Compensatory Strategy Intervention: What Older Patients Want and Why

OBJECTIVE

Compensatory strategies can improve performance of instrumental activities of daily living in people with cognitive impairment. This study investigated patient interest in compensatory strategy interventions and preference for various intervention formats.

METHODS

Semi-structured qualitative interviews with 38 older adults with cognitive impairment queried motivation to improve strategy use and interest in intervention formats/delivery methods. Two coders used thematic analysis to determine rates of interest in each intervention type and explore patient-reported barriers and facilitators to motivation and intervention models.

RESULTS

Most of the samples reported motivation to enhance compensatory strategy use. Degree of motivation was driven by current experiences with strategy use, perceived benefit of potential changes, intrinsic desire to improve life and self, and current perceived need. The vast majority were interested in hour-long, multi-session, instructor-led interventions. Just over half of the sample was interested in a self-directed virtual program, and just under half was interested in involving family/friends. Facilitators and barriers to interest in intervention formats and delivery methods varied based on participants' previous experiences, preferred learning style, content, and time commitment of the intervention, and perceived current need for intervention. One-fifth of the sample expressed no interest in any intervention type, though they expressed openness to assistance in the future as needed.

CONCLUSIONS

Older adults with cognitive impairment are generally motivated to enhance their compensatory strategy use. Clinicians/researchers designing compensatory strategy interventions should consider instructor-led formats, present individualized benefits of interventions, and demonstrate the benefits of both preventative and remedial intervention to optimize patient engagement.

Factor Structure of the Memory for Intentions Test (MIsT): A Conceptual Replication in Older Adults and People with HIV Disease

OBJECTIVE

The Memory for Intentions Test (MIsT) is a clinical measure of prospective memory that has strong evidence for convergent, discriminative, and ecological validity. This study uses a conceptual replication design to evaluate the latent structure of the MIsT in two parallel samples who commonly experience prospective memory deficits: older adults and people living with HIV disease.

PARTICIPANTS AND METHODS

Study participants included 303 people with HIV disease (ages 18-67) and 267 community-dwelling older adults (ages 50-91). Confirmatory factor analyses of the MIsT were conducted separately in each sample. We evaluated a one-factor model, as well as three two-factor models with the MIsT items loading onto each factor based on cue type, delay interval, or response modality.

RESULTS

The one-factor model provided the best (and most parsimonious) fit to the data in both study samples. All two-factor models also demonstrated good fit statistics, although correlations between the two factors in each model were high and none of the two-factor models provided a significantly better fit than the one-factor model.

CONCLUSIONS

Results of this conceptual replication study provide support for a robust factor structure of the MIsT across older adults and people with HIV disease. A total score for the MIsT provides the most parsimonious solution, although available evidence and theory also support the potential use of subscales (e.g., cue type). Future studies of the MIsT would be useful to determine its psychometrics in different clinical populations and across demographic factors (e.g., race/ethnicity).

The complementary utility of cognitive testing and the medication management ability assessment in older adults

OBJECTIVE

Older adults are susceptible to cognitive declines that may limit independence. Though neuropsychologists opine about risk of functional decline, the degree to which cognitive testing and in-office simulations approximate everyday behavior is unclear. We assessed the complementary utility of cognitive testing and the face-valid Medication Management Ability Assessment (MMAA) to predict medication management among older adults.

METHOD

This was a retrospective study of 234 older adults (age = 72 ± 7.7 years; 59% women) who completed the MMAA during outpatient neuropsychological evaluations. Based on comprehensive clinical assessment, most participants (n = 186) were independent in medication management, while 48 received assistance. Demographically adjusted composite scores were derived for attention/processing speed (A/PS), executive functioning (EF), visuospatial/constructional ability (VC), language, and memory domains. Univariate differences in cognition were examined across Assisted versus Independent groups. Logistic regression assessed which cognitive domains independently predicted group status. The incremental value of the MMAA was assessed, holding uniquely associated cognitive test scores constant.

RESULTS

Those receiving assistance with medication management performed worse across all neurocognitive domains and the MMAA compared with independent counterparts. EF was the only unique cognitive predictor of medication management status. When modeled alone, EF and MMAA performance correctly classified 79.5% and 80.8% of cases, respectively. When modeled together, both were independently associated with medication management status and correctly classified 83.3% of cases.

CONCLUSIONS

EF uniquely predicted medication management status beyond other cognitive domains. The MMAA provided complementary predictive utility. Concurrent interpretation of executive functioning and MMAA performance is advised when assessing older adults suspected of medication mismanagement. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Neurocognitive performance differences between black and white individuals with HIV disease are mediated by health literacy

Objective:Health disparities are evident for Black Americans with HIV disease, who are disproportionally affected by the epidemic in the United States. The current study investigated whether the higher rates of neurocognitive impairment in Black Americans with HIV disease may be at least partly attributable to health literacy, which is a potentially modifiable factor. Method: Participants were 61 White and 25 Black participants (ages 27-70) with HIV disease who were enrolled in studies at an urban academic center in Southern California. Neurocognitive function was assessed by an age-adjusted global score from the Cogstate battery. Health literacy was measured by a composite score derived from the Rapid Estimate of Adult Literacy in Medicine, Newest Vital Sign, and 3-Brief. Results: Bootstrap confidence interval mediation analyses showed that health literacy was a significant mediator of the relationship between race and neurocognition; that is, there were no direct ethnoracial differences in neurocognition after accounting for health literacy. A follow-up model to confirm the directionality of this association demonstrated that neurocognition was not a significant mediator of the relationship between race and health literacy. Conclusions: Low health literacy may contribute to the higher rates of neurocognitive impairment for Black Americans with HIV disease. Future studies might examine the possible mechanism of this mediating relationship (e.g., access to health information, health behaviors, socioeconomics) and determine whether culturally tailored interventions that improve health literacy also confer broader brain health benefits for Black Americans with HIV disease.

A pilot study of cognition and creativity among persons with HIV disease referred for neuropsychological evaluation

Creativity can help people to innovate, overcome obstacles, and successfully navigate challenges in daily life. Some aspects of creativity rely on the prefrontostriatal loops and executive functions, which can be compromised in persons with HIV (PWH). This pilot study examined whether neuropsychological functioning plays a role in creativity in PWH. A consecutive series of 41 PWH who were referred to an urban neuropsychology clinic in southeastern Texas were enrolled. Participants completed the Abbreviated Torrance Test for Adults (ATTA) to measure creativity, from which standardized creativity scores of fluency, originality, elaboration, and flexibility were derived. Participants also completed several measures of everyday functioning and a brief clinical neuropsychological battery measuring executive functions, motor skills, memory, and visuoconstruction. Global neuropsychological functioning showed a large, positive association with ATTA creativity performance that did not vary meaningfully by creativity domain and was independent of premorbid IQ. ATTA creativity scores were not associated with any measure of everyday functioning. Findings from this pilot study suggest that higher levels of neuropsychological functioning may support multiple dimensions of creativity in adults with HIV disease. Future studies might examine whether creativity moderates the association between HIV-associated neurocognitive impairment and various health behaviors (e.g., adherence, appointment attendance).

Longitudinal declines in event-based, but not time-based, prospective memory among community-dwelling older adults

Age-related deficits in prospective memory (PM) are well established, but it is not known whether PM is stable over time among older adults. In this study, 271 community-dwelling older adults underwent abaseline neuropsychological evaluation and up to three follow-up visits, approximately 2.4 years apart. Mixed effects linear longitudinal models revealed small, but significant linear declines and between-subjects variability in event-based PM performance. There were no changes in performance on measures of time-based PM, retrospective memory, or executive functions. Changes in event-based PM were not associated with age, retrospective memory, executive functions, or everyday functioning. Among older adults, event-based PM appears to be more susceptible to linear declines than does time-based PM, which future research might examine with regard to the possible underlying cognitive mechanisms of cue encoding, monitoring, detection, and retrieval processes.

