Evaluation of variation in special educational needs provision and its impact on health and education using administrative records for England: umbrella protocol for a mixed-methods research programme

INTRODUCTION

One-third of children in England have special educational needs (SEN) provision recorded during their school career. The proportion of children with SEN provision varies between schools and demographic groups, which may reflect variation in need, inequitable provision and/or systemic factors. There is scant evidence on whether SEN provision improves health and education outcomes.

METHODS

The Health Outcomes of young People in Education (HOPE) research programme uses administrative data from the Education and Child Health Insights from Linked Data-ECHILD-which contains data from all state schools, and contacts with National Health Service hospitals in England, to explore variation in SEN provision and its impact on health and education outcomes. This umbrella protocol sets out analyses across four work packages (WP). WP1 defined a range of 'health phenotypes', that is health conditions expected to need SEN provision in primary school. Next, we describe health and education outcomes (WP1) and individual, school-level and area-level factors affecting variation in SEN provision across different phenotypes (WP2). WP3 assesses the impact of SEN provision on health and education outcomes for specific health phenotypes using a range of causal inference methods to account for confounding factors and possible selection bias. In WP4 we review local policies and synthesise findings from surveys, interviews and focus groups of service users and providers to understand factors associated with variation in and experiences of identification, assessment and provision for SEN. Triangulation of findings on outcomes, variation and impact of SEN provision for different health phenotypes in ECHILD, with experiences of SEN provision will inform interpretation of findings for policy, practice and families and methods for future evaluation.

ETHICS AND DISSEMINATION

Research ethics committees have approved the use of the ECHILD database and, separately, the survey, interviews and focus groups of young people, parents and service providers. These stakeholders will contribute to the design, interpretation and communication of findings.

How Could Different Obesity Scenarios Alter the Burden of Type 2 Diabetes and Liver Disease in Saudi Arabia?

INTRODUCTION

Obesity is a major risk factor for type 2 diabetes (T2DM) and liver disease, and obesity-attributable liver disease is a common indication for liver transplant. Obesity prevalence in Saudi Arabia (SA) has increased in recent decades. SA has committed to the WHO "halt obesity" target to shift prevalence to 2010 levels by 2025. We estimated the future benefits of reducing obesity in SA on incidence and costs of T2DM and liver disease under two policy scenarios: (1) SA meets the "halt obesity" target; (2) population body mass index (BMI) is reduced by 1% annually from 2020 to 2040.

METHODS

We developed a dynamic microsimulation of working-age people (20-59 years) in SA between 2010 and 2040. Model inputs included population demographic, disease and healthcare cost data, and relative risks of diseases associated with obesity. In our two policy scenarios, we manipulated population BMI and compared predicted disease incidence and associated healthcare costs to a baseline "no change" scenario.

RESULTS

Adults <35 years are expected to meet the "halt obesity" target, but those ≥35 years are not. Obesity is set to decline for females, but to increase amongst males 35-59 years. If SA's working-age population achieved either scenario, >1.15 million combined cases of T2DM, liver disease, and liver cancer could be avoided by 2040. Healthcare cost savings for the "halt obesity" and 1% reduction scenarios are 46.7 and 32.8 billion USD, respectively.

CONCLUSION

SA's younger working-age population is set to meet the "halt obesity" target, but those aged 35-59 are off track. Even a modest annual 1% BMI reduction could result in substantial future health and economic benefits. Our findings strongly support universal initiatives to reduce population-level obesity, with targeted initiatives for working-age people ≥35 years of age.

The future health and economic burden of obesity-attributable type 2 diabetes and liver disease among the working-age population in Saudi Arabia

Background

Obesity and type 2 diabetes (T2DM) are increasing in Saudi Arabia (SA). Among other conditions, these risk factors increase the likelihood of non-alcoholic fatty liver disease (NAFLD), which in turn increases risks for advanced liver diseases, such as non-alcoholic steatohepatitis (NASH), cirrhosis and cancer. The goal of this study was to quantify the health and economic burden of obesity-attributable T2DM and liver disease in SA.

Methods

We developed a microsimulation of the SA population to quantify the future incidence and direct health care costs of obesity-attributable T2DM and liver disease, including liver cancer. Model inputs included population demographics, body mass index, incidence, mortality and direct health care costs of T2DM and liver disease and relative risks of each condition as a function of BMI category. Model outputs included age- and sex-disaggregated incidence of obesity-attributable T2DM and liver disease and their direct health care costs for SA’s working-age population (20–59 years) between 2020 and 2040.

Results

Between 2020 and 2040, the available data predicts 1,976,593 [± 1834] new cases of T2DM, 285,346 [±874] new cases of chronic liver diseases, and 2,101 [± 150] new cases of liver cancer attributable to obesity, amongst working-age people. By 2040, the direct health care costs of these obesity-attributable diseases are predicted to be 127,956,508,540 [± 51,882,446] USD.

