The assessment and management of foot and toe oedema as part of holistic lower limb care

Toe and foot swelling can manifest as lymphoedema or chronic oedema but can also be a complication of the treatment of these conditions. In this article, the authors discuss the assessment and treatment options for toe and foot swelling, highlighting the importance of prevention in the first instance.

Incidental Colonic Masses and Cytomegalovirus (CMV) Infection in a Treatment- Naïve Chronic Lymphocytic Leukemia Patient without GI symptoms

Introduction/Objective

Gastrointestinal (GI) involvement by leukemia ranges from 5.7 to 13 % with very few published reports describing infiltration of the GI tract by chronic lymphocytic leukemia (CLL). GI bleeding, abdominal pain, and obstruction have been described as presenting symptoms of GI involvement. Yet, discrete lesions are rare. Infection is a common complication in patients with CLL. In untreated patients, these infections are typically by encapsulated bacteria involving the respiratory tract and associated with hypogammaglobulinemia. Viral infections often happen after therapy. This report presents a patient with a history of treatment- naïve CLL and HSV who presented for colostomy reversal and was incidentally found to have two partially obstructing colonic masses, as well as cytomegalovirus (CMV) infection.

Methods/Case Report

This is a 78-years-old female with treatment-naïve CLL and past medical history of hypertension, atrial fibrillation, diverting colostomy secondary to chronic perineal HSV-2 ulcer and recent perirectal abscess. She presented for colostomy reversal in the absence of any reported GI symptoms at that time. Labs showed leukocytosis; WBCs count of 25 K/MM3, anemia and neutropenia. Endoscopic studies incidentally discovered two partially obstructing masses in the ascending and transverse colon that were biopsied. A right hemicolectomy and colostomy closure were followed, and the patient was discharged on valganciclovir.

Results (if a Case Study enter NA)

Histopathological examination demonstrated mucosal ulceration with viral cytopathic changes and positive CMV IHC stain. In addition, a dense atypical, small sized lymphoid cell infiltrate with no sheets of large cells or confluent necrosis were identified. Flowcytometry and IHC stains showed aberrant CD5+ B cells with CD23 co-expression consistent with the patient’s history of CLL.

Conclusion

The case describes the unique presentation of a patient with treatment- naïve CLL without any GI symptoms, yet was incidentally found to have colonic involvement by CLL forming discrete colonic masses as well as CMV and HSV infections. Since she is untreated, her infections (HSV and CMV) are likely secondary to being immunocompromised by CLL and neutropenia. In conclusion, although rare, GI involvement by CLL should be considered in treatment naïve CLL patient’s and concomitant infections should be evaluated.

Treating chronic oedema of the lower limb using circular knit garments: how garment characteristics affect outcomes

The use of compression therapy to treat chronic oedema of the lower limbs can be a challenge, especially when this is undertaken by clinicians who have limited experience and knowledge of the theoretical principles which underpin its use in clinical practice. This articles aims to discuss the reasoning which underpins the use of compression hosiery in the management of lymphoedema and how this understanding can improve treatment outcomes and reduce the burden of disease on patients and clinical resources.

Rethinking decongestive lymphoedema treatment during the pandemic

During the course of the COVID-19 pandemic, lymphoedema and community clinicians have had to modify how they implement intensive treatments for patients with lymphoedema and chronic oedema. Using novel approaches to treat and move patients towards self-management regimes has enabled patients to be in control of their condition, particularly if they are unable to attend normal clinic appointments. This article explores how using Haddenham easywrap instead of time- and resource-intensive bandaging regimes, alongside the Haddenham LymphFlow Advance, as part of self-management programmes, can benefit patients' quality of life, reduce costs and resource use and enable patients to self-manage this long-term chronic condition more effectively.

Empowering patient self-management through tailored compression garment regimens

Over recent years, compression wraps, also known as adjustable compression wrapping devices (ACWDs), have become an increasingly important part of lymphoedema management. Widely used in lymphoedema clinics, they are also now a popular treatment choice within tissue viability, as well as in practice and community nursing, where their cost- and resource-saving advantages are greatly appreciated. Easywrap from Haddenham Healthcare is a popular choice among both health professionals and patients, due to its low profile, making it a comfortable option for wearing beneath normal clothes, and its uncomplicated design, making it easy for patients to put on and take off themselves. This article will evaluate the advantages of using Easywrap for self-management and explore why the Fusion liner, which is now available on drug tariff, can further improve self-care in lymphoedema management.

Use of Haddenham Venex armsleeve for lymphoedema management in clinical practice

Lymphoedema of the upper limb can be an unwelcome side effect of treatment for breast cancer, some skin cancers, as well as having non-cancer-related causes. Treatment focuses on patient self-management, and involves skin care, exercise, lymphatic drainage massage and compression. Lymphoedema is a chronic, life-long condition, and the correct choice of garment will influence treatment outcomes, enhancing concordance and improving quality of life. This article examines how, following recent improvements to the comfort and overall fit of the Haddenham Venex lymphoedema sleeve, patient feedback informed the implementation of further modifications, and how gaining feedback from patients has empowered them to manage and monitor their own condition. By taking ownership for their own care, long-term control of the condition is improved and self-management is enhanced.

