Diagnosis of dementia in a heterogeneous population. Development of a neuropsychological paradigm-based diagnosis of dementia and quantified correction for the effects of education

A brief diagnostic battery of neuropsychological tests was developed for a large-scale epidemiological study of dementia. We operationally defined dementia as defective memory and defective performance in at least two other areas, including orientation, abstract reasoning, construction, and language. Criterion scores for defining defective performance on each test were developed. In a pilot study that used 51 different subjects with a working diagnosis based on physicians' assessment (ie, 32 demented and 29 nondemented subjects), the test-based diagnosis agreed with the working diagnosis in all but two cases. The test battery was then applied to 430 healthy elderly subjects. Eighteen percent of those with 8 or less years of education met criteria for dementia compared with 5% of those with more than 8 years of education. We computed education-corrected scores for each test with the use of residuals from the regression of each test score on education. Based on corrected scores, 12 subjects were reclassified as nondemented and 11 as demented. Subjects who were reclassified as demented were significantly more impaired in activities of daily living than nondemented subjects who were not reclassified. Activities of daily living in subjects who were reclassified as nondemented did not differ from those in demented subjects who were not reclassified. These findings suggest that the neuropsychological battery may have utility in the diagnosis of dementia. However, neuropsychological performance may be influenced by education, and some form of adjustment, such as correction for activities of daily living, may be required in epidemiological studies.

Toward a Microprocess Perspective on Adolescent Identity Development

An abundance of research has been conducted on identityformation during adolescence, however, very little is bwwn about the processes that actually drive identity development. Furthermore, limited attention has been paid to the active influence of relationships with parents and peers on identity. Recentl, control theory has-been recognized as a useful framewor*from which to examine the microprocesses involved in identityformation. The purpose of this article is to describe identity development from this microprocess perspective and to extend the Grotevant model of identity formation processes. When applied to identity, control theory brings attennon to such intrapersonal factors as identity standards and self-perceptions, and such interpersonal factors as reflected appraisals and social behaviors as major contrbutors to the process of identity development. Implicationsfor using identty control theory to elaborate the identity statuses, to understand reciprocal identity influences in interpersonal relationships, and to drive methodologies used to exanune identity processes, are offered.

Youth's Attitudes Toward the Elderly

This paper examines the attitudes of 35 male and 122 female college students toward six target groups of elderly individuals: males and females aged 65-74, 75-99 and 100 or older. A twenty-item semantic differential scale was used. Findings support the conclusion that the elderly are perceived as a heterogeneous group with age being an important discriminator, and with gender being less potent but, nevertheless, important. Older target groups were perceived less favorably than younger target groups, but actual values of attitude scores indicate that the least favorable means were in a neutral affect range rather than the more extreme negative range of possible scores. Finally, the effects of several characteristics of respondents on attitudes toward the elderly were examined. Only modest differences were found, suggesting that perceived differences between target groups are widely shared. Implications are discussed.

Predictors of emergency room use by homeless adults in New York City: the influence of predisposing, enabling and need factors

Employing data from a 1987 shelter survey of 1260 homeless adults in New York City, multivariate models of emergency room (ER) use are developed which include an array of risk factors for visiting a hospital ER including health and mental health problems, victimization and injuries. The study's primary goal is to identify factors that predict ER use in this population. Multivariate logistic and linear regression models were tested separately for men and women predicting three outcomes: any use of the ER during the past 6 months, use of the ER for injuries vs all other reasons (given any ER use), and the number of ER visits (given any ER use). Lower alcohol dependence, health symptoms and injuries were strong predictors for both men and women; other significant predictors differed markedly by gender. Both models were highly significant and produced strikingly high risk profiles. A high prevalence of victimization and injuries underlies ER use among the homeless. Based upon the findings, we recommend expanded health and victim services as well as preventive measures. Until primary care becomes available for this population, we advise against policies that discourage ER use by the homeless.