Economic evaluations of interventions against influenza at workplaces: systematic review

BACKGROUND

The burden of influenza is mostly felt by employees and employers because of increased absenteeism rates, loss of productivity and associated direct costs. Even though interventions against influenza among working adults are effective, patronage and compliance to these measures especially vaccination are low compared to other risk groups.

AIMS

This study was aimed to assess evidence of economic evaluations of interventions against influenza virus infection among workers or in the workplace setting.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guideline for systematic reviews was followed. Three databases, PubMed, Web of Science and EconLit, were searched using keywords to identify relevant articles from inception till 25 October 2020. Original peer-reviewed papers that conducted economic evaluations of influenza interventions using cost-benefit, cost-effectiveness or cost-utility analysis methods focused on working-age adults or work settings were eligible for inclusion. Two independent teams of co-authors extracted and synthesized data from identified studies.

RESULTS

Twenty-four articles were included: 21 were cost-benefit analyses and 3 examined cost-effectiveness analyses. Two papers also presented additional cost-utility analysis. Most of the studies were pharmaceutical interventions (n = 23) primarily focused on vaccination programs while one study was a non-pharmaceutical intervention examining the benefit of paid sick leave. All but two studies reported that interventions against influenza virus infection at the workplace were cost-saving and cost-effective regardless of the analytic approach.

CONCLUSIONS

Further cost-effectiveness research in non-pharmaceutical interventions against influenza in workplace settings is warranted. There is a need to develop standardized methods for reporting economic evaluation methods to ensure comparability and applicability of future research findings.

How did individual differences in neurocognition and health literacy influence the initial uptake and use of health-related information about COVID-19?

Introduction: The rapid development of coronavirus disease 2019 (COVID-19) into a pandemic required people to quickly acquire, evaluate, and apply novel complex health-related information about the virus and transmission risks. This study examined the potentially unique and synergistic roles of individual differences in neurocognition and health literacy in the early uptake and use of COVID-19 public health information.Method: Data were collected between April 23 and 21 May 2020, a period during which 42 out of 50 states were under a stay-at-home order. Participants were 217 healthy adults who completed a telephone-based battery that included standard tests of neurocognition, health literacy, verbal IQ, personality, and anxiety. Participants also completed measures of COVID-19 information-seeking skills, knowledge, prevention intentions, and prevention behaviors.Results: A series of hierarchical multiple regressions with data-driven covariates showed that neurocognition (viz, episodic verbal memory and executive functions) was independently related to COVID-19 knowledge (e.g. symptoms, risks) at a medium effect size, but not to information-seeking skills, prevention intentions, or prevention behaviors. Health literacy was independently related to all measured aspects of COVID-19 health information and did not interact with neurocognition in any COVID-19 health domain.Conclusions: Individual differences in neurocognition and health literacy played independent and meaningful roles in the initial acquisition of knowledge related to COVID-19, which is a novel human health condition. Future studies might examine whether neurocognitive supports (e.g. spaced retrieval practice, elaboration) can improve COVID-19-related knowledge and health behaviors in vulnerable populations.

Verbal Learning Mediates the Relationship Between Executive Functions and a Laboratory Task of Medication Management in HIV Disease

OBJECTIVE

Impairments in executive functions and learning are common in HIV disease and increase the risk of nonadherence to antiretroviral therapy. The mixed encoding/retrieval profile of HIV-associated deficits in learning and memory is largely driven by dysregulation of prefrontal systems and related executive dysfunction. This study tested the hypothesis that learning may be one pathway by which executive dysfunction disrupts medication management in people living with HIV (PLWH).

METHOD

A total of 195 PLWH completed a performance-based laboratory task of medication management capacity and clinical measures of executive functions, verbal learning and memory, and motor skills.

RESULTS

Executive functions were significantly associated with verbal learning and medication management performance. In a model controlling for education, learning significantly mediated the relationship between executive functions and medication management, and this mediation was associated with a small effect size. In particular, executive dysfunction was associated with diminished use of higher-order learning strategies. Alternate models showed that executive functions did not mediate the relationship between learning and medication management nor did motor skills mediate the relationship between executive functions and medication management.

CONCLUSIONS

PLWH with executive dysfunction may demonstrate difficulty in learning new information, potentially due to ineffective strategy use, which may in turn put them at a higher risk for problems managing their medications in the laboratory. Future studies may wish to investigate whether compensatory neurocognitive training (e.g., using more effective learning strategies) may improve medication management among PLWH.

Future and past autobiographical memory in persons with HIV disease

Objective: While HIV disease is associated with impairment in declarative memory, the ability of people with HIV (PWH) to describe past and future autobiographical events is not known. Method: Participants included 63 PWH and 28 seronegative individuals ages 50-78 who completed standardized neurocognitive and everyday functioning assessments. Participants described four events from the recent past and four imagined events in the near future, details from which were classified as internal or external to the main event. Result: PWH produced fewer autobiographical details with small-to-medium effect sizes but did not differ from seronegative participants in meta-cognitive ratings of their performance. Performance of the study groups did not vary across past or future probes or internal versus external details; however, within the entire sample, past events were described in greater detail than future events, and more external than internal details were produced. Within the PWH group, the production of fewer internal details for future events was moderately associated with poorer prospective memory, executive dysfunction, and errors on a laboratory-based task of medication management. Conclusion: Older PWH may experience difficulty generating autobiographical details from the past and simulated events in the future, which may be related to executive dyscontrol of memory processes. Future studies might examine the role of future thinking in health behaviors such as medication adherence and retention in healthcare among PWH. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychometrics and Validity of the Survey of Memory-Related Quality of Life in HIV Disease

OBJECTIVE

Retrospective and prospective memory deficits are associated with lower quality of life (QoL); however, there are no validated measures that comprehensively and directly assess the impact of memory problems on QoL. The Survey of Memory-Related Quality of Life (SMRQoL) was developed as a 30-item questionnaire to measure memory-related QoL.

METHOD

Both HIV+ (n = 195) and HIV- (n = 146) participants completed the SMRQoL, a neurocognitive research battery, and validated self-report questionnaires of memory, QoL, and mood. Participants were recruited into younger (age ≤ 40 years) and older (age ≥ 50 years) groups per the parent study design.

RESULTS

The SMRQoL had a unidimensional factor structure and demonstrated measurement invariance across the HIV+ and HIV- participants. Analyses of 111 clinically stable participants (e.g., persons with no incident or remitting central nervous system disorders) who returned for a 14-month follow-up visit indicated that the SMRQoL had adequate test-retest stability. There was a significant interaction of age and HIV status on the SMRQoL, such that older HIV+ participants reported the lowest memory-related QoL. SMRQoL scores were associated with validated measures of mental and physical QoL, self-reported memory and cognitive symptoms, and performance-based memory and executive functions.

CONCLUSIONS

The SMRQoL shows evidence of reliability and validity as a measure of memory-related QoL that can be used to assess the impact of memory problems on everyday life, but future work is needed to demonstrate the measure's incremental value in the context of diagnosis and treatment.

A Clinical Pilot Study of Spaced Retrieval Practice with a Self-Generation Booster to Improve Health-Related Memory in Persons With HIV Disease

Objective

Spaced retrieval practice (SRP) and self-generation are among the most replicated and effective mnemonic strategies in the cognitive psychology literature, but their benefits have not yet been realized in healthcare settings. This study used a randomized, between-subjects design to examine the hypothesis that SRP with a self-generation booster can improve memory for health-related information among clinically referred persons with HIV (PWH), who often have difficulty acquiring new health knowledge.

Method

A consecutive series of 41 PWH referred to a county-funded urban neuropsychology clinic were enrolled. Participants were randomly assigned to learn four statements about the treatment of a mock infectious disease in either a massed study control condition (n = 20) or an SRP condition (n = 21) in which they received two distributed free recall training tests supplemented with self-generation for missed items. The primary outcome was participants’ free recall of the four treatment statements after a 20-minute delay filled with nonverbal tests.

