week, double-blind, placebo-controlled trial. Patents received either donepezil, 5 mg/day for the first 28 days and 10 mg/day thereafter according to the clinician's judgement (n = 102), or placebo (n = 105). The primary outcome measure was the Clinician's Interview-Based Impression of Change with caregiver input (CIBIC-plus) at week 24 using a last observation carried forward (LOCF) analysis.

RESULTS

Baseline patient demographics were similar between treatment groups. Mean age was 74.3 years (range 48-92). Least-squares (LS) mean sMMSE scores at baseline were 13.6 +/- 0.3 for the donepezil group and 13.9 +/- 0.3 for the placebo group. LS mean CIBIC-plus scores for donepezil-treated patients were improved from, or close to, baseline severity at all visits, and were significantly different from placebo at weeks 8, 12, 18, and 24 (week 24 LOCF mean difference = 0.53, p = 0.0003). LS mean change from baseline scores on the sMMSE and Severe Impairment Battery (SIB) for the donepezil group improved throughout the study, and were significantly different from placebo at each visit for the sMMSE (week 24 LOCF mean difference = 2.06, p = 0.0002) and from week 8 for the SIB (week 24 LOCF mean difference = -4.44, p = 0.0026). LS mean change scores on the Disability Assessment for Dementia remained at or above baseline levels throughout the study for the donepezil group, while the placebo group showed a steady decline; treatment differences were significant at each visit (week 24 LOCF mean difference = -9.25, p < 0.0001). LS mean change scores on the Neuropsychiatric Inventory 12-item total improved throughout the study for the donepezil group and were significantly different from placebo at weeks 4 and 24 (week 24 LOCF mean difference = 5.92, p = 0.0022). Eighty-one per cent of donepezil-treated and 89% of placebo-treated patients completed the trial, with 9% and 5%, respectively, discontinuing due to adverse events (AEs). Eighty-two per cent of donepezil-treated and 80% of placebo-treated patients experienced AEs, the majority of which were rated mild in severity and, in general, were similar between treatment groups.

CONCLUSION

The significant treatment responses observed with donepezil in these patients reinforce the findings from earlier studies that show donepezil to have important benefits, compared wih placebo, across functional, cognitive, and behavioral symptoms, with good tolerability, in patients with AD of moderate severity.

Serum p97 levels as an aid to identifying Alzheimer's disease

Background: The application of formal clinical diagnostic criteria for the identification of Alzheimer's Disease (AD) has improved diagnostic sensitivity. However, there remains a need for non-invasive biological markers and laboratory tests, which can facilitate case identification, and the assessment of treatment response. The p97 protein is a secreted protein specifically expressed by amyloid plaque associated reactive microglia that may have AD diagnostic ability. Methods: A quantitative radioimmunoassay was developed to measure serum p97. This study, under a double blind protocol, evaluated the utility of serum p97 as diagnostic test for AD. All subjects were referred to the UBC Clinic for Alzheimer's Disease and Related Disorders (CADRD) for clinical assessment of dementia. A serum p97 sample was obtained at the time of assessment but diagnosis of disease was determined independently of p97 examination. Results: "Possible" and "probable" AD cases (n = 41) and cognitively normal controls (n = 64) showed a highly significant difference in mean p97 concentration (41 vs. 20 ng/ml, p<0.001). There was some overlap in p97 distributions between AD cases and control subjects. The area under the curve (AUC) for the receiver operator curve (ROC) was 0.812. Conclusions: These results further support the specificity of high serum p97 levels in AD and its potential utility as a biological marker in AD. The reproducible elevation of serum p97 in AD underlines the need to further determine its role as a biological marker and diagnostic adjunct for AD.

Progression of impairment in patients with vascular cognitive impairment without dementia

Little is known about progression, short of dementia, in vascular cognitive impairment. In the Canadian Study of Health and Aging, 149 participants (79.3 +/- 6.7 years; 61% women) were found to have vascular cognitive impairment, no dementia (CIND). After 5 years, 77 participants (52%) had died and 58 (46%) had developed dementia. Women were at greater risk of dementia (OR 2.1, 1.0 to 4.5). Of 32 participants alive without dementia, cognition had deteriorated in seven and improved in four. Half of those with vascular CIND developed dementia within 5 years, suggesting a target for preventive interventions.

A 24-week, randomized, double-blind study of donepezil in moderate to severe Alzheimer's disease

OBJECTIVE

To investigate the efficacy and safety of donepezil in patients with moderate to severe AD (standardized Mini-Mental State Examination [sMMSE] scores of 5 to 17; Functional Assessment Staging score < or =6 at baseline).

METHODS

Two-hundred ninety patients were randomized to treatment in this 24-week, double-blind, placebo-controlled trial. Patients received either donepezil 5 mg/day for the first 28 days and 10 mg/day thereafter as per the clinician's judgment (n = 144) or placebo (n = 146). The primary outcome measure was the Clinician's Interview-Based Impression of Change with caregiver input (CIBIC+).

RESULTS

Patients' mean age was 73.6 years (range 48 to 92 years). Baseline demographics were similar between the treatment groups. Least squares (LS) mean +/- SE sMMSE scores at baseline were 11.7 +/- 0.35 for the donepezil group and 12.0 +/- 0.34 for the placebo group. Patients receiving donepezil showed benefits on the CIBIC+, compared with placebo, at all visits up to week 24 (p < 0.001) and at week 24 last observation carried forward (LOCF) (p < 0.0001). All other secondary measures (including sMMSE, Severe Impairment Battery, Disability Assessment for Dementia, Functional Rating Scale, and Neuropsychiatric Inventory) showed significant differences between the groups in favor of donepezil at week 24 LOCF. Eighty-four percent of donepezil- and 86% of placebo-treated patients completed the trial. Adverse events (AE) were experienced by 83% of donepezil- and 80% of placebo-treated patients, the majority of which were rated mild in severity; 8% of donepezil- and 6% of placebo-treated patients discontinued because of AE. Laboratory and vital sign abnormalities were similar between the treatment groups.