The instability of possible selves: identity processes within late adolescents' close peer relationships

Understanding how identities emerge and stabilize within the context of interpersonal relationships is an important issue in identity research. Seventy-six late adolescents and their peer partners participated in a laboratory study that focused on the possible selves tied to anticipated career, marriage, and parenthood roles. Control theory (people work to maintain existing identities) and the concept of psychosocial moratorium (identity exploration involves actively "trying on" different selves) were integrated to explain identity construction processes. Consistent with notions of exploration and commitment, emerging self-definitions for highly desired possible selves were unstable. Consistent with control theory, stable self-definitions for anticipated selves occurred when adolescents were committed to avoiding the role. The relationship context mattered only minimally for the adolescents' exploration activities. The behavior of peer partners, however, made it more likely that adolescents would engage in identity exploration of highly important possible selves. The integration of control theory with the concept of psychosocial moratorium offers explanations for the emergence of new identities and their ultimate stabilization.

Diagnosis of dementia in a heterogeneous population. A comparison of paradigm-based diagnosis and physician's diagnosis

Each of 430 subjects received a diagnosis using two independent methods: a test-based quantitative paradigm and a semistructured neurological examination by a physician. The paradigm diagnosis was based on a battery of tests that assessed short- and long-term verbal memory and short-term nonverbal memory, orientation, construction, abstract reasoning, and language. The subjects came from a community in Manhattan County, in New York City, and were characterized by diversity with respect to both ethnicity (29.1% black, 33.4% Hispanic) and educational level (23.5% with 6 or fewer years of education, 25.6% college educated). Based on the paradigm, 10.5% of subjects received diagnoses of dementia, 29.1% of cognitive impairment, and 60.5% of normal. Based on the physician's diagnosis, 9.8% were demented, 21.6% cognitively impaired, and 68.6% normal. There was agreement between the two diagnostic methods for 71.8% of subjects. Diagnostic disagreement (n = 121) was in most cases between normal and cognitively impaired (71.0%) or between cognitively impaired and demented (21.5%). There were only nine cases (7.5%) in which a subject was judged demented by one method and normal by the other. The reliability of each method with respect to the other was moderate (intraclass correlation coefficient, .62), while the reliability of a composite diagnosis based on both methods was much higher (.77). The paradigm was more likely than the physician to give the diagnosis of dementia to patients with low educational levels. The physician's diagnosis was strongly influenced by measures of functioning and by the mental status test administered in the semistructured neurological examination. Race and diagnosis were not related when the effect of education was controlled.(ABSTRACT TRUNCATED AT 250 WORDS)

Sex as a predictor of outcomes in patients treated with thrombolysis for acute stroke

OBJECTIVE

To determine the association between sex and functional outcomes after thrombolytic treatment for acute ischemic stroke in the context of a clinical trial.

METHODS

We analyzed predictors of outcome among patients treated with recombinant tissue plasminogen activator (rtPA) in the Glycine Antagonist in Neuroprotection for Patients with Acute Stroke Americas trial, a multicenter, randomized, double-blind, placebo-controlled study of a putative neuroprotectant.

RESULTS

Among 1,367 trial patients, 333 (24%) were treated with rtPA within 3 hours. The proportion of patients achieving good functional outcomes at 3 months differed by sex (47.5% of men vs 30.3% of women had Barthel Index [BI] > or = 95; 32.2% of men vs 23.4% of women had modified Rankin Score [mRS] < or = 1). NIH Stroke Score was similar by sex. Men were more likely to have good functional outcomes after adjusting for relevant covariates: for BI > or = 95, adjusted odds ratio (OR) 3.28 (1.74 to 6.17); for mRS < or = 1, adjusted OR 2.12 (1.11 to 4.03). Survival was worse among men: adjusted OR 0.45 (0.20 to 1.01). Other predictors of functional outcomes included age, stroke side, severity, complications, and infections.

CONCLUSIONS

Among tissue plasminogen activator-treated patients in this clinical trial population, men were approximately three times as likely to have good functional outcomes, despite elevated mortality. Thrombolysis for stroke may not reverse the tendency for women to have worse functional outcomes after stroke.