The presence of biofilm structures in atherosclerotic plaques of arteries from legs amputated as a complication of diabetic foot ulcers

OBJECTIVE

Atherosclerosis, rather than microcirculatory impairment caused by endothelial cell dysfunction, is the main driver of circulatory compromise in patients with diabetic limbs. The presence of atherosclerotic plaque at the trifurcation is a significant contributor to amputation of diabetic legs. The presence of bacteria and other microorganisms in atherosclerotic plaque has long been known, however, the cause of chronic inflammation and the role of bacteria/viruses in atherosclerosis have not been studied in detail. The objective of this study was to clarify the cause of the chronic inflammation within atherosclerotic plaques, and determine if any bacteria and/or viruses are involved in the inflammatory pathway.

METHOD

This study uses fluorescence microscopy and fluorescence in-situ hybridisation (FISH) to identify components of biofilm in atherosclerotic arteries. These tools are also used to identify individual bacteria, and determine the architectural spatial location within the atherosclerotic plaque where the bacteria can be found.

RESULTS

The results indicate that the presence of biofilms in grossly involved arteries may be an important factor in chronic inflammatory pathways of atherosclerotic progression, in the amputated limbs of patients with diabetic foot ulcers and vascular disease.

CONCLUSION

While the presence of bacterial biofilm structures in atherosclerotic plaque does not prove that biofilm is the proximate cause of atherosclerosis, it could contribute to the persistent inflammation associated with it. Second, the synergistic relationship between the atherosclerotic infection and the diabetic foot ulcer may ultimately contribute to higher amputation rates in diabetics.

DECLARATION OF INTEREST

RAW and RDW have equity interest in PathoGenius, a clinical laboratory using DNA to identify microbes.

Ferrous iron formation following the co-aggregation of ferric iron and the Alzheimer's disease peptide β-amyloid (1-42)

For decades, a link between increased levels of iron and areas of Alzheimer's disease (AD) pathology has been recognized, including AD lesions comprised of the peptide β-amyloid (Aβ). Despite many observations of this association, the relationship between Aβ and iron is poorly understood. Using X-ray microspectroscopy, X-ray absorption spectroscopy, electron microscopy and spectrophotometric iron(II) quantification techniques, we examine the interaction between Aβ(1–42) and synthetic iron(III), reminiscent of ferric iron stores in the brain. We report Aβ to be capable of accumulating iron(III) within amyloid aggregates, with this process resulting in Aβ-mediated reduction of iron(III) to a redox-active iron(II) phase. Additionally, we show that the presence of aluminium increases the reductive capacity of Aβ, enabling the redox cycling of the iron. These results demonstrate the ability of Aβ to accumulate iron, offering an explanation for previously observed local increases in iron concentration associated with AD lesions. Furthermore, the ability of iron to form redox-active iron phases from ferric precursors provides an origin both for the redox-active iron previously witnessed in AD tissue, and the increased levels of oxidative stress characteristic of AD. These interactions between Aβ and iron deliver valuable insights into the process of AD progression, which may ultimately provide targets for disease therapies.

Effects of chronic iron deficiency anaemia on myoglobin content, enzyme activity, and capillary density in the human skeletal muscle

The influence of chronic iron deficiency anaemia on myoglobin content, maximal enzyme activities and capillarization in the human skeletal muscle was investigated. Muscle samples from musculus vastus lateralis were screened in an Indonesian population. The causes of iron deficiency were chronic intestinal bleeding or repeated pregnancy combined with low iron intake. The maximal activities of iron-dependent and non-iron-dependent glycolytic and oxidative enzymes as well as myoglobin showed similar values in the iron-deficient group and the matched control group. The activities of the oxidative enzymes in both the iron-deficient group and the controls were lower, however, compared even to untrained Swedish subjects. The capillary density was essentially within a normal range in both groups. It is concluded that chronic iron deficiency anaemia of a moderate or severe degree, with Hb concentrations of about 80-100 g.1(-1), does not cause an impaired biochemical function of the human skeletal muscle.

The NCI pediatric central institutional review board (PedCIRB) initiative: Progress and impact

