A much needed metric: Defining reliable and statistically meaningful change of the oral version Symbol Digit Modalities Test (SDMT)

BACKGROUND

The Symbol Digit Modalities Test (SDMT) has been recommended for use in clinical trials and outcome studies to monitor cognitive change. However, defining what is a meaningful change has been elusive for several years.

OBJECTIVE

The present investigation aimed to develop methods for assessing individual-level statistically significant change on the SDMT - reliable change indices (RCIs) and standardized regression-based (SRB) equations.

METHODS

A total of 219 healthy individuals completed the oral version SDMT at baseline, 6-month and 1-year follow-up.

RESULTS

The SDMT demonstrated high reliability across all time points (r's = 0.83 to 0.86). Reliable change scores of 7, 8, and 10 points for the 6-month intervals represented statistically meaningful change at the 0.70, 0.80, and 0.90 confidence intervals, respectively. Over 1-year, a difference of 8, 10, and 12 was statistically meaningful at the 0.70, 0.80, and 0.90 confidence intervals, respectively. SRB equations are also provided taking into account additional factors found to be predictive of SDMT scores over time.

CONCLUSION

Clinicians frequently denote a decline of 4 points on the SDMT as meaningful. Results in this large normative sample show that higher cut-points are needed to demonstrate statistically significant decline at the individual level. RCIs are provided for 6 month and one year assessment, which is typical in clinical practice and trials. SRB equations are also provided for use when applicable and may provide a more precise assessment of meaningful change.

A quick assessment of reliable change in fatigue: Reliable change indices of the modified fatigue impact scale - 5 item (MFIS-5)

BACKGROUND

Reliably monitoring changes in fatigue is an ongoing concern.

OBJECTIVE

Evaluate reliable change using the Modified Fatigue Impact Scale 5-item version (MFIS-5) in people with MS (PwMS).

METHODS

The MFIS-5 was administered at three time points in 157 PwMS. Test-retest reliability and reliable change scores were calculated at the 0.70, 0.80, 0.90, and 0.95 confidence intervals.

RESULTS

Difference scores of 3, 4, 5, and 6 represent statistically meaningful change at the 0.70, 0.80, 0.90, and 0.95 confidence intervals, respectively.

CONCLUSION

Cut points derived from this study and prior work can help reliably assess changes in fatigue over time.

A new look at an old test: Normative data of the symbol digit modalities test -Oral version

BACKGROUND

The Symbol Digit Modalities Tests (SDMT) is the most sensitive measure to multiple sclerosis (MS)-related cognitive dysfunction. However, existing normative data has been under scrutiny. Specifically, they are outdated, do not take into account gender, and are poorly stratified by education. More importantly, there exists no oral only version norms, which is typical administration among individuals with MS.

OBJECTIVE

The present investigation aimed to develop updated normative data of the oral version SDMT in which age, gender, and education were taken into consideration.

METHODS

A total of 675 healthy individuals, stratified by age, gender, and education completed the oral version SDMT.

RESULTS

Significant effects were found for age, gender, and education, consistent with previous contentions. Specifically, performance on the SDMT tends to decline with age, with the most noticeable decline beginning in the third decade of life and continuing into the sixth decade. Women, in general perform better than men, with an average of 5.1 more points. Finally, education effects were apparent among those aged 25-54.

CONCLUSION

Based on these findings, updated normative data are provided. Utilization of these updated norms will result in a much needed and more accurate assessment of processing speed for individuals with MS.

Testing the Hybrid Battery Approach to Evaluating Sports-Related Concussion in the National Hockey League: A Factor Analytic Study

Purpose

Traditional “paper and pencil” neuropsychological tests and computerized test batteries have been employed in the assessment of sports-related concussion (SRC). Each type of test has inherent strengths and weaknesses. The NHL has constructed a “hybrid” battery of tests that uses both traditional and computerized measures in the evaluation of its players suspected of SRC. The purpose of this paper is to use factor analytic techniques to examine the relationships among the measures that comprise this battery.

Methods

Post-injury neuropsychological test data using the hybrid battery were obtained from 343 NHL players following their first concussion while playing in the league. ImPACT was used as the computer test battery. The traditional battery included: Hopkins Verbal Learning Test, Brief Visuospatial Memory Test, Color Trails, PSU Cancellation, Symbol Digits Modalities Test (including incidental memory), and Verbal Fluency.

Results

Five factors were extracted explaining 64.55% of the variance. The factor labels and the measures principally loading on each factor were as follows: Factor 1, Verbal Learning and Memory (HVLT Total and Delayed Recall); Factor 2, Processing Speed (Color Trails A/B, PSU Cancellation, and SDMT-Total); Factor 3, Visual Memory (BVMT- Total and Delayed); Factor 4, Cued Memory (ImPACT-Visual and Verbal Memory Composites); and Factor 5, Reaction Time (ImPACT Reaction Time and Visual Motor Speed composites).