Conclusions

The increase in obesity-associated T2DM and liver disease emphasises the urgent need for obesity interventions and strategies to meaningfully reduce the future health and economic burden of T2DM, chronic liver diseases and liver cancer in SA.

Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review

Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding 'domains' (baby's behaviour; mother's behaviour; position; latching; effective feeding; breast health; baby's health; mother's view of  feed; number, timing and length of feeds). Results: We identified 29 breastfeeding assessment tools and 45 validation studies. Eight tools had not been validated. Evidence underpinning most tools was low quality and mainly from high-income countries and hospital settings. The most comprehensive tools were the Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools and CARE training package. The tool with the strongest evidence was the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form. Conclusions: Despite many possible tools, there is currently no one gold standard. For assessing malnourished infants in resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools, Module IFE and the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form are the best available tools but could be improved by adding questions from other tools. Allowing for context, one tool for rapid community-based assessment plus a more detailed one for clinic/hospital assessment might help optimally identify breastfeeding problems and the support required. Further research is important to refine existing tools and develop new ones. Rigorous testing, especially against outcomes such as breastfeeding status and growth, is key.

Breastfeeding assessment tools for at-risk and malnourished infants aged under 6 months old: a systematic review

Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding 'domains' (baby's behaviour; mother's behaviour; position; latching; effective feeding; breast health; baby's health; mother's view of  feed; number, timing and length of feeds). Results: We identified 29 breastfeeding assessment tools and 45 validation studies. Eight tools had not been validated. Evidence underpinning most tools was low quality and mainly from high-income countries and hospital settings. The most comprehensive tools were the Breastfeeding, Evaluation and Education Tool, UNICEF Baby-Friendly Hospital Initiative tools and CARE training package. The tool with the strongest evidence was the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form. Conclusions: Despite many possible tools, there is currently no one gold standard. For assessing malnourished infants in resource-poor settings, UNICEF Baby-Friendly Hospital Initiative tools, Module IFE and the WHO/UNICEF B-R-E-A-S-T-Feed Observation Form are the best available tools but could be improved by adding questions from other tools. Allowing for context, one tool for rapid community-based assessment plus a more detailed one for clinic/hospital assessment might help optimally identify breastfeeding problems and the support required. Further research is important to refine existing tools and develop new ones. Rigorous testing, especially against outcomes such as breastfeeding status and growth, is key.

Estimates of Caffeine Use Disorder, Caffeine Withdrawal, Harm and Help-seeking in New Zealand: A cross-sectional survey

BACKGROUND

Caffeine Use Disorder (CUD) is not yet formally recognized in the DSM-5, but emerging evidence suggests CUD could impact up to one in five people. The primary aim of this study was to estimate levels of caffeine consumption and its associations with CUD and withdrawal, taking socio-demographic characteristics (age, gender, ethnicity, income) into account. Secondary aims were to measure caffeine-related harm and treatment preferences.

METHODS

We administered an online cross-sectional survey via Facebook to a convenience sample of 2379 adults in New Zealand. Caffeine consumption was assessed across six products: coffee, tea, energy drinks, cola, alcohol mixed with caffeine, and other products (e.g., caffeine pills, sports supplements).

RESULTS

20% of participants met proposed criteria for CUD, with 30% meeting DSM-5 criteria for caffeine withdrawal. Moderate (200-400 mg per day) and high consumption (>400 mg per day) was associated with a three-fold increase in the odds of CUD and a two-fold increase in the odds of withdrawal. Women and current smokers were at higher risk of CUD and withdrawal even at moderate consumption levels. Nearly 85% of respondents experienced at least one caffeine-related harm in the past 12-months. The number of harms increased with level of caffeine consumption. Nearly 50% indicated a self-help treatment for caffeine reduction would be of interest.

CONCLUSIONS

High rates of CUD and caffeine withdrawal amongst moderate caffeine users, women and smokers suggests caffeine consumption guidelines may need refinement. Caffeine-related harm that is not clinically meaningful may still be of concern to individuals and warrants further investigation.

Impact of coal-carrying trains on particulate matter concentrations in South Delta, British Columbia, Canada

Transport of coal by train through residential neighborhoods in Metro Vancouver, British Columbia, Canada may increase the possibility of exposure to particulate matter at different size ranges, with concomitant potential negative health impacts. This pilot study identifies and quantifies train impacts on particulate matter (PM) concentrations at a single location. Field work was conducted during August and September 2014, with the attributes of a subset of passing trains confirmed visually, and the majority of passages identified with audio data. In addition to fixed ground based monitors at distances 15 and 50 m from the train tracks, an horizontally pointing mini-micropulse lidar system was deployed on three days to make backscatter and depolarization measurements in an attempt to identify the zone of influence, and sources, of train-generated PM. Ancillary wind and dust fall data were also utilized. Trains carrying coal are associated with a 5.3 (54%), 4.1 (33%), and 2.6 (17%) μgm^-3 average increase in concentration over a 14 min period compared to the average concentrations over the 10 min prior to and after a train passage ("control" or "background" conditions), for PM₃, PM₁₀, and PM₂₀, respectively. In addition, for PM₁₀ and PM₂₀, concentrations during train passages of non-coal-carrying trains were not found to be significantly different from PM concentrations during control conditions. Presence of coal dust particles at the site was confirmed by dust fall measurements. Although enhancements of PM concentrations during 14 min train passages were generally modest, passing coal trains occasionally enhanced concentrations at 50 m from the tracks by ∼100 μgm^-3. Results showed that not every train passage increased PM concentrations, and the effect appears to be highly dependent on wind direction, local meteorology and load related factors. LiDAR imagery suggests that re-mobilization of track-side PM by train-induced turbulence may be a significant contributor to coarse particle enhancements.