Right and left heart failure in severe H1N1 influenza A infection

Influenza infection can affect cardiac function. The recent pandemic of H1N1 influenza A provided an opportunity to study echocardiographic findings in critically ill infected patients. We hypothesised that critically ill patients with H1N1 infection would have a higher incidence of right and left heart failure than is seen in unselected populations of patients with septic shock and/or acute respiratory distress syndrome (ARDS). We retrospectively studied all patients admitted to four intensive care units at three hospitals in Salt Lake County, UT, USA, with laboratory-confirmed H1N1 infection in whom a clinical echocardiogram was available. 23 out of 48 patients had qualifying echocardiograms. Right ventricular (RV) dilatation (50-80%) and at least moderate systolic impairment (23%) were common, higher than the range described in general populations with ARDS. Left ventricular systolic dysfunction was present in 17% of patients. No single echocardiographic parameter was associated with 28-day mortality or ventilator-free days to 28 days. Critically ill patients with H1N1 infection frequently exhibit right heart dilatation and failure. RV basal dilatation was extremely common. These patients have less left heart failure than expected on the basis of prior descriptions of influenza myopericarditis or of general populations of septic patients.

Enhancement of pain control with ketorolac tromethamine in patients with sickle cell vaso-occlusive crisis

Twenty one patients with sickle cell disease admitted to the hospital with the pain of vaso-occlusive crisis (VOC) were treated by continuous IV infusion of ketorolac or normal saline for up to 5 days. All patients received supplemental IM injections of meperidine, 100 mg, as necessary, but not more frequently than every 3 hr. Over the 5 days the ketorolac treated patients (KT) required 33% less meperidine than did the placebo treated patients (PL), P = 0.04, and had significantly better pain relief as assessed by categorical, visual analog, and pain relief scales. By the end of 5 days infusions had been discontinued in six KT and one PL. The time to discontinuation of the infusion was significantly shorter in KT, (P = 0.009). The median duration of hospital stay from the start of treatment was 3.3 days for KT and 7.2 days for PL, P = 0.027. Adverse events were mainly related to the digestive system. This study showed that continuous infusion of ketorolac significantly reduced total meperidine requirement and that the analgesia produced by this combination was superior to that produced by meperidine alone. Further evaluation of this drug in the management of sickle cell VOC is warranted.

Communication between members of the cardiac arrest team--a postal survey

AIMS

Effective communication enhances team building and is perceived to improve the quality of team performance. A recent publication from the Resuscitation Council (UK) has highlighted this fact and recommended that cardiac arrest team members make contact daily. We wished to identify how often members of this team communicate prior to a cardiopulmonary arrest.

METHOD

A questionnaire on cardiac arrest team composition, leadership, communication and debriefing was distributed nationally to Resuscitation Training Officers (RTOs) and their responses analysed.

RESULTS

One hundred and thirty (55%) RTOs replied. Physicians and anaesthetists were the most prominent members of the team. The Medical Senior House Officer is usually nominated as the team leader. Eighty-seven centres (67%) have no communication between team members prior to attending a cardiopulmonary arrest. In 33%, communication occurs but is either informal or fortuitous. The RTOs felt that communication is important to enhance team dynamics and optimise task allocation. Only 7% achieve a formal debrief following a cardiac arrest.

CONCLUSION

Communication between members of the cardiac arrest team before and after a cardiac arrest is poor. Training and development of these skills may improve performance and should be prioritised. Team leadership does not necessarily reflect experience or training.

Obsessive-compulsive disorder and comorbid anxiety problems in a national anxiety screening sample

Questionnaire data were obtained from 5867 participants attending a national anxiety screening program. These participants were selected from more than 15,000 respondents on the basis of never having received treatment for a mental health problem. A screening instrument was designed to assess five anxiety disorders (obsessive-compulsive disorder, posttraumatic stress disorder, social phobia, generalized anxiety disorder, and panic disorder). The present study focused on those participants meeting full or partial screening criteria for obsessive-compulsive disorder (n = 3212), with those not meeting criteria for obsessive-compulsive disorder (n = 2655) serving as a comparison group. Significant relationships were found between questionnaire scores on both interference with daily living, readiness for treatment, and the number of comorbid anxiety problems. These findings shed light on the extent to which undiagnosed and untreated persons with obsessional or compulsive symptoms, or both, are experiencing, as well as the factors that may lead them to seek formal psychiatric or psychological treatment.