Conclusion

These data underscore the unique contributions of traditional and ImPACT neuropsychological measures to the evaluation SRC in a sample of professional hockey players. It appears that both approaches measure different aspects of cognitive functioning. The next logical step is to use these data in evaluating the diagnostic utility of these measures as part of a combined battery.

The Utility of the King-Devick Test in Evaluating Professional Ice Hockey Players with Suspected Concussion

Purpose

The King-Devick (KD) is a measure of rapid number naming used in the evaluation of sports-related concussion (SRC). Recent data from the Canadian Football League and Rugby Union suggest that the KD should not be used as a stand-alone measure of SRC. The purpose of this study was to examine the diagnostic utility of the KD in professional ice hockey players.

Methods

NHL players who were suspected of having a concussion were evaluated with the KD and either the SCAT3 or the SCAT5. Players who were evaluated and not diagnosed with concussion served as Active controls. A small group of non-Active control players was also tested twice and was included in the present study for comparison.

Results

1605 players were evaluated with the KD at baseline. Of these, 53 were diagnosed with concussion, 76 were Active controls, and 11 were non-Active controls. Concussed players revealed a decline in performance from baseline to acute evaluation, t(52)=3.05, p<.01, d=.42 while Active controls significantly improved, t(75)=2.05, p<.05, d=.24. No significant change between baseline and acute testing was observed for non-Active controls. Using a cut score of any decline in performance from baseline to suspected injury evaluation yielded Sensitivity=64%, Specificity=61%, Positive Predictive Value=53% and Negative Predictive Value=71%.

Conclusion

Our data are consistent with previous studies suggesting that while the KD is useful in differentiating concussed and not concussed athletes acutely, the relatively low predictive values indicate that a decline in KD performance should not be used as a standalone measure to diagnose concussion.

Multimodality imaging of paragangliomas of the head and neck

Paragangliomas arise from paraganglion cells which serve varied regulatory tasks in the body. When these cells demonstrate neoplasia within the head and neck, they typically present in characteristic locations including the carotid space, the jugular foramen, the middle ear, and along the course of the vagus nerve. The goal of this article is to review the relevant anatomy related to head and neck paragangliomas, as well as their typical imaging characteristics on cross-sectional imaging including CT, MR, ultrasound, and nuclear medicine studies. Additionally, differential considerations, as well as relevant involvement of adjacent structures which should be conveyed to the clinician, will be discussed.

Implementation of the European health interview survey (EHIS) into the German health update (GEDA)

Background

This methodological paper describes the integration of the ‘European Health Interview Survey wave 2’ (EHIS 2) into the ‘German Health Update’ 2014/2015 (GEDA 2014/2015-EHIS).

Methods

GEDA 2014/2015-EHIS is a cross-sectional health survey. A two-stage stratified cluster sampling approach was used to recruit persons aged 15 years and older with permanent residence in Germany. Two different modes of data collection were used, self-administered web questionnaire and self-administered paper questionnaire. The survey instrument implemented the EHIS 2 modules on health status, health care use, health determinants and social background variables and additional national questions. Data processing was conducted according to the quality and validation rules specified by Eurostat.

Results

In total, 24,824 questionnaires were completed. The response rate was 27.6%. The two-stage cluster sample method seems to have been successful in achieving a sample with high representativeness. The final micro data file was inspected, approved and certified by Eurostat. Access to micro data of the EHIS 2 can be provided by Eurostat via research contract and to the GEDA 2014/2015-EHIS public use file by the Research Data Centre of the Robert Koch Institute. First EHIS 2 results are available at the Eurostat website.

Conclusions

Integrating a multinational health survey into an existing national health monitoring system was a challenge in Germany. The national survey methodology for conducting the survey had to be further developed in order to meet the overarching goal of harmonizing the health information from national statistical offices and public health research institutes across the European Union. The harmonized EHIS 2 data source will profoundly impact international public health research in the near future. The next EHIS wave 3 will be conducted around 2019.

Acute ocular traumatic imaging: what the radiologist should know [corrected]

Acute ocular trauma accounts for a substantial number of emergency department visits in the USA, and represents a significant source of disability to patients; however, the orbits remain a potential blind spot for radiologists. The goal of this article is to review the relevant anatomy of the orbit and imaging findings associated with commonly encountered acute ocular traumatic pathology, while highlighting the salient information which should be reported to the ordering clinician. Topics discussed include trauma to the anterior and posterior chamber, lens dislocations, intraocular foreign bodies, and open and contained globe injuries.