Handwashing, sanitation and family planning practices are the strongest underlying determinants of child stunting in rural indigenous communities of Jharkhand and Odisha, Eastern India: a cross-sectional study

The World Health Organisation has called for global action to reduce child stunting by 40% by 2025. One third of the world's stunted children live in India, and children belonging to rural indigenous communities are the worst affected. We sought to identify the strongest determinants of stunting among indigenous children in rural Jharkhand and Odisha, India, to highlight key areas for intervention.

We analysed data from 1227 children aged 6–23.99 months and their mothers, collected in 2010 from 18 clusters of villages with a high proportion of people from indigenous groups in three districts. We measured height and weight of mothers and children, and captured data on various basic, underlying and immediate determinants of undernutrition. We used Generalised Estimating Equations to identify individual determinants associated with children's height‐for‐age z‐score (HAZ; p < 0.10); we included these in a multivariable model to identify the strongest HAZ determinants using backwards stepwise methods.

In the adjusted model, the strongest protective factors for linear growth included cooking outdoors rather than indoors (HAZ +0.66), birth spacing ≥24 months (HAZ +0.40), and handwashing with a cleansing agent (HAZ +0.32). The strongest risk factors were later birth order (HAZ −0.38) and repeated diarrhoeal infection (HAZ −0.23).

Our results suggest multiple risk factors for linear growth faltering in indigenous communities in Jharkhand and Odisha. Interventions that could improve children's growth include reducing exposure to indoor air pollution, increasing access to family planning, reducing diarrhoeal infections, improving handwashing practices, increasing access to income and strengthening health and sanitation infrastructure.

Evaluation of an 8-item Severe Impairment Battery (SIB-8) vs. the full SIB in moderate to severe Alzheimer's disease patients participating in a donepezil study

AIM

The Severe Impairment Battery (SIB), a reliable cognitive measure for evaluating treatment response in advanced Alzheimer's disease (AD), takes approximately 20 min to administer. A recently derived 8-item version of the SIB - the SIB-8 - which takes about 3 min to administer, may represent a more convenient tool for use in clinical practice. The current analyses further explored the SIB-8 scale with respect to its validity and sensitivity.

METHODS

A post hoc analysis was performed using data from a 24-week trial of donepezil 23 mg/day and 10 mg/day in > 1400 patients with moderate to severe AD [baseline Mini-Mental State Examination (MMSE) score 0-20]. Treatment effects on cognition (patterns of score change) were assessed using the full SIB and SIB-8 in the total study population and subgroups based on concomitant memantine use and baseline MMSE. Internal consistency/agreement and correlations between the SIB and SIB-8 and other clinical end points were evaluated.

RESULTS

Assessment of score changes from baseline to week 24 with donepezil (23 or 10 mg/day) demonstrated comparable patterns of change when using the SIB-8 and the full SIB, despite inherent differences in the total score ranges for the two scales. Internal consistency/agreement between the full SIB and SIB-8 was good (Cronbach's alphas: 0.77-0.95). SIB-8 scores reliably correlated with SIB total scores (r = 0.859, baseline; r = 0.900, week 24; p < 0.0001), as well as MMSE scores (r = 0.7163, baseline; r = 0.7963, week 24; p < 0.0001). Scores on both SIB scales were moderately associated with functional measures at baseline and week 24.

CONCLUSIONS

In this post hoc analysis, similar treatment effects were measured by the full SIB and the SIB-8. Very good internal consistency/agreement and strong correlations between the SIB and the more rapid and convenient SIB-8 indicate that the SIB-8 may be a useful and efficient clinical proxy for the full SIB in evaluating treatment response in patients with advanced AD.

Previous reproductive history and post-natal family planning among HIV-infected women in Ukraine

BACKGROUND

Ukraine has the highest antenatal HIV prevalence in Europe. The national prevention of mother-to-child transmission (MTCT) programme has reduced the MTCT rate, but less attention has been given to the prevention of unintended pregnancy among HIV-positive women. Our objectives were to describe the reproductive health, condom use and family planning (FP) practices of HIV-positive childbearing Ukrainian women and to identify factors associated with different methods of post-natal contraception.