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NCI has developed a central IRB (PedCIRB) to review NCI-sponsored pediatric clinical trials conducted by the Children's Oncology Group (COG). COG comprises ∼200 U.S. medical institutions and protocol activation traditionally requires separate protocol review by each local IRB (LIRB) and, subsequently, a review of each protocol amendment and significant adverse event. The PedCIRB model seeks to increase patient protection by improving the expertise of protocol reviewers and making their review available to all PedCIRB participating institutions. The PedCIRB consists of experts in pediatric oncology, pediatric medicine, nursing, pharmacy, bioethics, biostatistics, as well as patient advocates and childhood cancer survivors. The PedCIRB model also eliminates redundant reviews, reduces administrative burdens on local COG investigators and LIRBs, and can accelerate the pace of local protocol activation, thus increasing the availability of clinical trials to children with cancer. The PedCIRB conducts a full board protocol review that is available via a confidential website to participating LIRBs. LIRBs can choose to perform a facilitated review, using PedCIRB materials, that focuses on local concerns, rather than a full LIRB protocol review. If the LIRB accepts the PedCIRB review, the PedCIRB becomes the IRB of record for that protocol and takes responsibility for the review of subsequent protocol amendments, adverse events and continuing reviews. Since starting in November 2004, the PedCIRB has reviewed 59 protocols. Initial reviews resulted in 44 approvals pending modification and 15 protocols being tabled for further information. The time from protocol submission to final approval by the PedCIRB has ranged from 3 to 28 weeks with an average time of 16.9 weeks during year one and 12.7 weeks during year two of the project. As of November 2006, 117 of a possible 197 U.S. COG institutions (59%) have signed on to the PedCIRB initiative and 70% of the participating institutions have conducted facilitated reviews (total 750) for the 30 protocols available on the PedCIRB website. The PedCIRB's influence on protocol development and patient accrual timelines will be discussed.

No significant financial relationships to disclose.

Use of the Internet to optimize self-management of type 1 diabetes: preliminary experience with DiasNet

Six patients with type 1 diabetes participated in a pilot trial. Their median age was 36 years (range 29-61) and the median duration of diabetes was 10 years (range 3-29). They were asked to enter, from their home or work PC, blood glucose values, insulin doses and a food diary. From the data entered, a computer model generated a simulation of the blood glucose concentration for the data collection period. It could then suggest alternative insulin doses (or regimes), or meal sizes, to reduce the risk of hypo- and hyperglycaemia. During a six-month study, patients entered a median of five sets of data (range two to eight). Feedback from participants revealed that while the system was helpful, difficulties with data entry hindered its use. Information gained from this exercise is shaping further development of the system.

[Schizophrenia and performance on the Wisconsin Card Sorting Test (WCST): deficits and rehabilitation]

In recent years, there has been a sustained interest in the so-called "frontal hypothesis" of schizophrenia: the idea that clinical symptoms and cognitive deficits characteristic of schizophrenia might be explained by defective function of the frontal lobes. Several studies have attempted to test this hypothesis by examining the performance of schizophrenic subjects on the Wisconsin Card Sorting Test (WCST), a neuropsychological evaluation widely believed to reflect the functional capacity of frontal lobes. A typical finding is that schizophrenic patients demonstrate a tendency to perseverate in producing an inappropriate response in spite of negative feedback. This perseverative tendency resembles the perseveration often seen in patients with frontal brain damage. This article proposes a critical examination of the available evidence linking frontal deficits with schizophrenia via the WCST. As we will show, in most of these studies, only a relatively small number of the available measures on the WCST are made, and consequently many interesting cognitive capacities in schizophrenic subjects have not been adequately examined with this test. These "non-classical" measures will be described and critically examined with respect to their pertinence for further work on schizophrenic subjects. Of particular interest are the "failure to maintain set", which measures cognitive instability, "conceptual responses", which can indicate a certain conceptual capacity even in subjects who show perseveration, and "learning to learn", which can demonstrate a capacity to profit from experience on the test. A second objective will be to critically examine the evidence concerning the capacity of schizophrenic patients to improve their performance on the WCST. To the extent that performance on the WCST reflects the functional level of cognitive capacities important for everyday life, any capacity in schizophrenic patients to improve their performance could have important implications for therapeutic intervention and re-education.

The application of non-combinatorial chemistry to lead discovery

Non-combinatorial chemistry is a powerful technology for the synthesis of large numbers of compounds, with complete control over the properties of those compounds. We have developed a Library Creation, Registration and Automation system (LiCRA), which harnesses an efficient non-combinatorial chemistry design and synthesis engine, together with high-throughput automated purification. This LiCRA system also operates in a closed loop mode for hit-to-lead optimization, and contains an integrated IT system that controls and facilitates all aspects of the operation from design to registration. Quality has been our watchword, from the quality of compound design through to the quality of the products.

Prospective evaluation of an outpatient heart failure management program

BACKGROUND

Although considerable effort has been devoted to the follow-up of hospitalized patients, the effectiveness and process of heart failure outpatient management have not been well demonstrated.

METHODS AND RESULTS

All new patients referred to the program from April 1997 to September 1998 were followed and managed by comprehensive strategies including preemptive hospitalization. Quality of life (QOL) and patients' self-care adherence behaviors were measured at baseline, 3 months, and 6 months. Clinical outcomes were compared for the 6 months before and 6 months after referral. A total of 108 patients were recruited. Patients' self-care knowledge score was improved over time (difference score = 0.9, P <.01). The proportion of patients weighing themselves daily increased by 24% (P =.02). The proportion of patients with New York Heart Association (NYHA) class III to IV was 67.6% at baseline and 49.1% at 6 months (P =.01). Compared with 6 months before referral, the program intervention was accompanied by a 52% reduction in the risk of hospitalization for cardiovascular causes (56.1% v 27.2%, P <.001) and a 72% reduction in emergency room visits (53.6% v 14.5%, P <.01). The total hospital admissions for cardiovascular causes decreased by 59% from 94 to 39; the total emergency room visits decreased by 77% from 83 to 19. The patients' QOL was improved over time with a change score of 11.2 (P <.001) at 3 months and 10.7 (P <.001) at 6 months.