Results

PWH participants in the SRP condition were four times more likely than controls to recall at least one treatment statement at the 20-minute delay. SRP was not related to post-test recognition or health-related decision-making performance but was associated with moderately better self-efficacy for decision-making.

Conclusions

Findings from this pilot study show the potential of SRP with a self-generation booster to improve learning and memory for health-related information among PWH in clinic.

Latent Structure of a Brief Clinical Battery of Neuropsychological Tests Administered In-Home Via Telephone

Objective

To examine the factor structure and sociodemographic correlates of a battery of clinical neuropsychological tests administered in-home and via telephone.

Method

Participants included 280 healthy adults who completed a 35–40 min battery consisting of seven auditory-verbal neuropsychological tests (i.e., 10 variables) that included digit span, list learning and memory, prospective memory, verbal fluency, and oral trail making.

Results

After removing oral trail making part A, a three-factor model comprised of executive functions, memory and attention demonstrated the best fit to the data. Nevertheless, the shared variance between the nine remaining neuropsychological variables was also adequately explained by a single-factor model and a two-factor model comprised of executive functions and memory. Factor scores were variably associated with education, race/ethnicity, and IQ, but not with sex or age.

Conclusions

Findings provide preliminary support for the feasibility and factor structure and sociodemographic correlates of a brief telephone-based screening neuropsychological battery comprised mostly of commonly administered clinical measures. Future studies are needed to determine the test–retest reliability, sensitivity, and ecological relevance of this battery, as well as equivalency to in-person assessment.

Does the Key Task Measure Prospective Memory? Cautionary Findings from Parallel Studies in HIV Disease and Older Adults

OBJECTIVE

Despite its brevity and face validity, little is known about the construct validity of the naturalistic "Key Task" of prospective memory (PM), in which an examinee is instructed to remind the examiner at a designated time to retrieve keys (or another belonging) placed out of sight.

METHOD

Study 1 included 162 HIV+ and 52 HIV- comparison participants who completed the Key Task alongside well-validated measures of PM and a comprehensive neuropsychological battery that included everyday functioning measures. Study 2 used broadly parallel methods in 168 older community-dwelling Australians.

RESULTS

Overall, the Key Task was not reliably associated with neurocognitive functioning (including clinical and experimental measures of PM), PM symptoms, or everyday functioning in either sample.

CONCLUSIONS

The Key Task did not demonstrate compelling evidence of construct validity among persons living with HIV disease or older adults, which raises doubts regarding its clinical usefulness as a measure of PM.

One-year stability of prospective memory symptoms and performance in aging and HIV disease

Introduction: HIV disease and aging can both affect prospective memory (PM), which describes the complex process of executing delayed intentions and plays an essential role in everyday functioning. The current study investigated the course of PM symptoms and performance over approximately one year in younger and older persons with and without HIV disease. Method: Participants included 77 older (>50 years) and 35 younger (<40 years) HIV+ individuals and 44 older and 27 younger seronegative adults. Participants completed the Memory for Intentions Test to measure PM in the laboratory, the Prospective and Retrospective Memory Questionnaire to measure PM symptoms in daily life, and several clinical measures of executive functions and retrospective memory as a part of a comprehensive neurocognitive evaluation at baseline and at 14-month follow-up. Results: Findings showed additive, independent main effects of HIV and aging on time- and event-based PM performance in the laboratory, but no change in PM over time. There were no interactions between time and HIV or age groups. Parallel findings were observed for clinical measures of retrospective memory and executive functions. Older HIV+ adults endorsed the greatest frequency of PM symptoms, but there was no change in PM symptom severity over time and no interactions between time and HIV or age groups. There were no effects of HIV or aging on naturalistic PM performance longitudinally. Conclusion: Overall these findings suggest that PM symptoms and performance in the laboratory are stably impaired over the course of a year in the setting of aging and HIV disease.

Prospective memory partially mediates the association between aging and everyday functioning

Objective: Older adults commonly experience declines in everyday functioning, the reasons for which are multifactorial. Prospective memory (PM), or remembering to carry out intended actions, can be an executively demanding cognitive process that declines with older age and is independently associated with a variety of everyday functions (e.g. taking medication). This study examined the hypothesis that PM mediates the relationship between older age and poorer everyday functioning.Method: A total of 468 community-dwelling adults (ages 18-75) with a range of medical comorbidities (e.g. viral infection) were classified as dependent on four well-validated measures of manifest everyday functioning: activities of daily living, employment status, the Karnofsky Scale of Performance Status, and self-reported cognitive symptoms. Participants completed the Memory for Intentions Test (MIsT) to measure PM, alongside clinical tests of executive functions and retrospective memory.Results: Controlling for education and comorbidities, bootstrap analysis revealed a significant direct effect of age on everyday functioning and a significant mediated effect of age on everyday functioning through the indirect effect of time-based b = .006 [.003, .010] and event-based PM (b = .005, [.002, .009]), as well as slightly smaller effects for executive functions (b = .003, [.001, .005]) and retrospective memory (b = .002, [.001, .005]).Conclusions: These cross-sectional data suggest that executively demanding aspects of declarative memory play an important partial mediating role between an individual factor (i.e. age) and daily life activities, and highlight the possible benefit of targeting PM for improving everyday functioning in older adults.

Lower Neurocognitive Functioning Disrupts the Effective Use of Internet-Based Health Resources in HIV Disease: The Mediating Effects of General Health Literacy Capacity

HIV-associated neurocognitive impairment is an independent predictor of low general health literacy, which can be associated with poor disease outcomes (e.g., viremia). Given the increasing frequency with which health behaviors occur in an online environment (e.g., health information seeking, provider interactions), there is a specific need to understand the predictors of electronic health (eHealth) literacy of persons living with HIV disease. In this study, 90 HIV+ persons completed the eHealth Literacy Scale (eHEALS), which measures one's awareness, skills and evaluation of online health resources. Participants also completed a comprehensive battery of clinical neurocognitive tests and well-validated performance-based measures of general health literacy capacity (e.g., knowledge, numeracy). Results showed that, independent of education, lower neurocognitive function was moderately related to lower eHEALS scores, particularly in the domains of learning and motor skills. Of particular note, general health literacy capacity emerged as a significant mediator of the relationship between neurocognition and eHealth literacy. Thus, the adverse effects of neurocognition on health literacy capacity carries a downstream adverse influence on HIV+ persons' awareness, skills, and evaluation of health-related resources in the online environment.

Intraindividual variability in neurocognitive performance is associated with time-based prospective memory in older adults

INTRODUCTION

Older adults demonstrate poorer prospective memory (PM) performance than younger adults, particularly for time-based cues and other strategically demanding PM tasks. Intraindividual variability (IIV) in neurocognitive test performance is an index of cognitive control that may be related to the execution of strategically demanding PM tasks.

METHOD

Participants included 194 older Australian adults (age 50 to 88 years) who completed the Memory for Intentions Screening Test (MIST), the Prospective and Retrospective Memory Questionnaire (PRMQ), and clinical measures of executive functions. A measure of naturalistic time-based PM was also administered, in which participants were asked to call the examiner 24 hours after their appointment to report how many hours they slept. IIV was calculated as the mean-adjusted coefficient of variation (CoV) across subtests of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

RESULTS

IIV was significantly associated with time-based PM in the laboratory, independent of demographics. Additionally, IIV significantly predicted performance on a naturalistic time-based PM trial, independent of demographics and chronic medical conditions. IIV was not related to event-based laboratory PM or self-reported PM symptoms in daily life. Clinical measures of executive functions were similarly associated with time-based PM and the naturalistic PM task, but not with event-based PM or subjective PM symptoms.

CONCLUSIONS

These results indicate that cognitive control, as indexed by IIV in neurocognitive performance, may play a role in naturalistic PM, as well as in highly strategic, but not automatic, laboratory-based PM among older adults.

A systematic review of prospective memory in HIV disease: from the laboratory to daily life

OBJECTIVE

Prospective memory (PM) is described as the capacity to form and maintain an intention that is executed in response to a specific cue. Neural injury and associated neurocognitive disorders are common among persons living with HIV disease, who might therefore be susceptible to impairment in PM.