METHODS

HIV-infected childbearing women, diagnosed before or during pregnancy, were enrolled prospectively in a post-natal cohort study in four regional HIV/AIDS centres in Ukraine from December 2007. Logistic regression models were used to identify factors associated with post-natal FP practices.

RESULTS

Data were available for 371 women enrolled by March 2009; 82% (n = 303) were married or cohabiting, 27% (97 of 363) reported a current HIV-negative sexual partner and 69% were diagnosed with HIV during their most recent pregnancy. Overall, 21% (75 of 349) of women were not using contraception post-natally (of whom 80% reported no current sexual activity), 50% (174 of 349) used condoms, 20% (74 of 349) relied solely/partially on coitus interruptus and 4% used hormonal methods or intrauterine device. Among married/cohabiting women, consistent use of condoms in the previous pregnancy [AOR 1.96 (95%CI 1.06–3.62)], having an HIV-positive partner [AOR 0.42 (0.20–0.87)], current sexual activity [AOR 4.53 (1.19–17.3)] and study site were significantly associated with post-natal condom use; 16% of those with HIV-negative partners did not use condoms. Risk factors for non-use of FP were lack of affordability [AOR 6.34 (1.73–23.2)] and inconsistent use of condoms in the previous pregnancy [AOR 7.25 (1.41–37.2)].

CONCLUSIONS

More than 40% of HIV-positive women in this population are at risk of unintended pregnancy and the one in six women in HIV-discordant couples not using barrier methods risk transmitting HIV to their partners. Our study results are limited by the observational nature of the data and the potential for both measured and unmeasured confounding.

Weight status and perceived body size in children

OBJECTIVE

To investigate associations between weight status and body size perception in children in the UK.

DESIGN

Cross-sectional survey.

SETTING

School-based sample in the UK.

PARTICIPANTS

399 children (205 boys, 194 girls) aged 7-9 years.

MAIN OUTCOME MEASURES

Perceived body size was assessed using a visual method (Children's Body Image Scale, matching to images representing body mass indexes (BMI) from 3rd to 97th percentiles) and verbal descriptors from "too thin" to "too fat". BMI (converted to BMI SD scores using UK data) was assessed and demographic information was recorded.

RESULTS

Modest associations between actual and perceived body size were found with visual (r = 0.43, p<0.001) and verbal (r = 0.41, p<0.001) methods, but there was a consistent response bias towards underestimation. Using visual matching, most children (45%) underestimated their body size, with significantly greater underestimation (p<0.001) at higher BMI. A gender-by-weight group interaction (p = 0.001) showed that at lower weights girls were more accurate than boys, but at higher weights girls were less accurate. Using the verbal scale, the majority of children reported their body size as "just right" in all weight groups (52-73%), with no sex differences.

CONCLUSIONS

Children can estimate their body size using visual or verbal methods with some accuracy, but show greater underestimation at higher weights, especially in girls. These findings suggest that underestimation is more widespread than has been assumed, which has implications for health education among school-aged children.

Functional and cognitive criteria produce different rates of mild cognitive impairment and conversion to dementia

OBJECTIVE

To compare rates of mild cognitive impairment (MCI) and rates of progression to dementia using different MCI diagnostic systems.

METHODS

MCI was investigated at baseline in 3063 community dwelling non-demented elderly in the Ginkgo Evaluation of Memory (GEM) study who were evaluated every 6 months to identify the presence of dementia. Overall MCI frequency was determined using (1) a Clinical Dementia Rating (CDR) score of 0.5 and (2) neuropsychological (NP) criteria, defined by impairment on standard cognitive tests.

RESULTS

40.2% of participants met CDR MCI criteria and 28.2% met NP MCI criteria (amnestic MCI = 16.6%). 15.7% were classified as MCI by both criteria and 47.4% as normal by both. Discordant diagnoses were observed in 24.5% who met NP normal/CDR MCI and in 12.4% who met NP MCI/CDR normal. Factors associated with CDR MCI among NP normal included lower education, lower NP scores, more instrumental activities of daily living impairment, greater symptoms of depression and subjective health problems. Individuals meeting NP MCI/CDR normal were significantly more likely to develop dementia over the median follow-up of 6.1 years than those meeting NP normal/CDR MCI.

CONCLUSIONS

Different criteria produce different MCI rates and different conversion rates to dementia. Although a higher percentage of MCI was identified by CDR than NP, a higher percentage of NP MCI progressed to dementia. These findings suggest that the CDR is sensitive to subtle changes in cognition not identified by the NP algorithm but is also sensitive to demographic and clinical factors probably leading to a greater number of false positives. These results suggest that identifying all individuals with CDR scores of 0.5 as Alzheimer's disease is not advisable.

Long-term effects of the concomitant use of memantine with cholinesterase inhibition in Alzheimer disease

BACKGROUND

Patients using cholinesterase inhibitors (ChEIs) have a delay in nursing home (NH) admission compared with those who were not using the medication. There are no long-term studies of the effects of memantine in combination with ChEIs use in Alzheimer disease (AD). This study was conducted to examine the effects of ChEIs and memantine on time to death and time to NH admission.