CONCLUSION

Our study shows the effectiveness of this heart failure outpatient management program.

Performance of patients with schizophrenia on the Wisconsin Card Sorting Test (WCST)

OBJECTIVE

To directly compare the performance of patients with schizophrenia and control subjects on the Wisconsin Card Sorting Test (WCST). Specifically, we sought to verify if there are significant differences on the "classical" WCST measurements (perseverative errors and number of categories), as well as on more rarely reported scores, and assess the extent to which patients with schizophrenia can improve their performance with card-by-card instructions and continuous verbal reinforcement.

DESIGN

Prospective cross-sectional study.

SETTING

Psychiatry department in a university-affiliated hospital.

PARTICIPANTS

30 patients with schizophrenia, diagnosed according to DSM-IV criteria, and 30 control subjects, matched to patients according to age and education.

INTERVENTION

The WCST was administered according to the criteria of Heaton, and a subgroup of the patients with schizophrenia was given a retest after an explanation of the WCST and verbal reinforcements.

RESULTS

Patients with schizophrenia succeeded on fewer categories (t = 23.3, p < 0.001), committed more perseverative errors (t = 15.6, p < 0.001), made more perseverative responses (t = 14.6, p < 0.001), needed more trials to succeed at the first category (t = 9.2, p < 0.003) and gave significantly lower conceptual level responses (t = 14.1, p < 0.001) than the controls. However, on retest, patients with schizophrenia committed significantly fewer perseverative errors (t = 5.1, p < 0.001) and showed higher conceptual level responses (t = -3.45, p < 0.003).

CONCLUSION

Consistent with a hypothesis of frontal dysfunction in schizophrenia, patients with schizophrenia tend to show a perseverative deficit; however, some are able to partially overcome this deficit when given verbal reinforcement.

Reducing hospital inpatient length of stay for patients with diabetes

AIMS

To ascertain the effect of routine review by a diabetes nurse advisor on length of stay for medical and surgical inpatients with diabetes.

METHODS

Inpatients with diabetes were identified prospectively from January 1997 until December 1998 (792 in 1997 and 819 in 1998). A new post of diabetes nurse advisor was introduced in January 1998 to optimize diabetes management. Length of stay was calculated retrospectively from hospital computer records.

RESULTS

Median length of stay in 1997 was 11 days in medicine and 8 days in surgery. In 1998, the nurse advisor made 1936 visits to 819 patients; median length of stay fell to 8 days in medicine and 5 days in surgery (P < 0.001). Bed occupancy by patients with diabetes fell from 6.8 to 4.0%. Mean length of stay across the hospital remained unchanged.

CONCLUSIONS

The introduction of a ward-based diabetes nurse advisor was associated with significant reductions in length of stay in inpatients with diabetes. Since this study was not a randomized study, other factors may have contributed to this change. However, the consistency of the reduction across specialities suggests the post itself had an important effect.

Driving and insulin--consensus, conflict or confusion?

AIMS

All drivers requiring insulin treatment must be able to demonstrate satisfactory diabetic control and recognition of hypoglycaemic symptoms before being allowed to drive a motor vehicle. Clinicians have a duty to discuss fitness to drive with their patients. However, is the advice given consistent and in line with the regulations published by the Driver and Vehicle Licensing Authority (DVLA)?

METHODS

Six 'real-life' case scenarios were posted to clinicians (consultant diabetologists, specialist registrars and diabetes specialist nurses) within Wessex, UK. The identical cases were also sent to the DVLA for their comments.

RESULTS

Sixty-six doctors (36 consultants) and 70 diabetes specialist nurses were contacted by postal questionnaire of which replies were received from 17 consultants (47%), 17 specialist registrars (57%) and 39 diabetes specialist nurses (56%). Although there was general agreement in cases of hypoglycaemia unawareness, there was disagreement where patients had or were at risk of unstable control albeit for a short time.

CONCLUSIONS

Patients treated with insulin may receive conflicting information concerning their ability to drive.