Adolescent psychological well-being by identity style

High school-age adolescents (N=262) in two samples completed a measure of identity style, along with measures of self-esteem, hopelessness, delinquent attitudes, educational expectations, and optimism/efficacy. Analysis of variance was used to evaluate the relationship between identity style and the other psychosocial variables. Participants classified as having a diffuse/avoidant orientation had lower self-esteem and higher delinquent attitude scores than those with either an information or normative orientation. At the same time, the diffuse-avoidant style was associated with higher hopelessness and lower optimism/efficacy scores than the normative and information styles. The normative and information styles did not differ significantly in terms of the dependent variables. Results also indicated that males were more likely to be diffused and females more likely to be information-oriented.

Social-ecological network analysis for sustainability sciences: a systematic review and innovative research agenda for the future

Social-ecological network (SEN) concepts and tools are increasingly used in human-environment and sustainability sciences. We take stock of this budding research area to further show the strength of SEN analysis for complex human-environment settings, identify future synergies between SEN and wider human-environment research, and provide guidance about when to use different kinds of SEN approaches and models. We characterize SEN research along a spectrum specifying the degree of explicit network representation of system components and dynamics. We then systematically review one end of this spectrum, what we term "fully articulated SEN" studies, which specifically model unique social and ecological units and relationships. Results show more focus on methodological advancement and applied ends. While there has been some development and testing of theories, this remains an area for future work and would help develop SENs as a unique field of research, not just a method. Authors have studied diverse systems, while mainly focused on the problem of social-ecological fit alongside a scattering of other topics. There is strong potential, however, to engage other issues central to human-environment studies. Analyzing the simultaneous effects of multiple social, environmental, and coupled processes, change over time, and linking network structures to outcomes are also areas for future advancement. This review provides a comprehensive assessment of (fully articulated) SEN research, a necessary step that can help scholars develop comparable cases and fill research gaps.

Propranolol as xanthine oxidase inhibitor: implications for antioxidant activity

Propranolol is the beta-blocker most widely used in the management of cardiovascular disorders. It has been proposed that propranolol may act as a "chain-breaking" antioxidant. We have directly examined the ability of propranolol to inhibit superoxide-dependent, iron-promoted cardiac membrane phospholipid peroxidation, with xanthine oxidase (XOD) as a physiologically-recognized, enzymatic superoxide generator. Our results demonstrate that propranolol not only protects cardiac-membrane lipid from peroxidative damage, but also acts as a simple, reversible XOD inhibitor, noncompetitive with xanthine substrate. Propranolol, at effective antiperoxidant and XOD-inhibitory concentrations, cannot scavenge superoxide radical. The antiperoxidative profile of propranolol resembles that of the known XOD inhibitor allopurinol, although allopurinol, a tight-binding substrate-analog competitive with xanthine, inhibits XOD in a manner mechanistically very different from that of propranolol. Furthermore, the antiperoxidative profiles of both propranolol and allopurinol do not resemble those of chain-breaking antioxidants such as alpha-tocopherol. These data, along with the tendency of propranolol to concentrate in myocardial membranes and cytosol, suggest that the observed antioxidant action of propranolol, as a consequence of XOD inhibition, could play a pharmacologic role in propranolol's cardioprotective effects.

Comparing maltreating fathers and mothers in terms of personal distress, interpersonal functioning, and perceptions of family climate

OBJECTIVE

This study compared perceptions of personal distress, interpersonal and marital problems, and aspects of family climate of maltreating fathers and mothers.

METHODS

Subjects were 2841 offenders (1918 of whom were fathers or father-figures) who were identified and treated by the USAF Family Advocacy Program between 1988 and 1996. Independent variables for the analysis were parent sex (mother vs. father) as well as type and severity of maltreatment, history of repeat offenses, and history of abuse in childhood.