METHODS

Time to NH admission and death was examined in 943 probable AD patients who had at least a 1-year follow-up evaluation. Of these patients, 140 (14.9%) used both ChEIs and memantine, 387 (41%) [corrected] used only ChEIs, and 416 (44.1%) [corrected] used neither. The mean (SD) follow-up time was 62.3 (35.8) months. The analysis was conducted with multivariable Cox proportional hazard models controlling for critical covariates (ie, age, education level, gender, severity of the dementia, hypertension, diabetes mellitus, heart disease, psychiatric symptoms and use of psychotropic medications).

RESULTS

Compared with those who never used cognitive enhancers, patients who used ChEIs had a significant delay in NH admission (HR: 0.37, 95% CI 0.27 to 0.49); this effect was significantly augmented with the addition of memantine (HR: 0.29, 95% CI 0.11 to 0.72) (memantine+ChEI vs ChEI alone). ChEIs alone, or in combination with memantine had no significant association on time to death.

CONCLUSIONS

This observational study revealed that the addition of the NMDA receptor antagonist memantine to the treatment of AD with ChEI significantly altered the treated history of AD by extending time to nursing home admission.

Maternal education is associated with feeding style

Maternal feeding styles may be influenced by maternal education, with implications for children's dietary quality and adiposity. One-hundred and eighty mothers completed the Parental Feeding Style Questionnaire, which includes scales assessing four aspects of feeding style, ie, control over feeding, emotional feeding, instrumental feeding, and encouragement/prompting to eat. Mothers with higher education had significantly higher scores on control over feeding [F(1,177)=8.79; P=0.003] and significantly lower emotional feeding scores [F(1,177)=7.26; P=0.008] than those with lower education. There were no differences for instrumental feeding or encouragement/prompting to eat (P>0.05). These findings suggest modest but potentially important differences in maternal control and emotional feeding styles by maternal education. Should these feeding characteristics prove salient to childhood diet and weight, this could inform appropriately targeted parental feeding advice.

Exercise training improves cutaneous microvascular endothelial function in post-surgical varicose vein patients

This study investigated the effects of exercise training on cutaneous microvascular function in post-surgical varicose vein patients. Sixteen post-surgical (4-5 weeks) varicose vein patients were randomised to a treadmill-walking exercise group or a non-exercise control group. The exercise group trained twice weekly for 8 weeks. Changes in cutaneous microvascular function of the gaiter area were assessed using laser Doppler flowmetry combined with incremental-dose iontophoretic administration of acetylcholine chloride (ACh) and sodium nitroprusside (SNP) in both supine and standing positions. At 8 weeks, peak flux responses to ACh in the supine position were increased in the exercise group (44+/-30 to 62+/-33 PU; P=0.03) with a similar trend in the standing position (37+/-27 to 74+/-31 PU; P=0.08). There were no such changes in the control group (P>0.05). Additionally, peak flux responses to SNP were unchanged in both groups and body positions (P>0.05). The results suggest that moderate-intensity lower-limb exercise training improves microvascular endothelial vasodilator function in post-surgical varicose vein patients.

Effects of ulapualide A and synthetic macrolide analogues on actin dynamics and gene regulation

Several marine macrolide toxins act as potent and specific actin-severing molecules. Recent elucidation of their stereochemistries and modes of interaction with actin has allowed the syntheses of bioactive analogues. Here we used synthetic analogues in a structure-function analysis of ulapualide A, a trisoxazole-based macrolide. Ulapualide A harboured potent actin-depolymerising activity both in cells and in vitro. Its synthetic diastereoisomer was three orders of magnitude less active than the natural toxin and synthetic macrolide fragments lacked actin-capping/ severing activity altogether. Modulation of serum response factor (SRF)-dependent gene expression, as described for other actin-binding toxins, was also examined. Specific changes in response to ulapualide A were not observed, primarily due to its profound effects on cytoskeletal integrity and cell adhesion. Several synthetic fragments of ulapualide A also had no effect on SRF-dependent gene expression. However, inhibition was observed with a molecule corresponding to the extended aliphatic side chain of halichondramide, a structurally related macrolide. These findings indicate that side-chain derivatives of trisoxazole-based macrolides may serve to uncouple gene-regulatory events from actin dynamics.