Preventive effects of diltiazem on cyclosporin A-induced vascular smooth muscle dysfunction

Cyclosporin A may cause vascular smooth muscle dysfunction due to calcium overload as a consequence of chronically augmented calcium influx. In the present study, the responsiveness to vasocontrictors was investigated in rats after chronic treatment for 6 weeks with placebo, cyclosporin A (30 mg/kg per day), diltiazem (60 mg/kg per day), or cyclosporin A plus diltiazem. Twenty-four hours after the last oral treatment the animals were sacrificed and rings of the thoracic aorta were suspended in organ chambers under isometric conditions in the absence of cyclosporin A or diltiazem. Chronic treatment with cyclosporin A significantly augmented contractions to angiotensin II (10(-9)-10(-5) M). This effect was prevented by cotreatment with diltiazem. Diltiazem did not affect the cyclosporin A-induced reduction in the response to potassium chloride (10-80 mM). The contractions to phenylephrine (10(-9)-10(-6) M) and endothelin-1 (10(-9)-10(-7) M) were not significantly different in the four groups. The preventive effect of diltiazem against the cyclosporin A-induced hypersensitivity to angiotensin II supports the hypothesis of increased calcium influx during cyclosporin A therapy. The results may provide an additional rationale for the use of calcium antagonists in the treatment of the vascular side effects of cyclosporin A.

Calcium entry blockade may prevent cyclosporin A-induced hypersensitivity to angiotensin II and endothelial dysfunction in the rat aorta

Vascular smooth muscle dysfunction after chronic treatment with cyclosporin A was in part explained by chronically augmented calcium influx leading to calcium overload. The potential protective effect of calcium antagonism with diltiazem as regards endothelial and vascular smooth muscle reactivity was investigated during chronic treatment with cyclosporin A. Male Wistar rats were orally treated for 6 weeks with either cyclosporin A (30 mg.kg-1 x day-1 in 1 ml, n = 8), with the vehicle alone (n = 10), with diltiazem (60 mg.kg-1 x day-1, n = 10) or with a combination of cyclosporin A and diltiazem (30 mg.kg-1 x day-1 and 60 mg.kg-1 x day-1, n = 8), respectively. Rings of the isolated thoracic aorta were mounted in organ chambers to measure isometric force. Chronic treatment with diltiazem alone did not affect the responsiveness to any of the drugs tested, but the augmentation of contractions to angiotensin II (10(-9) to 10(-6) M) after treatment with cyclosporin, was prevented by co-treatment with diltiazem. Co-treatment with diltiazem, however, did not affect the response to potassium chloride (20-80 mM), endothelin-1 (10(-9) to 10(-7) M) or phenylephrine (10(-9) to 10(-6) M). Endothelium-dependent relaxations to calcitonin gene-related peptide (CGRP, 10(-10) to 10(-7) M) and acetylcholine (10(-8) to 10(-5) M) were reduced in cyclosporin A treated rats. Co-treatment with diltiazem normalized the response to CGRP. The response to acetylcholine was not significantly affected.(ABSTRACT TRUNCATED AT 250 WORDS)

Endothelial and vascular smooth muscle function after chronic treatment with cyclosporin A

We wished to characterize the altered reactivity of vascular smooth muscle and endothelial cells in rat aorta during chronic treatment with cyclosporin. Male adult rats were treated orally for 6 weeks with either cyclosporin A (30 mg/kg/day in 1 ml olive oil, n = 9) or with vehicle alone (n = 10). Rings of isolated thoracic aorta were mounted in organ chambers to measure the change in isometric force in response to smooth muscle-contracting drugs and endothelium-dependent and independent vasodilators. Contractions to potassium chloride (20-80 mM) were markedly reduced in cyclosporin-treated rats. Contractions to phenylephrine (10(-10)-10(-6) M) were reduced at high concentrations (> or = 10(-7) M); those to endothelin-1 (10(-10)-10(-7) M) were not significantly altered. In contrast, contractions to angiotensin II (AII 10(-9)-10(-6) M) were significantly augmented. Endothelium-dependent relaxations to acetylcholine (ACh 10(-8)-10(-5) M) or ADP (10(-7)-10(-5) M) were reduced in cyclosporin-treated rats; endothelium-independent relaxations to SIN-1 (10(-7)-10(-5) M) and atrial natriuretic peptide (ANP 10(-10)-10(-7) M) remained unaffected. Thus, chronic treatment with cyclosporin affects both endothelium-dependent vasodilation and vascular smooth muscle contraction in rat aorta depending on the stimulus applied. The enhanced response to AII and the reduced release of endothelium-derived relaxing factor (EDRF) may contribute to augmented vascular tone and further damage to the arterial wall.