METHOD

This literature review utilized a structured qualitative approach to summarize and evaluate our current understanding of PM functioning in people living with HIV disease. 33 studies of PM in HIV+ persons met criteria for inclusion.

RESULTS

Findings showed that HIV is associated with moderate deficits in PM, which appear to be largely independent of commonly observed comorbid factors. The pattern of PM deficits reveals dysregulation of strategic processes that is consistent with the frontal systems pathology and associated executive dysfunction that characterizes HIV-associated neural injury. The literature also suggests that HIV-associated PM deficits present a strong risk of concurrent problems in a wide range of health behaviors (e.g. medication non-adherence) and activities of daily living (e.g. employment). Early attempts to improve PM in HIV disease have revealed that supporting strategic processes might be effective for some individuals.

CONCLUSIONS

HIV-associated PM deficits are common and exert a significant adverse effect on the daily lives and health of infected persons. Much work remains to be done to understand the cognitive architecture of HIV-associated PM deficits and the most efficient means to enhance PM functioning and improve health outcomes in persons living with HIV.

Streamlining Participant Recruitment for TBI and PTSD Research Studies

OBJECTIVES

Recruitment of participants for traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) studies is a major challenge, causing delays in study timelines and even study failures. To address this challenge, the Center for Neuroscience and Regenerative Medicine (CNRM) Recruitment Core developed procedures for identification, screening, and referral of participants from screening studies to a broad range of TBI and PTSD studies.

METHODS

Participants were recruited from civilian hospitals, Military Treatment Facilities, and through various events and presentations. Enrolled participants were referred to other studies during initial enrollment, follow-up visits, or ad hoc as new CNRM studies became active. A centralized online database was used to streamline the eligibility and referral process.

RESULTS

As of October 25, 2016, 1,040 enrolled participants from the two screening studies have been assessed for eligibility for active CNRM studies. Referrals have led to 197 total enrollments into other CNRM studies. Common reasons for exclusion from studies included age, date of injury, injury severity, contraindication to Magnetic Resonance Imaging, state of residence, and military status.

CONCLUSION

Collaborative work with multiple disciplines and institutions, and the use of diverse media, was critical to augmenting participant enrollment, and significantly diversified the demographics of the participant population. Streamlining the referral process helps studies meet their timelines and target enrollment.

Leveraging the test effect to improve maintenance of the gains achieved through cognitive rehabilitation

OBJECTIVE

An important aspect of the rehabilitation of cognitive and linguistic function subsequent to brain injury is the maintenance of learning beyond the time of initial treatment. Such maintenance is often not satisfactorily achieved. Additional practice, or overtraining, may play a key role in long-term maintenance. In particular, the literature on learning in cognitively intact persons has suggested that it is testing, and not studying, that contributes to maintenance of learning. The present study investigates the hypothesis that continuing to test relearned words in persons with anomia will lead to significantly greater maintenance compared with continuing to study relearned words.

METHOD

The current study combines overtraining with the variable of test versus study in examining the effects of overtesting and overstudying on maintenance of word finding in 3 persons with aphasia. First, treatment successfully reestablished the connections between known items and their names. Once the connections were reestablished (i.e., items could be named successfully), each item was placed into 1 of 4 overtraining conditions: test and study, only test, only study, or no longer test or study. Maintenance was probed at 1 month and 4 months following the end of overtraining.

RESULTS

The results are consistent with an advantage of testing compared with studying. All 3 participants showed significantly greater maintenance for words that were overtested than for words that were overstudied. This testing benefit persisted at 1 month and 4 months after completion of the treatment. In fact, there was no clear evidence for any benefit of overstudying.

CONCLUSIONS

The present study demonstrates that overtesting, but not overstudying, leads to lasting maintenance of language rehabilitation gains in patients with anomia. The implications for the design of other treatment protocols are immense. (PsycINFO Database Record

Abstract P4-08-01: AMPK facilitates breast cancer cell survival by modulating microenvironmental stress

Recurrent and metastatic breast cancers are responsible for the majority of breast-cancer related deaths. These cancer cells are able to adapt to stressors within the tumor microenvironment including hypoxia, low nutrient levels, and chemotherapy-induced toxicities. Breast cancer cells can respond to these microenvironmental stressors through a variety of mechanisms, including cell cycle inhibition and metabolic alteration. Tumor cell survival is dependent on the ability to alter these mechanisms in response to stress. AMPK (AMP-activated protein kinase) is the main metabolic sensor of the cell, and both its expression and activity have been reported to be altered in breast cancer. Moreover, there are two isoforms of the catalytic subunit (α1 and α2), and differential functionality of these isoforms has been suggested. Using estrogen receptor-positive human breast cancer cell lines, we investigated the effect of differential AMPKα isoform expression on breast cancer cell survival. We found that over-expression of AMPKα2 in MCF-7 cells resulted in decreased ATP production in response to low glucose levels, while the knockdown of AMPKα2 in HCC1500 cells ablated this response to low glucose conditions. A similar difference in response was also seen when the cells were treated with a combination of nutrient stress and the estrogen receptor alpha (ERα) inhibitor, ICI182780. In response to this finding, we compared the glycolytic and oxygen consumption rates of our MCF-7 GFP and MCF-7 AMPKα2 cells. We found that in response to low glucose stress, AMPKα2 expressing MCF-7 cells maintained both a higher glycolytic rate and a higher oxygen consumption rate as compared to GFP cells. Furthermore, these cells seem to alter their cellular signaling in response to metabolic stress faster than GFP cells. To evaluate this differential response to microenvironmental stress in vivo, MCF-7 cells expressing either GFP or AMPKα2 were injected into athymic nude mice previously implanted with slow-release estradiol pellets. After one week, the estradiol pellets were removed to induce cellular dormancy for thirty days. Analysis of tumors at this time indicated that more of the AMPKα2 expressing cells survived estradiol deprivation than did the control cells. Analysis of proliferation by Ki67 staining indicated that the GFP cells maintained proliferation during deprivation, while AMPKα2 cells were largely negative for proliferation. ApoTag staining revealed a similar trend for apoptotic cells. This suggests that an inability to control cell cycle resulted in a decreased survival of the GFP cells under estradiol deprivation. Following the deprivation period, estradiol pellets were re-implanted and residual dormant tumors resumed growth. AMPKα2 tumors grew to roughly double the size of GFP tumors. Interestingly, AMPKα2 tumors had a higher number of mitotic events than did GFP tumors as visualized by Ki67 staining. This could be due to more viable cells being present following estradiol deprivation. We conclude that the expression of AMPKα2 promotes long-term breast cancer survival in estrogen-sensitive cells, due to their increased ability to sense and respond to changes in their microenvironment, which therefore increases their chances for survival.

Citation Format: Sullivan KL, Kopsiaftis S, Phoenix KN, Fox MM, Tsurutani N, Vella AT, Claffey KP. AMPK facilitates breast cancer cell survival by modulating microenvironmental stress. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-08-01.

A randomized trial of varenicline (Chantix) for the treatment of spinocerebellar ataxia type 3

OBJECTIVE

The objective of this double-blind, placebo-controlled, randomized study was to evaluate the efficacy of varenicline (Chantix), a partial agonist at α4β2 neuronal nicotinic acetylcholine receptors used for smoking cessation, in patients with spinocerebellar ataxia (SCA) 3.

METHODS

Patients with genetically confirmed SCA3 were randomly assigned to receive either varenicline (4 weeks for titration and 4 weeks at a dose of 1 mg twice daily) or placebo. Outcome measures included changes in the Scale for the Rating and Assessment of Ataxia (SARA) scores at endpoint (8 weeks) compared with baseline, a timed 25-foot walk and 9-hole peg test, measurements of mood and anxiety, and adverse events.