Functional neuroimaging indicators of successful executive control in the oldest old

Attentional control, motor planning abilities, and executive cognitive functions (ECF) rapidly decline with age. In particular, older adults experience difficulty in manipulating selected motor responses in the presence of conflicting or distracting information. To examine age-related changes in the neural substrates of the attentional and motor planning components of ECF, we assessed the patterns of brain activation in 8 cognitively normal older adults (mean age 81.5) and 20 young individuals (mean age 23.0) while they responded to low and high loads of attentional demands of the Preparing to Overcome Prepotency (POP) task. In the POP task, the selection of one out of two possible motor responses in the presence of increasing attentional task loads determines the accuracy of the performance. Older individuals were slower than young adults (P < 0.001) but achieved a strikingly high accuracy similar to the young group (P = 0.2), regardless of the task load. Both groups showed a load-related fMRI signal increase in the anterior cingulate cortex (ACC), posterior parietal cortex (PPC: Brodmann areas 7 and 40), and dorsolateral prefrontal cortex (dLPFC: Brodmann areas 9, 45, and 46) bilaterally. Compared to young individuals, older adults had lower activation in dLPFC (Brodmann areas 9, 45, and 46: P = 0.007, P = 0.043, and P = 0.040) and Brodmann area 7, P = 0.002. Activation in Brodmann areas 40 and ACC was similar in the two groups (P > 0.05). Among older adults, the most successful performers were those who responded to increasing task loads with greater activation in PPC (Brodmann area 40), despite lower dLPFC activation. Older adults who are able to perform executive control tasks as well as young adults, also seem to implement speed-accuracy trade-off strategies which may rely on increased parietal activation.

Preclinical Alzheimer disease: Neuropsychological test performance 1.5 to 8 years prior to onset

OBJECTIVE

To determine if individuals ultimately diagnosed with Alzheimer disease (AD) exhibited evidence of cognitive impairment on neuropsychological tests administered between 1.5 years and 8.1 years before dementia onset.

METHODS

A total of 693 community-dwelling individuals, part of the Cardiovascular Health Study, completed a neuropsychological test battery in 1991/92. Subjects were followed annually over the next 8 years (median follow-up = 7.4 years). Seventy-two individuals were ultimately diagnosed with AD (median follow-up = 4.5 years): 24 with AD onset 1.5 to 3.4 years after baseline neuropsychological testing, 20 with AD onset 3.5 to 5.0 years after testing, and 28 with onset 5.1 to 8.1 years after testing. A total of 621 individuals remained nondemented throughout the 8 years of follow-up (median follow-up = 7.5 years).

RESULTS

Subjects ultimately diagnosed with AD had poorer scores on baseline neuropsychological measures than subjects who remained nondemented. Although individuals closest to AD onset (i.e., 1.5 to 3.4 years) performed the most poorly, cognitive impairment was detected in individuals who did not develop AD until 5 to 8 years later.

CONCLUSIONS

Cognitive changes can be detected well before onset of Alzheimer disease.

A critique of a UK standardized test of finger rewarming after cold provocation in the diagnosis and staging of hand-arm vibration syndrome

BACKGROUND

Accurate diagnosis and staging of hand-arm vibration syndrome (HAVS) is important in health surveillance of vibration-exposed workers and the substantial number of related medico-legal cases. The measurement of the rewarming rate of fingers after cold provocation to the hands (CPT) has been suggested as a useful test in diagnosing HAVS.

AIM

To investigate the diagnostic value of a standardized version of the CPT test using a 15 degrees C cold challenge for 5 min applied in the recent compensation assessment of UK miners.

METHODS

Analysis of a subset of UK miners assessed at our unit, together with data from a small repeatability study of the standardized CPT in normal subjects.

RESULTS

Rewarming time in the CPT was significantly lower in those subjects classified as vascular Stockholm stage 0 compared with Stockholm stages 1-3 combined, but did not discriminate between the stages of abnormality. Using the suggested cut-off in the CPT test, the sensitivity and specificity were calculated as 43 and 78%, respectively. Receiver operator characteristic analysis suggested that the rewarming time of highest accuracy gave a sensitivity of 66% and specificity of 59%. In 10 miners who reported unilateral hand blanching, there was no significant difference in CPT measurements between blanching and non-blanching hands. Repeat CPT measurements in normal subjects suggested mean differences of 52 and 107 s for each hand, and the Bland-Altman coefficient of repeatability was approximately 600 s for all fingers.

CONCLUSION

Single application of this standardized CPT test may have limited value in diagnosing the vascular component of HAVS in an individual.

Does weight loss improve incontinence in moderately obese women?

The aim of this study was to evaluate the effect of weight reduction on urinary incontinence in moderately obese women. This prospective cohort study enrolled moderately obese women experiencing four or more incontinence episodes per week. BMI and a 7-day urinary diary were collected at baseline and on the completion of weight reduction. The study included 10 women with a mean (+/-SD) baseline BMI of 38.3 (+/-10.1) kg/m2 and 13 (+/-10) incontinent episodes per week. Participants had a mean BMI reduction of 5.3 (+/-6.2) kg/ m2 (P < 0.03). Among women achieving a weight loss of > or = 5%, 6/6 had > or = 50% reduction in incontinence frequency compared to 1 in 4 women with < 5% weight loss (P < 0.03). Incontinence episodes decreased to 8 (+/-10) per week following weight reduction (P < 0.07). The study demonstrated an association between weight reduction and improved urinary incontinence. Weight reduction should be considered for moderately obese women as part of non-surgical therapy for incontinence.