[Cognitive inhibition and psychopathology: toward a less simplistic conceptualization]

"Cognitive inhibition" is a concept that has found a firm place in the interpretation of performance by normal subjects on tasks involving adherence to a plan and suppression of incorrect responses to distractors. The presence of "negative priming" is the classical indicator of cognitive inhibition. Negative priming occurs when, in a sequence of stimuli each of which is composed of a target and a distractor, the distractor of the first stimulus becomes the target of the second stimulus: reaction time to the second stimulus is slowed because of the inhibition applied to the distractor of the first stimulus. The concept has been extended to the interpretation of pathological behavior and symptoms. Pathological subjects have been found to show deficient negative priming. Thus, negative ideation in depression as well as intrusive paranoid associations in schizophrenia have been related to a deficit in the capacity to inhibit inappropriate representations. In this paper, we briefly review some of the experimental evidence from normal subjects that has contributed to the acceptance of cognitive inhibition as a key process in the control of normal cognition, as well as more recent evidence that has led to a revision of the concept. Negative priming in normal subjects has been found to be dependent upon characteristics of the experimental situation as perceived by the subject. In particular, priming is observed when the subject anticipates difficulty in determining the response and proceeds with caution. Thus, inhibition is not an automatic "brake" applied to irrelevant material, but rather the product of strategic considerations within the experimental situation. This revision of the cognitive inhibition hypothesis leads to a re-interpretation of the apparently deficient cognitive inhibition seen in depressed or schizophrenic subjects. According to this more recent interpretation, deficient cognitive inhibition in pathological subjects can be seen as a less adaptive strategic adjustment to the task. The pathology seems to touch higher-level executive functions rather than a deficient inhibitory "brake". In depressed subjects, abnormal performance in selective attention tasks could be related to the underlying pathology in two ways: some depressed subjects show a marked lack of energy and a psychomotor slowing: these subjects do not exhibit normal negative priming, probably because of a reduction of cognitive resources. Other depressed subjects show abnormal performance as reflected by negative priming greater than normal: this result could be related to an exaggerated tendency to verify a correct response. Schizophrenic subjects show a lack of negative priming that seems most plausibly to be related to an ineffectual integration of the experimental instructions concerning both speed and accuracy in the response. This re-interpretation of the cognitive deficiency in pathological patients provides a better fit with recent experimental results from normal subjects, and with cognitive deficits measured in pathological subjects.

[Deficit in suppression of interference in visual information processing by schizophrenic subjects]

Although many studies have indicated information processing deficits in schizophrenic patients, the precise nature and underlying causes of these deficits remain largely uncertain. One prominent hypothesis is that these patients show insufficient attentional inhibition. This deficit to inhibition has been linked to certain cognitive disorders in schizophrenic patients, including attention deficits, as well as to some clinical symptoms, especially those involving delusional thought, hallucinations,and poor contact with reality. The hypothesis of deficient attentional inhibition, although attractive in some ways, is difficult to work with, because it is not easy to directly measure "attentional inhibition". Several studies involving normal subjects have linked attentional inhibition with performance on a task demanding the suppression of distracting information: the presumption is that efficient attentional inhibition will permit rapid responses because the distracting information will be quickly suppressed, allowing undistracted processing of the target information. The present study measures schizophrenic patients' performance on a task demanding suppression of rapidly-presented visual information. An important methodological feature of this study is that performance is measured in terms of "percent correct responses" rather than the reaction time measures typically used in tasks demanding distractor suppression, such as Stroop-like selective attention tasks. Since reaction times are not considered, the results cannot be interpreted in terms of deficient response organization and execution. Schizophrenic (18) and normal (18) subjects underwent trials in which a visual target was the second of two stimuli presented in rapid succession. Interference produced by a non-target significantly impaired perception of the target for schizophrenic patients. This effect persisted longer in the schizophrenic subjects possibly because of deficient attentional inhibition.

The Morehouse Faculty Development Program: methods and 3-year outcomes

BACKGROUND AND OBJECTIVES

Faculty development is an established method for increasing the number and effectiveness of faculty in family medicine. However, few published studies focus specifically on the use of faculty development to increase minority representation among faculty. Underrepresented minorities comprise 20% of the nation's population but only 3% of medical school faculty. In the entire nation, only 52 full-time teachers of family medicine are African-Americans. Morehouse School of Medicine has developed an effective model for training large numbers of underrepresented minority physicians to become academic family physicians. From 1993-1996, we trained 23 community-based physicians, three new faculty, six existing faculty, and three full-time fellows as teachers of family medicine. Of 35 participants, 33 were underrepresented minorities. Cultural issues in teaching and communication are an integral part of the curriculum. Seventy-three percent of graduates now teach medical students or residents either full-time or part-time. Further studies are needed to test the replicability of this model in non-minority institutions, as well as to achieve greater cost-effectiveness and improve academic outcomes such as publications and research. Significant faculty diversity is necessary and achievable, if institutions are willing to commit significant resources and network with minority health professionals and institutions.

Distractibility and processing resource deficit in major depression. Evidence for two deficient attentional processing models

Performance on the Stroop Color-Word Test is impaired in depression, but it is not clear whether this impairment reflects a distractor inhibition disturbance or a reduction of processing resources. In this study, untreated major depressives were evaluated using a modified computerized Stroop Test composed of three tasks: to name the color of XXXXXs, of nonconflicting words, and of conflicting color words. It was hypothesized that, unlike color words, nonconflicting word distractors would disturb the color naming task only in the presence of a primary distractor inhibition disturbance. The slow reaction time (RT) depressives and normal RT depressives, according to their color naming speed without distractors, were contrasted to distinguish depressives with and without clear signs of resource deficit. It was found that interference produced by nonconflicting words was greater in normal RT depressives than in either slow RT depressives or control subjects, while interference caused by color words was dramatically stronger in slow RT depressives than in other groups. Results suggest the existence of two different attentional deficit patterns in clinical depression: some depressives have a distractor inhibition disturbance while others are deficient in processing resources.