RESULTS

Maltreating mothers were more distressed and reported more problems from individuals outside the family than maltreating fathers; fathers reported more rigid expectations for children, less cohesive families, and less organized families than did maltreating mothers. Regardless of parental sex, victimization in the family of origin was related to distress and unhappiness. Similarly, both victimization in the family of origin and history of repeated offenses were powerful predictors of a more negative family climate regardless of the offending parent's sex. No significant statistical interactions between parental sex and other independent variables were found when predicting personal and interpersonal distress, marital problems, or family climate.

CONCLUSIONS

Studies rarely examine maltreating fathers except in the context of sexual abuse. Fewer still compare maltreating mothers and fathers. This study identified meaningful, though generally small, differences between maltreating mothers and fathers. Patterns suggest that maltreating mothers may tend to cope more poorly with personal distress, whereas maltreating fathers tend to operate in a family climate that is both distant and rigid, while holding inappropriate expectations for children's behavior. The absence of interactions between parental sex and the other independent variables included in the analysis indicate that these patterns do not vary by the history of victimization in the family of origin, the type or severity of child maltreatment, or the history of prior maltreatment in the family.

Patient-controlled analgesia in patients with sickle cell vaso-occlusive crisis

Pain control using intramuscular analgesia is often unsatisfactory in sickle cell patients. In a pilot study, 15 patients with sickle cell anemia (SS) and one patient with SB thalassemia in vaso-occlusive crisis were treated with the Patient-Controlled Analgesia (PCA) technique using a Pharmacia Deltec Programmable pump (CADD PCA). Age range was 19-50 years (median = 27); there were nine females and seven males. The protocol consisted of 3 days of therapy using a background of continuous infusion meperidine. The starting dose was 20 mg/hr and was escalated to 30 mg/hr. The average amount given was 25.8 mg/hr. One to two boluses of 2.5-5.0 mg/dose (mode = 5.0) were also allowed each hour. In addition, patients number 8 through 16 were given hydroxyzine (Vistaril) 50 mg PO q6h. The number of days in pain prior to study entry (mean +/- SD) was 3.3 +/- 1.6. The number of pain sites per patient was 3.6 +/- 1.2. Using categorical and analog pain scales, patients' pain scores decreased only about 30%. However, most patients were fairly satisfied with the treatment and rated it overall as follows: 1 poor, 1 fair, 3 good, 6 very good, 4 excellent, 1 no comment. Patients number 8 through 16 gave higher ratings probably because a more idealized dosage regimen was being used by that time in the study. There were no adverse effects or major problems noted. It is our impression that PCA, when optimized, will be a safe and effective alternative method for providing patients with sickle cell vaso-occlusive crisis pain relief.

Identity and intimacy during adolescence: connections among identity styles, romantic attachment and identity commitment

Integration of adult attachment and psychosocial development theories suggests that adolescence is a time when capacities for romantic intimacy and identity formation are co-evolving. The current study addressed direct, indirect and moderated associations among identity and romantic attachment constructs with a diverse sample of 2178 middle adolescents. Identity styles were found to have unique and direct associations with identity commitment. Attachment anxiety showed only indirect associations and attachment avoidance had both direct and indirect associations with identity commitment. Tests of moderation revealed that gender, race and relationship status had no influence on the direct associations of identity styles or romantic attachment with identity commitment. Few differences in association strength among identity styles and romantic attachment emerged for gender or race. However, the differences found for relationship status suggested that relationship experiences adolescents bring to their exploration of identity and intimacy matter for how these two areas of development articulate.

Using census and mortality data to target small areas for breast, colorectal, and cervical cancer screening

OBJECTIVES

The goal of this study was to develop and validate quantitative models for estimating cancer incidence in small areas.

METHODS

The outcome for each cancer site was the incidence of disease that had reached a late stage at the time of diagnosis. Two sets of predictors were used: (1) census-based demographic variables and (2) census-based demographic variables together with the cancer-specific mortality rate.