The relation of White Matter Hyperintensities to implicit learning in healthy older adults

OBJECTIVE

This study examined whether MRI evidence of cerebrovascular disease in the form of white matter hyperintensities (WMH) was associated with decreased implicit sequence learning performance in a high-functioning group of normal elderly volunteers.

METHOD

One hundred and eight community-dwelling elderly individuals received an MRI and performed an implicit sequence learning task, the serial reaction time (SRT) task.

RESULTS

Hyperintensities present in the white matter were associated with a decreased learning effect. This association was found with both deep white matter and periventricular changes. Other factors affecting SRT performance (i.e., baseline reaction time and switch-cost) were not significantly related to the presence of WMH.

CONCLUSIONS

The results indicate that in addition to previously identified generalized cognitive deficits, WMH are also associated with a specific decrease in the implicit learning of sequences.

Clinical features and assessment of severe dementia. A review

Sound understanding of the dementia syndrome requires adequate acquaintance with its entire spectrum, from the lightest to the most advanced stages. Most studies of dementia deal with light to moderate stages of the condition, while relatively little attention has been paid to its most severe stages. This review presents a clinical description of patients with severe dementia and of the tests currently available to evaluate their cognitive, behavioural, and functional status. Available instruments such as the Hierarchic Dementia Scale or the Severe Impairment Battery now allow quantification of the cognitive and behavioural status of patients with severe dementia. Experience with severe dementia shows that, far from being in a "vegetative state", as is commonly thought, late-stage patients are in fact quite different from one another and in most cases continue to have an interaction with their environment. This ability to better define the characteristics of patients with severe dementia provides the basis for correlations between clinical data and data derived from neuroimaging, neurochemistry, or neuropathology. It also sets the stage for possible therapeutic trials involving these patients.

Cholinesterase inhibitor treatment alters the natural history of Alzheimer's disease

OBJECTIVE

To describe the effect of cholinesterase inhibitors (CEIs) on the natural course of Alzheimer's disease (AD).

METHODS

The short and long term effects of CEIs were evaluated in 135 patients with probable Alzheimer's disease relative to 135 patients who were never exposed to CEIs matched by age, education, duration of the symptoms, and cognitive status. We measured 1 year change in cognitive and functional performance, and the likelihood of arriving at each of four end points: (1) mini mental state examination (MMSE) of 9 or lower, (2) Blessed dementia rating scale for activities of daily living of 12 or higher, (3) nursing home admission, and (4) death, over an average 3 years of observation (36.7 (SD 21.5) months).

RESULTS

Patients on CEIs were better cognitively and functionally after 1 year compared with those patients who never used CEIs. A proportional hazard analysis with CEI use as a time dependent covariate showed that the use of CEIs decreased the risk of nursing home admission. There was no association, however, between use of CEIs and time to cognitive and functional end points, or to death.

CONCLUSIONS

This observational study showed that there was an initial cognitive and functional benefit from the use of CEIs in Alzheimer's disease, which waned as the disease progressed. However, the results suggest that there is a long term beneficial effect of the use of CEIs, as indicated by the delay in admission to nursing homes.

Serum response factor cleavage by caspases 3 and 7 linked to apoptosis in human BJAB cells

Apoptosis involves the cessation of cellular processes, the breakdown of intracellular organelles, and, finally, the nonphlogistic clearance of apoptotic cells from the body. Important for these events is a family of proteases, caspases, which are activated by a proteolytic cleavage cascade and drive apoptosis by targeting key proteins within the cell. Here, we demonstrate that serum response factor (SRF), a transcription factor essential for proliferative gene expression, is cleaved by caspases and that this cleavage occurs in proliferating murine fibroblasts and can be induced in the human B-cell line BJAB. We identify the two major sites at which SRF cleavage occurs as Asp(245) and Asp(254), the caspases responsible for the cleavage and generate a mutant of SRF resistant to cleavage in BJAB cells. Investigation of the physiological and functional significance of SRF cleavage reveals that it correlates with the loss of c-fos expression, whereby neither SRF cleavage fragment retains transcriptional activity. Moreover, the expression of a noncleavable SRF in BJAB cells suppresses apoptosis induced by Fas cross-linking. These results suggest that for apoptosis to proceed, the transcriptional events promoting cell survival and proliferation, in which SRF is involved, must first be inactivated.

Alcohol dementia: "cortical" or "subcortical" dementia?

Most dementias are considered to exhibit either a predominantly "cortical" (e.g. Alzheimer's disease, AD) or "subcortical" (e.g. Parkinson's disease) pattern. A double dissociation has been reported, such that cortical and subcortical dementias can be differentiated based on performance on tests of declarative and procedural learning. The goal of this study was to determine if subjects with alcohol dementia exhibit a predominantly cortical or subcortical dementia profile. The performance of 10 elderly subjects diagnosed with alcohol dementia, 29 elderly subjects with histories of alcohol dependence but who were not demented, and 11 subjects with AD was compared to 20 elderly control subjects. The results indicated that the procedural learning task did not differentiate among the groups, whereas the discriminability index from the California Learning Test (the declarative learning task) did. Thus, alcohol dementia cannot clearly be ascribed to either dementia classification.