[Deficit in selective attention and its evolution in depression]

Selective attention was measured in 34 depressed patients and 34 controls using a computerized version of the Stroop test, that included a manipulation of the stimulus onset asynchrony (SCA) in order to explore the efficacy of cognitive inhibition as a function of depression and of clinical amelioration of degression after therapy. Clinical tests included a measure of psychomotor slowing [Echelle de Ralentissement de Widlöcher (ERD), the Hamilton (Psychiatric Rating Scale for Depression (HAMD), and the Brief Psychiatric Rating Scale (BPRS)]. Selective attention was measured with the Stroop test, which includes four measures: Word, Color, Color-Word, and Color-Word minus Color, or interference. All of these measures were deficient in the depressed patients, particularly Stroop interference. Even when additional time was given to inhibit the Stroop distractor in the SOA condition, depressed subjects still showed significantly inferior performance. After four weeks of anti-depressive treatment, fifteen of the patients were retested, and showed significant improvement on all the Stroop measures, particularly on Stroop interference. The improvement in performance on the attentional measures was comparable in magnitude to that seen on the clinical scales, and suggests that the interference measure can be a sensitive indicator of clinical status in depressed patients.

Attention deficits in depression: an electrophysiological marker

EVENT-RELATED POTENTIALS were recorded in young depressed subjects and compared with results from controls. Subjects were required to respond to targets (rare high-frequency sounds) presented to a designated ear, and to ignore targets presented to the non-designated ear as well as standards (frequent low-frequency sounds) presented to either ear. The results confirm those previously obtained with elderly depressed patients, showing the same general profile of electrophysiological and behavioural differences, and in particular a substantial reduction of the N200 amplitude in response to attended targets in depressed subjects. It is suggested that the N200 component could be a marker of depression.

Obesity and hypertension among African Americans: do African-American primary care providers address these conditions when secondary to primary illness?

This study examined the extent that black family medicine residents manage African-American patients with hypertension and obesity secondary to the primary health problem. A retrospective chart survey of 1806 outpatients was used to select a sample of 362 patients being treated by 12 African-American family medicine residents. Of the 362 patient charts, 31.2% of the patients had hypertension (ie, blood pressure > or = 140/90 mm Hg). A plan for managing hypertension was found in the charts for 77% of these patients. Obesity was present among 37% of the patients, and yet there was documentation of a treatment plan for managing this condition for only 38% of these patients. Black family medicine residents appear to be sensitized about addressing the problem of hypertension among African-American patients being treated for other illnesses. However, there is a vital need to teach family medicine physicians how to address and aggressively manage the problem of obesity among African-American patients, particularly those patients for whom obesity was not the primary reason for seeking medical care.

Attention disturbance in clinical depression. Deficient distractor inhibition or processing resource deficit?

Cognitive impairments in depression have recently been proposed as secondary to more basic attentional disturbances. Studies have shown that performance on the Stroop Color-Word Test is impaired in depressives, but it is not clear whether this impairment reflects a primary distractor inhibition disturbance or a more global cognitive dysfunction, such as a reduction of processing resources. In the present study, unmedicated clinical depressives were evaluated using a computerized Stroop Color-Word Test and the Visuo-Spatial Interference Test, a selective attention task that makes fewer demands on resources. Compared with normal subjects, depressives presented increased choice reaction times (CRT) and interference in both tests. Correlations were found between CRT and interferences only in depressives, favoring the processing resource hypothesis. Further exploratory analysis comparing the more rapid depressives and the slower normal subjects on CRT revealed that although these subgroups had comparable CRT, rapid depressives still exhibited increased interference on the Visuo-Spatial Interference Test. Thus, in non- or mildly retarded patients, a specific distractor inhibition deficit was observed in absence of resource deficit.

HLA-DR mismatching correlates with early cardiac allograft rejection, incidence, and graft survival when high-confidence-level serological DR typing is used