RESULTS

Twenty patients with SCA3 (mean age = 51 ± 10.98 years; mean disease duration = 14 ± 9.82 years; mean SARA score = 16.13 ± 4.67) were enrolled in the study, and data on 18 patients were analyzed in period I. The most common side effect associated with varenicline was nausea. Improvements were noted in the SARA subsections for gait (p = 0.04), stance (p = 0.03), rapid alternating movements (p = 0.003), and timed 25-foot walk (p = 0.05) and Beck Depression Inventory scores (p = 0.03) in patients taking varenicline compared with those taking placebo at endpoint, with a trend toward improvement in the SARA total score (p = 0.06) in the varenicline group.

CONCLUSIONS

In this controlled study, varenicline significantly improved axial symptoms and rapid alternating movements in patients with SCA3 as measured by SARA subscores and was fairly well tolerated.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that varenicline improved the axial functions of gait, stance, and timed 25-foot walk but did not improve appendicular function, except for rapid alternating movements, in adult patients with genetically confirmed SCA3.

Evidence-based guideline update: treatment of essential tremor: report of the Quality Standards subcommittee of the American Academy of Neurology

BACKGROUND

This evidence-based guideline is an update of the 2005 American Academy of Neurology practice parameter on the treatment of essential tremor (ET).

METHODS

A literature review using MEDLINE, EMBASE, Science Citation Index, and CINAHL was performed to identify clinical trials in patients with ET published between 2004 and April 2010.

RESULTS AND RECOMMENDATIONS

Conclusions and recommendations for the use of propranolol, primidone (Level A, established as effective); alprazolam, atenolol, gabapentin (monotherapy), sotalol, topiramate (Level B, probably effective); nadolol, nimodipine, clonazepam, botulinum toxin A, deep brain stimulation, thalamotomy (Level C, possibly effective); and gamma knife thalamotomy (Level U, insufficient evidence) are unchanged from the previous guideline. Changes to conclusions and recommendations from the previous guideline include the following: 1) levetiracetam and 3,4-diaminopyridine probably do not reduce limb tremor in ET and should not be considered (Level B); 2) flunarizine possibly has no effect in treating limb tremor in ET and may not be considered (Level C); and 3) there is insufficient evidence to support or refute the use of pregabalin, zonisamide, or clozapine as treatment for ET (Level U).

Practice Parameter: treatment of nonmotor symptoms of Parkinson disease: report of the Quality Standards Subcommittee of the American Academy of Neurology

OBJECTIVE

Nonmotor symptoms (sleep dysfunction, sensory symptoms, autonomic dysfunction, mood disorders, and cognitive abnormalities) in Parkinson disease (PD) are a major cause of morbidity, yet are often underrecognized. This evidence-based practice parameter evaluates treatment options for the nonmotor symptoms of PD. Articles pertaining to cognitive and mood dysfunction in PD, as well as treatment of sialorrhea with botulinum toxin, were previously reviewed as part of American Academy of Neurology practice parameters and were not included here.

METHODS

A literature search of MEDLINE, EMBASE, and Science Citation Index was performed to identify clinical trials in patients with nonmotor symptoms of PD published between 1966 and August 2008. Articles were classified according to a 4-tiered level of evidence scheme and recommendations were based on the level of evidence.

RESULTS AND RECOMMENDATIONS

Sildenafil citrate (50 mg) may be considered to treat erectile dysfunction in patients with Parkinson disease (PD) (Level C). Macrogol (polyethylene glycol) may be considered to treat constipation in patients with PD (Level C). The use of levodopa/carbidopa probably decreases the frequency of spontaneous nighttime leg movements, and should be considered to treat periodic limb movements of sleep in patients with PD (Level B). There is insufficient evidence to support or refute specific treatments for urinary incontinence, orthostatic hypotension, and anxiety (Level U). Future research should include concerted and interdisciplinary efforts toward finding treatments for nonmotor symptoms of PD.

Treatment of imbalance with varenicline Chantix(R): report of a patient with fragile X tremor/ataxia syndrome

We describe the case of a man with Fragile X tremor/ataxia syndrome, whose ataxia and imbalance improved with the use of varenicline (Chantix) and reverted to baseline 10 days after varenicline was discontinued. Varenicline was started as part of a smoking cessation program.

Social Security Disability Insurance (SSDI) in Parkinson's disease

OBJECTIVE

Parkinson's disease (PD) causes significant economic burden for patients and caregivers. Social Security Disability Insurance (SSDI) provides insurance to workers in the United States who have been gainfully employed, but who are no longer able to work due to a medical condition. We performed a descriptive pilot study that examined PD patients' experience with SSDI.

METHODS

PD patients who were diagnosed with PD prior to age 60 and were followed at an academic movement disorders center were consecutively invited to participate in a survey concerning their employment history and experience with SSDI.

RESULTS

All 68 invited patients participated in the study (mean age 58 years, mean disease duration 9.5 years). Eighty-two percent of patients felt that they were too disabled to work full time at a mean of 3.4 years after PD diagnosis. Patients applied for SSDI at a mean of 5 years after diagnosis, and two-thirds of PD patients who applied for SSDI obtained it on their first attempt. The primary debilitating symptom that subjectively contributed to work disability was fatigue (49% of patients). Patients who successfully acquired SSDI had extensive documentation of physician visits, and the aid of a disability lawyer.

CONCLUSIONS

Patients felt they were too disabled to work full time at a mean of 3.4 years after diagnosis. Those who applied for SSDI did so at a mean of 5 years after diagnosis. Patients who obtained SSDI awards had extensive documentation of medical records or the help of a disability lawyer.

Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology

BACKGROUND

Essential tremor (ET) is one of the most common tremor disorders in adults and is characterized by kinetic and postural tremor. To develop this practice parameter, the authors reviewed available evidence regarding initiation of pharmacologic and surgical therapies, duration of their effect, their relative benefits and risks, and the strength of evidence supporting their use.

METHODS

A literature review using MEDLINE, EMBASE, Science Citation Index, and CINAHL was performed to identify clinical trials in patients with ET published between 1966 and August 2004. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based on the level of evidence.

RESULTS AND CONCLUSIONS

Propranolol and primidone reduce limb tremor (Level A). Alprazolam, atenolol, gabapentin (monotherapy), sotalol, and topiramate are probably effective in reducing limb tremor (Level B). Limited studies suggest that propranolol reduces head tremor (Level B). Clonazepam, clozapine, nadolol, and nimodipine possibly reduce limb tremor (Level C). Botulinum toxin A may reduce hand tremor but is associated with dose-dependent hand weakness (Level C). Botulinum toxin A may reduce head tremor (Level C) and voice tremor (Level C), but breathiness, hoarseness, and swallowing difficulties may occur in the treatment of voice tremor. Chronic deep brain stimulation (DBS) (Level C) and thalamotomy (Level C) are highly efficacious in reducing tremor. Each procedure carries a small risk of major complications. Some adverse events from DBS may resolve with time or with adjustment of stimulator settings. There is insufficient evidence regarding the surgical treatment of head and voice tremor and the use of gamma knife thalamotomy (Level U). Additional prospective, double-blind, placebo-controlled trials are needed to better determine the efficacy and side effects of pharmacologic and surgical treatments of ET.

Heart failure in Parkinson's disease: analysis of the United States medicare current beneficiary survey

OBJECTIVE

We sought to examine the prevalence of heart failure in elderly PD versus non-PD patients using a national sample of Medicare beneficiaries in the United States.

SCOPE

The prevalence of heart failure in elderly PD patients was 2.27 times that of non-PD patients (19.4% versus 8.7%, 95% CI = 1.43-3.60, p 0.0005), and remained twice as high after excluding patients with stroke and possible vascular parkinsonism.

CONCLUSIONS

In this cross-sectional study of a national Medicare database, heart failure occurred twice as frequently in elderly PD patients as in non-PD patients. Prospective studies are warranted to verify these findings.

Quantification of elastic recoil after balloon angioplasty in the iliac arteries

PURPOSE

Elastic recoil of the arterial wall has been shown to be responsible for a significant loss of luminal area after balloon angioplasty in the coronary arteries, but it has not been well studied in the peripheral arteries. Because elastic recoil depends on the presence of elastin in the arterial wall, and the amount of elastin varies by artery and proximity to the aorta, the importance of this response to angioplasty may be different in peripheral arteries. The purpose of this study is to document the degree of elastic recoil in the iliac arteries, and analyze variables that might influence the results.