RESULTS

The best models accounted for a substantial percentage of between area variability in late-stage rates for cancer of the breast (46%), cervix (61%), and colon/rectum (58%). A validation procedure indicated that correct identification of small areas with high rates of late-stage disease was two to three times more likely when model-based estimates were used than when areas were selected at random.

CONCLUSIONS

Additional testing is needed to establish the generality of the geographic targeting methodology developed in this paper. However, there are strong indications that small-area estimation models will be useful in many regions where planners wish to target cancer screening programs on a geographic basis.

Antineoplastic and biochemical properties of arylsulfonylhydrazones of 2-formylpyridine N-oxide

The structural parameters necessary for the antineoplastic potency of a new class of anticancer agents, arylsulfonylhydrazones of 2-formylpyridine N-oxide, were examined in mice bearing Sarcoma 180 ascites cells. The findings indicated that (a) replacement of the pyridine ring with benzene, quinoline, or isoquinoline resulted in loss of activity (b) movement of the formylhydrazone side chain from the 2 to the 3 or 4 positions of the pyridine N-oxide produced inactive agents (c) the pyridine N-oxide function was essential for anticancer activity, except for 4-substituted derivatives which were active without the N-oxide group, (d) replacement of the SO2 group by CO resulted in complete loss of activity, and (e) a carbon atom could be inserted between the SO2 and aryl ring with retention of anticancer potency. One of the most active members of this series, 1-oxidopyridine-2-carboxaldehyde p-toluenesulfonylhdrazone, exhibited antineoplastic activity against a broad spectrum of transplanted tumors including Sarcoma 180, Hepatoma 129, Ehrlich carcinoma, leukemia L1210, and a subline of Sarcoma 180 resistant to alpha-(N)-heterocyclic carboxaldehyde thiosemicarbazones. This agent caused inhibition of thymidine-3H and uridine-3H incorporation into DNA and RNA, respectively, of Sarcoma 180 ascites cells; protein biosynthesis was relatively insensitive to the action of this compound.

The role of romantic attachment security and dating identity exploration in understanding adolescents' sexual attitudes and cumulative sexual risk-taking

This study addressed how two normative developmental factors, attachment and identity, are associated with adolescents' sexual attitudes and sexual risk-taking behavior. The sample consisted of 2029 adolescents (mean age = 16.2 years) living in the Southeast United States. Path analysis was used to test the hypotheses. Higher levels of attachment anxiety predicted more dating identity exploration and less healthy sexual attitudes. Higher levels of attachment avoidance predicted less dating identity exploration and indirectly predicted less healthy sexual attitudes through dating identity exploration. Females with dating or sexual experience showed the weakest associations between the attachment dimensions and dating identity exploration. More dating identity exploration predicted healthier sexual attitudes; this association was strongest for non-virgins. Finally, higher levels of attachment avoidance were associated with higher cumulative sexual risk scores, but only among non-virgin males. Results are interpreted in light of theory and research on attachment, identity exploration, and adolescent sexual relationships.

Cloning and expression of Staphylococcus aureus and Treptococcus pyogenes murD genes encoding uridine diphosphate N-acetylmuramoyl-L-alanine:D-glutamate ligases

Bacterial UDP-N-acetylmuramyl-L-alanine:D-glutamate ligase (MurD), a cytoplasmic peptidoglycan biosynthetic enzyme, catalyzes the ATP-dependent addition of D-glutamate to an alanyl residue of the UDP-N-acetylmuramyl-L-alanine precursor, generating the dipeptide. The murD gene was cloned from both Staphylococcus aureus and Streptococcus pyogenes. Sequence analysis of the S. aureus murD gene revealed an open reading frame of 449 amino acids. The deduced aa sequence of S. aureus MurD is highly homologous to MurD from Escherichia coli, Haemophilus influenzae, Bacillus subtilis and St. pyogenes. Recombinant MurD protein from both S. aureus and St. pyogenes was separately overproduced in E. coli and purified as His-tagged fusion. Both recombinant enzymes catalyzed the ATP-dependent addition of D-glutamate to the precursor sugar peptide.