To determine if cardiac allograft outcome is improved among patients with fewer HLA-DR mismatches with their donors, we studied 132 recipients of a primary cardiac allograft who were transplanted between December 1985 and December 1991. These recipients and their donors all had high-confidence-level serological HLA-DR typing, previously shown to correlate highly with DNA DR typing. Patients were divided in two groups based on the HLA-DR mismatch with their donors. Group I consisted of 78 patients with 1 or zero DR mismatch and group II of 54 patients with 2 DR mismatches. Allograft outcome measurements included incidence of moderate rejection, incidence of allograft vasculopathy at 12 months, cardiac function measured as left ventricular ejection fraction (LVEF) and cardiac index (CI), and actuarial graft survival up to 7 years. Groups I and group II were not different with regard to recipient age, donor age, ischemia time, pulmonary vascular resistance, sex, or PRA greater than 0%. Group II had a higher incidence of moderate rejection on the first-week biopsy (47% vs. 25%, P = 0.019), and during the first month (84% vs. 58%, P = 0.006), but no difference was found in frequency of rejection from months 2 to 12. LVEF was not different in the groups at any point. CI was better in group I at 12 months (2.76 vs. 2.5, P = 0.03). No statistically significant difference was found in incidence of allograft vasculopathy (17% vs. 26%, P = 0.204). Actual graft survival at 1 year was better for group I (91% vs. 74%, P = 0.008), and actuarial graft survival at 6 years also favored group I (76% vs. 56%, P = 0.04). Using high-confidence-level serological HLA-DR typing assignments we demonstrated that HLA-DR mismatching correlates highly with cardiac allograft outcome. Implications are that heart transplant survival could be improved if prospective matching were feasible and prioritized or if immunosuppression were tailored to the HLA-DR match.

Changing from porcine to human insulin

The development of hypoglycaemia unawareness is associated with long duration of diabetes, improved glycaemic control, alcohol intake and recurrent hypoglycaemia. However, current evidence suggests that neither frequency of severe episodes nor mortality from hypoglycaemia are increased following a change from animal to human insulin. Nevertheless, a small number of patients continue to report an alteration in the nature of hypoglycaemic warning symptoms following a change in insulin species. This is possibly a consequence of a reduced catecholamine response to lowering blood glucose levels or to species differences in the effect of insulin on central nervous system function. In practical terms, it seems sensible to warn patients that the nature of the symptoms associated with hypoglycaemia might alter following conversion from porcine to human insulin. At the time of the changeover, patients should be encouraged to perform frequent blood glucose measurements. Also, the usual insulin dose should be reduced by 10% at the start of human insulin treatment. Other aspects of insulin treatment including injection technique, meal timing, exercise, etc. should be discussed. For patients who are convinced that loss of warning of hypoglycaemia occurred after conversion from porcine to human insulin, a change back to animal insulin would be preferred to relaxing glycaemic control in the first instance. Pressure should be brought to bear on the pharmaceutical industry to maintain the availability of animal insulins for the small number of patients who have experienced problems with human insulin.

[Frontal lobe hypoactivity in schizophrenia: change in perspective]

Many attempts to isolate a dysfunctional site in the brain of schizophrenic patients have converged in a neuropathological conception of the disease based on frontal lobe hypoactivity. Recent data from studies using cytoarchitectony, computerized tomographic scans, cerebral regional blood flow, smooth pursuit eye movements and neuropsychological assessments are discussed. Current data on the hypofrontality hypothesis in schizophrenia seem to suggest an associationist rather than a localisationist perspective of the disorder.

Inhibition through negative priming with Stroop stimuli in schizophrenia

Stroop stimuli were used to measure the negative priming effect in eight positive and 10 negative schizophrenics, 21 depressive and 35 healthy control subjects in order to test hypotheses of insufficient versus persistent cognitive inhibition in schizophrenia. Data show that schizophrenics do not increase their response times to suppressor Stroop items compared to identical but neutral Stroop stimuli because the insufficiency of their inhibitory processes weakens the distractor-suppression effect. However, pre-exposure of the lexical distractor can compensate for insufficient inhibitory mechanisms in positive but not negative schizophrenics, suggesting more severe deterioration in the latter. Depressed subjects showed a slower development of cognitive inhibition. The results suggest important differences in the temporal evolution of inhibitory processes, and are discussed in terms of Hemsley's (1977) and Frith's (1979) theories.

[Selective attention in major depression: clinical retardation and cognitive inhibition]

Relationships between clinical retardation (measured by the Hamilton Depression Inventory) and selective attention (measured with a computerized version of the Stroop word colour test) were studied in a population of 21 depressed patients. Stroop interference was higher in depressed patients than in normals. Desynchronized presentations of the distractor and the target and intervals between responses and succeeding stimuli permitted depressed subjects to respectively apply and lift inhibition of the distractor so that their interference was reduced to control levels. Finally, successive inhibition scores were correlated with the retardation score in depressed subjects. The results are consistent with the hypothesis of a retardation in the application and the lifting of cognitive inhibition in depression.

[Attention deficits and schizophrenia. Multidisciplinary approaches and the Stroop's test]

Since McGhie & Chapman's (1961) pioneering work, there have been continual attempts to clarify the link between attentional disturbances observable in schizophrenics and their schizophrenic symptoms. Venables (1964, 1977) claims that this diminution is a consequence of a badly controlled arousal, resulting in an inadequate filtering at the level of sensory input. Although the notion of a faulty sensory filter is simple and intellectually satisfying, this idea rapidly met with articulate opposition. Broadbent himself, in 1971, revised his model to take into account the way in which semantic aspects influence selective attention, and proposed the existence of a second stage of information processing, coming after the sensory filter. It became increasingly clear that progress in understanding selective attention would depend upon more centrally-directed approaches. In 1935, Stroop developed an ingenious way of studying selective attention. In his task, an "automatic", overlearned task (reading short words aloud) is put into conflict with a slightly more difficult task (colour-naming): the subject has to name the colour of the ink in which a word is printed, but the word itself is the name of a different colour. For instance, when the word "blue" is written in red ink, the correct response is "red". Typically, subjects find it difficult to inhibit the reading response, and take significantly more time to name a colour that forms an incompatible word than take to name the colour of a row of letters "x". This increased reaction time for the incompatible condition is attributed to an "interference" caused by the verbal information contained in the double stimulus.(ABSTRACT TRUNCATED AT 250 WORDS)