MATERIALS AND METHODS

A series of 19 patients with 25 iliac artery stenoses underwent balloon angioplasty followed by placement of a Palmaz stent with the same-sized angioplasty balloon. The minimum luminal diameter of the lesion was measured before treatment, immediately after balloon angioplasty, and again after stent placement. The arterial diameter after stent placement was defined as the diameter of the inflated balloon. The degree of recoil was correlated with nine variables: patient age and sex, lesion location and length, lesion severity (as percent stenosis), the balloon:artery ratio, and three factors related to lesion morphology--complex versus simple, eccentric versus concentric, and calcified versus noncalcified.

RESULTS

Elastic recoil averaged 36% +/- 11% and ranged from 19% to 54% in this series of patients. The only variable that significantly influenced the degree of elastic recoil was the balloon:artery ratio (P =.039), which was directly related.

CONCLUSION

Elastic recoil is a significant limitation of balloon angioplasty in the iliac arteries. This study illustrates the importance of techniques that limit recoil, such as vascular stents, in angioplasty of the iliac arteries.

Tacrolimus-FK506 induced immunosuppression in gnotobiotic piglets

Tacrolimus (FK506), an inhibitor of calcineurin, is an immunosuppressive agent used in clinical trials of transplant patients. Although FK506 targets Ca(2+)-mediated T-cell signaling, phenotype(s) of the specific target cells and the corresponding cytokine pathways are not well known. In this study, the impact of FK506 on number and characteristic of T-cells in selected lymphoid tissues of gnotobiotic (GB) piglets was determined. FK506-treated GB piglets were compared with untreated GB and conventional piglets. The T-helper, cytotoxic, natural killer, double-positive, and activated T-cell populations were analyzed in suspensions of mononuclear cells isolated from thymus, mesenteric lymph nodes and peripheral blood. In vitro secretion of interleukin-8 and interferon-gamma in concanavalin A-stimulated lymphoid cell-cultures was measured by ELISA. Daily intramuscular treatment of GB piglets with 1mg/kg of FK506 from birth for 4 weeks resulted in lowered (P<0.05) in vitro secretion of interferon-gamma and interleukin-8. Moreover, depletions of MNC in systemic and mucosa-associated lymphoid tissues were observed in piglets treated with FK506. The depletions of mononuclear cells and low levels of interferon-gamma and interleukin-8 in piglets treated with FK506 were accompanied by lower proportion of CD3+, CD2+CD4+ and CD2+CD8+ T-cell phenotypes in peripheral blood but not in thymus and mesenteric lymph nodes. These results indicate that FK506-treatment causes immunosuppression in GB piglet, and this effect could be exploited further to study opportunistic pathogens in pig model.

The relationship of clinical and academic productivity in a university hospital radiology department

OBJECTIVE

The purpose of this study was to evaluate the relationship between clinical and academic productivity over a 2-year period in a university hospital radiology department.

MATERIALS AND METHODS

Clinical productivity, as determined by the number of total professional relative value units generated, was compared with academic productivity, which was determined by the number of published peer-reviewed articles, published non-peer-reviewed articles, published abstracts, and presentations delivered by each full-time clinical faculty member. The relationships of age, academic rank, administrative position, and division within the department were also assessed for their effect on relative value units and academic productivity.

RESULTS

We found a significant inverse relationship between relative value units and the number of published peer-reviewed articles, published abstracts, and presentations. Age, academic rank, and administrative responsibilities had no effect on the number of relative value units. Faculty in the neuroradiology and cardiovascular-interventional radiology divisions generated more relative value units than did other faculty members.

CONCLUSION

Faculty members with higher levels of clinical productivity showed significantly lower levels of academic productivity. This finding is consistent with the idea that increases in the clinical workload may diminish research output.

Accuracy and safety of carbon dioxide inferior vena cavography

PURPOSE

The purpose of this study was to assess the accuracy of carbon dioxide compared to iodinated contrast material for determining inferior vena cava (IVC) diameter prior to filter placement, and to assess the safety of CO2 when used for this purpose.

PATIENTS AND METHODS

Consecutive patients undergoing inferior vena cavography prior to filter placement were prospectively evaluated with use of both CO2 and iodinated contrast material. The diameter of the IVC was measured and compared in the same four locations in each patient for both agents. The diameter was corrected for magnification and pin-cushion distortion. The ability of CO2 to correctly classify IVC diameter as < or =28 mm or >28 mm, based on the IVC diameter with iodinated contrast material, was determined. A consensus panel assessed renal vein visualization with CO2 and iodinated contrast material. Blood pressure and arterial oxygen saturation were measured immediately before and after CO2 injection.

RESULTS

Among 30 patients, there was no significant difference in the measured diameter of the IVC with CO2 versus iodinated contrast material after correction for magnification and pin-cushion distortion. One of 30 patients (3.3%) in this study was misclassified as having an IVC < or =28 mm with CO2 when, in fact, the IVC diameter was >28 mm based on iodinated contrast material. This could be clinically significant for certain IVC filters. Forty-seven percent of renal veins identified on contrast venography were identified by CO2 vena cavography. There was no significant difference in the blood pressure or oxygen saturation values measured before and after CO2 injection. However, one patient with pulmonary artery hypertension did experience transient, symptomatic hypotension after CO2 injection.

CONCLUSIONS

In most patients, CO2 vena cavography accurately evaluated IVC diameter prior to filter placement. In 3.3% of patients, the discrepancy in measurements between CO2 and iodinated contrast material could be clinically significant, depending on the type of filter placed. CO2 was less accurate than iodinated contrast material in identifying renal veins. Although CO2 vena cavography is safe in the majority of patients, it should be used with caution in patients with pulmonary hypertension.

Intravascular ultrasound as an alternative to positive-contrast vena cavography prior to filter placement

PURPOSE

In a nonconsecutive series of patients, intravascular ultrasound (IVUS) was investigated for safety and efficacy as an alternative to positive-contrast vena cavography for evaluating the inferior vena cava (IVC) prior to filter placement.

MATERIALS AND METHODS

In a 6.5-year period, 30 patients (15 women, 15 men) ranging in age from 22 to 98 years old (mean, 56 years) underwent vena cava filter placement without conventional positive-contrast vena cavography, after IVUS evaluation of the IVC with use of a 6.2-F, 12.5- or 20-MHz monorail catheter system. The rationale for using IVUS included contraindications to iodinated contrast material in 14 patients with renal insufficiency and in four patients with previous life-threatening anaphylactoid reaction to iodinated contrast material; limitations to radiation exposure in four pregnant patients; and inability to otherwise image the IVC of eight morbidly obese patients who exceeded the weight limits of available angiographic equipment. IVUS completely replaced positive-contrast vena cavography, although not fluoroscopy in the four pregnant patients and in the 18 patients with contrast material contraindications. In two of the eight obese patients, IVUS was the only imaging modality.

RESULTS

In all 30 patients, IVUS successfully determined the patency of the filter delivery route veins and the vena cava, the absence of thrombus, the location of renal veins, the absence of anatomical variants, and the vena cava diameter at the desired filter deployment level. Successful filter placement was confirmed in all 30 patients either with plain film alone (n = 12), IVUS alone (n = 3), computed tomography alone (n = 1), external ultrasound alone (n = 1), IVUS and another imaging modality (n = 10), or by combinations of other imaging modalities (n = 3). There were no complications.

CONCLUSIONS

IVUS is a safe and effective alternative to conventional positive-contrast vena cavography for imaging the IVC prior to filter placement in patients with contraindications to iodinated contrast material or ionizing radiation.

Carbon dioxide as a contrast agent to guide vascular interventional procedures

OBJECTIVE

The purpose of this study was to assess the value and limitations of carbon dioxide (CO2) as a contrast agent to guide vascular interventional procedures.