CONCLUSION

These data suggest that donepezil's benefits extend into more advanced stages of AD than those previously investigated, with very good tolerability.

The disability assessment for dementia scale: a 12-month study of functional ability in mild to moderate severity Alzheimer disease

The Disability Assessment for Dementia (DAD) scale was developed and validated as a measure of functional ability in dementia. DAD results have been reported in Alzheimer disease (AD) randomized, controlled treatment trials of up to 6 months, but results beyond 6 months have yet to be described. SAB INT 12 was a randomized, double-blind, placebo-controlled, parallel-group study in mild to moderate AD that included DAD assessments at baseline, month 6, and month 12. One hundred forty-four patients with AD in the placebo arm of SAB INT 12 were followed up for 12 months. DAD scores were obtained at baseline (mean DAD = 70.1, SD = 22.2), 6 months (mean DAD = 63.7, SD = 25.2), and 12 months (mean DAD = 59.3, SD = 28.9). The rate of decline was consistent across the domains of basic activities of daily living (ADLs) and instrumental ADLs, as well as the scoring of initiation, planning, and organization. The decline in DAD total scores in mild to moderate AD averages about one point per month, which equates to the loss of one item on the DAD scale every 2 months.

Effect of ethnicity on denial of authorization for emergency department care by managed care gatekeepers

OBJECTIVE

After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital.

METHODS

A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO.

RESULTS

African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94).

CONCLUSIONS

African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.

The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia

OBJECTIVE

i) To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians towards the recognition, assessment and management of dementing disorders; ii) to disseminate and evaluate the impact of these statements and guidelines built on these statements.

OPTIONS

Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral; management of complications (especially behaviour problems and depression) and use of cognitive enhancing agents. POTENTIAL OUTCOMES: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations, neuroimaging and referrals; appropriate use of cognitive enhancing agents.

EVIDENCE

Authors of each background paper were entrusted to: perform a literature search, discover additional relevant material including references cited in retrieved articles; consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based upon this evidence, consensus statements were developed by a group of experts, guided by a steering committee of eight individuals from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Medicine, Preventive Health Care and Health Care Systems.

VALUES

Recommendations have been developed with particular attention to the context of primary care and are intended to support family physicians in their ongoing assessment and care of patients with dementia.

BENEFITS, HARMS AND COSTS

Potential for improved clinical care of individuals with dementia. A dissemination and evaluation strategy will attempt to measure the impact of the recommendations.

RECOMMENDATIONS

See text.

VALIDATION

Four other sets of consensus statements and/or guidelines have been published recently. These recommendations are generally congruent with our own consensus statements. The consensus statements have been endorsed by relevant bodies in Canada.

Diagnosis, classification and natural history of degenerative dementias

The release of the first approved medications for the treatment of Alzheimer's disease in Canada has highlighted the renewed need and importance of diagnostic accuracy and understanding of the spectrum of the dementias. The epidemiological scope of the problem of dementia in Canada including risk factors, caregiving patterns and costs of care have been well-characterized through the Canadian Study of Health and Aging (CSHA 1991-1996) with some of the key findings reviewed here. Beyond Alzheimer's disease the phenotypes and genotypes of the other degenerative dementias have been emerging with proposed operational diagnostic criteria that should facilitate their recognition in clinical practice. This paper reviews the clinical phenotypes of the most common causes of dementia with a proposed classification scheme and with discussion of their relevance from a differential treatment standpoint. This paper served as a background document for the working group of the Consensus Conference on Dementia (C3D) in February 1998 and has been revised subsequently for this publication.

Age and sex differences in presentation of symptoms among patients with acute coronary disease: the REACT Trial. Rapid Early Action for Coronary Treatment

BACKGROUND

There are few data on possible age and sex differences in presentation of symptoms for patients with acute coronary disease.

OBJECTIVE

To investigate demographic differences in presentation of symptoms at the time of hospital presentation for acute myocardial infarction (AMI) and unstable angina.

METHODS

The medical records of patients who presented with chest pain and who also had diagnoses of AMI (n = 889) or unstable angina (n = 893) on discharge from 43 hospitals were reviewed as part of data collection activities of the Rapid Early Action for Coronary Treatment trial based in 10 pair-matched communities throughout the USA.

RESULTS

Dyspnea (49%), arm pain (46%), sweating (35%), and nausea (33%) were commonly reported by men and women of all ages in addition to the presenting complaint of chest pain. After we had controlled for various characteristics through regression modeling, older persons with AMI were significantly less likely than were younger persons to complain of arm pain and sweating, and men were significantly less likely to report vomiting than were women. Among persons with unstable angina, arm pain and sweating were reported significantly less often by elderly patients. Nausea and back, neck, and jaw pain were more common complaints of women.

CONCLUSIONS

Results of this study suggest that there are differences between symptoms at presentation of men and women, and those in various age groups, hospitalized with acute coronary disease. Clinicians should be aware of these differences when diagnosing and managing patients suspected to have coronary heart disease.