Cognitive effects of psychostimulant medication in hyperactive children

Hyperactive and normal children were given a test of selective attention (Stroop test) and a neurocognitive test sensitive to a functional deficit of prefrontal cortex (Wisconsin Card Sorting Test). Hyperactive children showed significant deficits on both measures. After a year of psychostimulant medication, the hyperactive children all showed clinical and neurocognitive improvement, but continued to show a selective attention deficit compared with normal children. The results indicate a dissociation between the cognitive processes measured by the Wisconsin test and selective attention as measured by the Stroop, and that the selective attention deficit is more resistant to psychostimulant intervention.

The selective attention deficit in schizophrenia. Limited resources or cognitive fatigue?

The Stroop Word-Color Test was used to study selective attention deficits in schizophrenic and nonschizophrenic psychiatric patients, compared with nonpsychiatric control subjects. Parts of the Weschler Memory Test and a shortened version of the Stroop Test were administered to test the hypotheses that the attentional deficit could be explained by problems of memory or cognitive fatigue. All patients showed deficits on all of the Stroop scales, but closer analysis of the results permitted discrimination of schizophrenic from nonschizophrenic patients. Schizophrenic patients showed as much difficulty as nonschizophrenic subjects on a limited-duration selective-attention task, but deteriorated significantly more when selective attention had to be maintained. The results could not be attributed to memory problems in the schizophrenic group. The results support the existence of two separable selective attention deficits in schizophrenic patients: a difficulty in selectively attending to the salient aspect of a complex stimulus, a difficulty shared with nonschizophrenic subjects, and a difficulty in maintaining selective attention over time that seems to be more marked in schizophrenic subjects.

The effect of graded exercise on cardiac output of the Jarvik-7-70 total artificial heart in humans

Animal exercise studies have shown a self-regulated change in cardiac output (CO) with the J-7 total artificial heart (TAH). A 49-year-old, 75 kg patient received a J-7-70 TAH as a bridge to transplant. During bicycle exercise, the TAH heart rate, drive pressures, percent systole, and vacuum were unchanged. Cardiac output was measured by analysis of diastolic air exhaust. Mean arterial pressure (MAP) was measured via a radial artery catheter. Daily recordings of hemodynamics were made from TAH day 35 to 56 at rest, cycling with zero resistance, 18 watts resistance, return to zero resistance, and at rest. Values were as follows: baseline MAP, 75.7 +/- 9.7; LCO, 6.4 +/- 0.2; RCO, 6.8 +/- 0.2. For zero watts resistance MAP was 92.2 +/- 7.2*; LCO, 7.1 +/- 0.2*; RCO, 7.8 +/- 0.3*. For eighteen watts resistance MAP was 101.3 +/- 6.2*; LCO, 7.6 +/- 0.3*; RCO, 8.4 +/- 0.4*. For zero watts resistance MAP was 98.5 +/- 4.9*; LCO, 7.2 +/- 0.4*; RCO, 8.0 +/- 0.4*. The postexercise MAP was 86.4 +/- 4.1*; LCO, 6.2 +/- 0.2; RCO, 6.9 +/- 0.2. For all but baseline and postexercise MAPs, the average response was over a 4 minute interval. The starred values were significant compared to baseline p less than 0.05. Exercise resulted in an autoregulated change in TAH CO in man. Increasing the work of exercise produced an increased CO, reflecting changes in venous return. A TAH patient can exercise for more than 30 minutes with an autoregulated CO and no deleterious effects.

[Neuropsychology of a psycho-organic syndrome caused by idiopathic hypoparathyroidism. Apropos of a case]

A case of organic psychosis secondary to an idiopathic hypoparathyroidism with intracranial calcifications affecting the basal ganglia and the cortico-medullary junction is described. The results of the skull X-ray, cerebral TACO and nuclear magnetic resonance imaging analyses are presented, as well as a battery of neuropsychological tests. In spite of the extensive calcifications found, deficits on the neuropsychological tests were minimal or non-existent; possible explanations of this discrepancy are discussed.

[Schizophrenia and selective attention]

A comparative study of selective attention was made on 22 schizophrenic inpatients, 18 non schizophrenic inpatients and a control of 22 non psychiatric adults. Signs of schizophrenia were quantified through the BPRS (Brief Psychiatric Rating Scale) and selective attention was expressed as the capacity to resist a distracting stimulus dimension in the Stroop word-colour test. The results indicated higher distractibility in schizophrenic patients, and a positive, significative relation was found between this interference and the "activation" cluster.