SUBJECTS AND METHODS

Twenty-two adults underwent 26 vascular interventional procedures (21 arterial, five venous). We aimed to use only CO2 if possible because these patients had renal insufficiency (n = 21; mean creatinine level, 2.8 mg/dl) or were allergic to contrast material (n = 1). Arterial procedures performed included renal angioplasty or stent (n = 6), iliac angioplasty or stent (n = 5), infrainguinal angioplasty (n = 5), arterial bypass graft angioplasty (n = 3), and thrombolysis (n = 2). Venous procedures included transjugular intrahepatic portosystemic shunt recanalization (n = 3), angioplasty of the venous anastomosis of a thigh dialysis graft (n = 1), and angioplasty of the inferior vena cava (n = 1).

RESULTS

Twenty-five of the 26 procedures were successfully performed. Of the 26 procedures, eight required no iodinated contrast material and 11 required less than or equal to 20 ml of contrast material. CO2 proved to be inadequate for the remaining seven procedures. Iliac artery angioplasty or stent placement required an average of 9 ml of iodinated contrast material; infrainguinal angioplasty required an average of 22 ml of iodinated contrast material.

CONCLUSION

CO2 can be successfully used as a contrast agent in a variety of vascular interventional procedures. Such procedures can usually be performed in the iliac and infrainguinal arteries using minimal supplemental iodinated contrast material. However, CO2 failed to provide satisfactory guidance in half of the intraabdominal procedures in our study.

Profiles of healing and nonhealing Cryptosporidium parvum infection in C57BL/6 mice with functional B and T lymphocytes: the extent of gamma interferon modulation determines the outcome of infection

This study describes healing and nonhealing models of Cryptosporidium parvum infection with adult mice that have functional T and B lymphocytes. In our nonhealing model, mice on a C57BL/6 background which have a targeted disruption in the gamma interferon (IFN-gamma) gene (GKO mice) are utilized. C. parvum-infected GKO mice shed extremely high levels of oocysts and displayed overwhelming infection of the entire small intestine. The majority of these mice succumbed within 2 to 3 weeks due to severe acute infection and profound mucosal destruction. In our healing murine model, C57BL/6J mice treated with a single injection of the neutralizing anti-IFN-gamma monoclonal antibody XMG 1.2 prior to infection were used. These mice developed two peaks of oocyst shedding but were ultimately free of parasites on day 30 of infection. Again, the small intestine was the primary site of infection. Mesenteric lymph node (MLN) cells isolated from C. parvum-infected nonhealing GKO mice proliferated and secreted interleukin 2 (IL-2) but not IFN-gamma or IL-4 in response to ex vivo restimulation with intact C. parvum sporozoites or a C. parvum sporozoite antigen preparation. In contrast, parasite-specific MLN cells isolated from healing C57BL/6J mice secreted IL-2 and IFN-gamma but not IL-4. These results suggest that IFN-gamma, either directly or indirectly, is important for resistance to and resolution of cryptosporidiosis. Moreover, these models now allow the analysis of parasite-specific cell-mediated and humoral mucosal immune responses to determine what constitutes protective immunity to C. parvum.

Malignant biliary duct obstruction: long-term experience with Gianturco stents and combined-modality radiation therapy

PURPOSE

To evaluate the effect of combined-modality therapy including intraluminal iridium-192 on stent patency and survival in patients with malignant biliary obstruction treated with Gianturco stents.

MATERIALS AND METHODS

Twenty-two patients with unresectable biliary obstruction caused by cholangiocarcinoma (n = 11) or by secondary extrahepatic bile duct malignant tumors (n = 11) were treated with percutaneous biliary drainage followed by intraluminal Ir-192 wire placement (mean dose, 25 Gy) before insertion of Gianturco metal stents. Eleven patients also received external-beam radiation therapy, and 13 patients received chemotherapy. Patency was defined as absence of jaundice or cholangitis that necessitated hospitalization, or as seen on hepatobiliary scans. Survival was determined from the time of stent insertion after brachytherapy.

RESULTS

Patients with cholangiocarcinoma had extended mean stent patency of 19.5 months (range, 2-46 months) and mean survival of 22.6 months (range, 2-72 months). Patients with secondary malignant tumors had a mean patency of 4.8 months (range, 1.5-8 months) and a mean survival of 5.3 months (range, 2-9 months).

CONCLUSION

Radiation therapy including intraluminal Ir-192 appears to extend stent patency and survival in patients with inoperable cholangiocarcinoma treated with Gianturco metal stents compared with patients with other extrahepatic bile duct malignant diseases and patients treated without combined-modality therapy in other studies.

Chemical ablation of the gallbladder: is it feasible?

PURPOSE

Transcatheter ablation of the gallbladder has been attempted in animals and humans with a variety of chemical and physical agents. Initial in vitro experiments suggested sodium hydroxide and hydrogen peroxide were more effective sclerosants than previously reported chemical agents. A phase I trial of escalating concentrations of and exposure times to these agents was performed in vivo.

MATERIALS AND METHODS

Fourteen domestic pigs underwent cholecystostomy tube placement and cystic duct ligation. Two weeks later, sclerosis was performed with sodium hydroxide/ethanol solutions and hydrogen peroxide.

RESULTS

Sequential 15- or 30-minute exposures to 0.1 N solutions of sodium hydroxide in ethanol followed by 3% peroxide failed to completely eliminate the pig gallbladder epithelium in vivo; 0.5 N and 1.0 N sodium hydroxide in ethanol caused gross gallbladder hemorrhage, mural dissection, and one perforation. Although the gallbladder lumen was ablated, the gallbladder epithelium was not completely eliminated in any animal.

CONCLUSION

Chemical ablation of the pig gallbladder epithelium was not feasible in this experimental model.

Utility of intra-access pressure monitoring in detecting and correcting venous outlet stenoses prior to thrombosis

Vascular access thrombosis is a major problem for hemodialysis patients. Over 7.75 years, we performed intra-access venous pressure monitoring at zero dialyzer blood flow (VP0), correlated VP0 with access anatomy angiographically, and examined the effect of two levels of stenosis, 50% and > 65% luminal diameter reduction (% D) as selection criteria for referral and elective angioplasty or surgical revision upon access outcomes. Summary receiver outcome curves for absolute intra-access pressure (VP0) and intra-access pressure normalized for systemic pressure (VP0/systolic BP) were constructed to evaluate sensitivity and specificity and compared to recirculation and duplex color-flow Doppler. Access outcomes included thrombosis, revision, replacement, and angioplasty rates that were normalized per 100 patient years (100 pt-yrs). During the 7.75 year long study period totaling 832 patient-access years of risk, the percentage of prosthetic bridge grafts increased from 65% to 80%. SROC showed better sensitivity for normalized (VP0/systolic BP) than absolute intra-access pressure (VP0) in grafts. Recirculation had poor predictive power in prosthetic bridge grafts compared to VP0. Predictive power of recirculation was superior to VP0 in native arteriovenous fistulae. The angioplasty rate correlated inversely with the degree of luminal reduction used as selection criterion for referral for angioplasty or surgical revision. A strong inverse relationship between thrombosis rate and the angioplasty rate (R2 = 0.99) but not between thrombosis rate and the number of angiograms performed (R2 = 0.39) was noted. A consistent, yet evolving, intensive graft maintenance protocol produced a 70% decrease in the thrombosis rate, a 79% decrease in the access replacement rate, and an increase in the average age of patent usable vascular accesses from 1.97 to 2.98 years that was associated with a 13-fold increase in the angioplasty rate. We conclude that vascular access monitoring with VP0/systolic BP provides excellent selection criteria for angiographic referral. Intervention for stenotic lesions > 50% D using angioplasty or surgical revision markedly reduces thrombosis and access replacement rates.

Venography with carbon dioxide as a contrast agent

PURPOSE

The purpose of this study was to evaluate the feasibility, safety, and potential role of carbon dioxide (CO2) as a contrast agent for venography.

METHODS

Consecutive patients with contraindications to iodinated contrast agents or with unsatisfactory iodinated contrast studies underwent CO2 digital subtraction venography. The images were rated by three experienced angiographers. Image quality and complications were assessed.

RESULTS

Over a 14-month period, 66 vein segments were studied in 21 patients. There was good correlation between experienced angiographers on CO2 image quality (Ri = 0.80) and good agreement on diagnosis (k = 0.62). In 91% of the vein segments evaluated with C02 there was interobserver agreement on the diagnosis. Upper extremity veins were adequately imaged with CO2 alone in all (6/6) patients with contraindications to iodinated contrast. Following suboptimal iodinated contrast studies in six patients, CO2 produced significantly better quality upper extremity central vein images (p < 0.05). Pain following injection into peripheral veins was the only CO2-related complication. Inferior vena cava (IVC) filters were successfully deployed with CO2 alone in 78% (7/9) of patients; two required iodinated contrast.

CONCLUSIONS

Based upon initial experience, CO2 venography can be recommended in patients with contraindications to iodinated contrast or unsatisfactory iodinated contrast studies.

Treatment of pelvic abscesses and other fluid collections: efficacy of transvaginal sonographically guided aspiration and drainage

OBJECTIVE

The purpose of this study was to evaluate the clinical efficacy of transvaginal sonographically guided aspiration and drainage of pelvic fluid collections.

MATERIALS AND METHODS

Forty patients underwent transvaginal sonographically guided aspiration of a possible pelvic abscess (41 pelvic collections). In patients with clinical findings highly suggestive of infection, both purulent and nonpurulent collections were immediately drained via a catheter. In patients with clinical findings moderately suggestive of infection, nonpurulent collections were completely removed by aspiration and the aspirates were cultured; however, purulent collections were immediately drained via a catheter.

RESULTS

All collections were successfully accessed by transvaginal sonography. For 27 of the 41 collections, the aspirate was purulent (18 collections) or the patient's clinical findings were highly suggestive of infection (nine collections) and catheter drainage was performed. Seventeen of the 27 collections completely resolved and surgery was not required. Four of the 27 collections were in patients who had surgery for reasons other than persistent infected collection. For six of the 27 collections, catheter treatment was not successful and surgery was required. The overall success rate of catheter drainage was 78%. In the remaining 14 of the 41 collections, the aspirate was serous or serosanguineous, and the patient's clinical findings were moderately suggestive of infection. Cultures of aspirates of seven collections were positive for microorganisms. Eleven collections were successfully treated with antibiotics or no therapy was required (based on culture results); for three, surgery was required. Two complications occurred: one vaginal fistula after catheter drainage and one disruption of vaginal sutures after aspiration.

CONCLUSION

Transvaginal sonographically guided drainage is effective treatment of pelvic abscess, being either completely curative or temporizing in 78% of patients. Catheter treatment was unsuccessful and surgery was necessary in 22% of patients. For nonpurulent collections, catheter drainage is indicated only when clinical findings are highly suggestive of infection.

Chemical ablation of the gallbladder: evaluation of multiple agents in vitro

PURPOSE

To find a more effective chemical regimen for transcatheter ablation of the gallbladder in an in vitro model.

MATERIALS AND METHODS

Sectioned and whole pig gallbladders were exposed in vitro to 12 different chemical solutions at varying conditions of exposure time, pH, and temperature.

RESULTS

In the in vitro studies, 0.1 N and 1.0 N solutions of sodium hydroxide in water or ethanol and 3% hydrogen peroxide were the most effective sclerosant agents. Ethanol and hydrochloric acid failed to completely eliminate the epithelium from the gallbladder sections. Increasing exposure time from 10 to 20 minutes or increasing the temperature of the solutions from 37 degrees C to 50 degrees C did not alter these results. Sequential 15-minute exposures to 0.1 N sodium hydroxide in ethanol followed by peroxide completely eliminated the epithelium from whole gallbladders in vitro.

CONCLUSION

Alkaline solutions and hydrogen peroxide are more effective than ethanol alone, acids, or detergents in eliminating gallbladder epithelium in this model. Further evaluation of these agents in vivo is merited.

Arterial abnormalities following orthotopic liver transplantation: arteriographic findings and correlation with Doppler sonographic findings

OBJECTIVE

We studied the findings on conventional arteriography in patients who had suspected graft ischemia after orthotopic liver transplantation to determine the value of a single Doppler signal in predicting these lesions.

MATERIALS AND METHODS

We retrospectively reviewed selective visceral arteriograms with abnormal findings from 20 adults who had suspected graft ischemia after orthotopic liver transplantation and a single Doppler signal from the hepatic artery at the porta hepatis on sonograms obtained before arteriography. Arteriographic abnormalities were categorized according to morphology and location as follows: stenosis of recipient's hepatic artery, occlusion or stenosis of the transplanted extrahepatic artery, and occlusion or stenosis of the transplanted intrahepatic artery.

RESULTS

Twenty-three arteriographic abnormalities were detected: four recipient celiac axis stenoses, seven extrahepatic occlusions, nine extrahepatic stenoses, and two occlusions and one stenosis of the transplanted intrahepatic artery. Six of the extrahepatic occlusions, two of the extrahepatic stenoses, and none of the recipient artery stenoses or the intrahepatic occlusions or stenoses were correctly diagnosed on the basis of Doppler findings. One patient with both an extrahepatic stenosis and an extrahepatic occlusion was thought to have an intrahepatic occlusion, and two patients with mild (< 50%) extrahepatic stenoses and one with an intrahepatic occlusion were thought to have an extrahepatic occlusion.

CONCLUSION

A wide spectrum of abnormalities in the recipient's celiac axis or the transplanted arteries that may be associated with graft ischemia after orthotopic liver transplantation are often not detected or findings are misinterpreted on routine Doppler examination. In patients with suspected graft ischemia, visceral arteriography should be performed promptly to confirm the diagnosis and to allow early intervention.

Role of selective arteriography in the diagnosis of a ruptured middle colic artery aneurysm

A case of a ruptured middle colic artery is reported. The diagnosis was initially overlooked and eventually made by selective arteriography. Aneurysms of visceral arteries are rare and rupture of them even more infrequent. Awareness of this potentially fatal and treatable entity should enable early detection by selective visceral arteriography. The roles of embolization and surgery in the management of visceral aneurysms are discussed.

Fallopian tube recanalization in an unrestricted patient population

PURPOSE

To review the effectiveness of fallopian tube recanalization (FTR) when performed without restriction based on history or tubal condition.

MATERIALS AND METHODS

From October 1989 to July 1992 in 37 consecutive women, aged 22-44 years (mean, 35 years), 42 FTRs were performed (five patients each underwent two FTRs). Water-soluble contrast material and selective ostial salpingography and/or microcatheter technique were used exclusively. Eighty tubes were evaluated, since four patients had previously undergone unilateral salpingectomy. Sixty-three tubes (79%) were occluded at the outset of the procedure.

RESULTS

Complete recanalization was achieved in 45 of 63 (71%) occlusions. Adhesions were present in 25 of 80 (31%) tubes, salpingitis isthmica nodosa in 12 (15%), and hydrosalpinx in nine (11%). The 42 procedures resulted in 14 (33%) conceptions, nine (64%) of which involved pathologic tubes. Eleven intrauterine pregnancies resulted in five spontaneous first-trimester abortions, five full-term deliveries, and one continuing pregnancy.

CONCLUSION

Favorable conception and live birth rates can be achieved with FTR, despite a high prevalence of tubal disease.

Use of a Colapinto needle in US-guided transvaginal drainage of pelvic abscesses

The ultrasound-guided transvaginal approach offers a direct, nonsurgical means for drainage of deep pelvic abscesses. It is often difficult, however, to place drainage catheters through the vaginal wall by using routine Seldinger technique. The authors describe four recent drainage procedures facilitated through use of a Colapinto needle as a dilator. In two cases, the Colapinto needle also served as a stiffening cannula for the passage of a fascial dilator.