Relationship of deep white matter hyperintensities and apolipoprotein E genotype to depressive symptoms in older adults without clinical depression

OBJECTIVE

This study examined whether evidence of cerebrovascular disease in the form of magnetic resonance imaging (MRI) signal hyperintensities in white matter was associated with depressive symptoms in a high-functioning group of normal elderly volunteers.

METHOD

Ninety-two community-dwelling elderly individuals participating in a study of white matter hyperintensities (WMHs) in normal aging whose apolipoprotein E (APOE) genotype had been determined completed the Geriatric Depression Scale and received an MRI scan. Univariate analyses of variance were used to examine the relationship between depressive symptoms and the location of WMHs (in deep white matter versus in periventricular white matter) and to determine whether WMHs were more likely to be associated with symptoms of impaired motivation and concentration or with mood symptoms. The effect on depressive symptoms of the interaction between severity of cerebrovascular disease as evidenced by WMHs and APOE genotype was also examined.

RESULTS

Hyperintensities in the deep white matter, but not in the periventricular white matter, were associated with depressive symptoms, especially symptoms of impaired motivation, concentration, and decision making. The relationship between deep WMHs and depressive symptoms was especially strong in individuals carrying the APOE-4 allele.

CONCLUSIONS

The pattern of depressive symptoms associated with WMHs in this study was similar to the pattern described in the literature as characterizing "vascular" depression in older persons with major depression. The results suggest that cerebrovascular disease may also underlie the depressive symptoms often found in older individuals who are not clinically depressed.

Alcohol, dementia, and Alzheimer's disease: comparison of neuropsychological profiles

Thirty-nine detoxified elderly alcoholics (mean age = 65.85) completed a comprehensive assessment designed to identify individuals meeting DSM-IV criteria for alcohol-related dementia. Ten subjects meeting criteria (mean age = 69.8; mean Mini-Mental State Examination [MMSE] = 25.1) were compared to the 29 nondemented alcoholics (mean age = 64.5; mean MMSE = 27.8), 9 patients with Alzheimer's disease (mean age = 73.4; mean MMSE = 22.3), and 15 control subjects (mean age = 70.8; mean MMSE = 28). Comparison of neuropsychological test scores revealed several statistically significant differences. Furthermore, the overall pattern of test performance between the two demented groups was different. Alzheimer's patients were more impaired on confrontation naming, recognition memory, animal fluency, and orientation. Alcohol dementia subjects were more impaired than controls on initial letter fluency, fine motor control, and free recall. However, alcohol dementia subjects did not differ from controls on tests of verbal recognition memory. This study suggests that it is possible to clinically differentiate the cognitive deficits of alcohol-related dementia from typical Alzheimer's disease. However, the results are preliminary and are based on small sample sizes so should be interpreted with caution.

Research evaluation and diagnosis of probable Alzheimer's disease over the last two decades: I

OBJECTIVE

To describe the experience of a research clinic diagnosing AD during the last two decades, with special emphasis on patients who meet the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for probable AD, their patterns of clinical presentation, and neuropathologic outcomes.

BACKGROUND

Probable AD has a heterogeneous clinical presentation, and can occur in the context of complicating factors. There are few reports, and none with this large of a sample, about the pattern of presentation, the nature of comorbidities, and the sensitivity and specificity of diagnosis.

RESULTS

The AD Research Center of Pittsburgh examined 1139 patients with probable AD between April 1983 and February 2000. Of these 1139 probable AD patients, 29 (2.5%) had slow progression, 27 (2%) had rapid progression, 70 (6%) had an atypical presentation, and 85 (7%) had coexistent cerebrovascular disease. Confluent periventricular white matter lesions were found in 348 (30.5%) patients with probable AD. The overall sensitivity for the diagnosis of AD was 97% and the specificity 80%. However, the accuracy for the diagnosis of AD varied over the years: from 1983 to 1989, the sensitivity was 94% and specificity 52%, and from 1990 to 2000, the sensitivity was 98% and specificity 88%.

CONCLUSION

Although the diagnosis of probable AD has been used to indicate the presence of a homogeneous clinical entity, these patients can vary in presentation, onset, or clinical course. This finding is of particular importance for the understanding of the pathophysiologic basis of the disease, and for the better identification of responders to dementia treatments. Although the sensitivity for the diagnosis of AD remained above 90% over the last two decades, the specificity increased, reflecting progressive improvement in the diagnosis of other dementing disorders.

Research evaluation and diagnosis of possible Alzheimer's disease over the last two decades: II

OBJECTIVE

To describe the experience of a research clinic diagnosing possible AD during the last two decades.

BACKGROUND

The National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for possible AD are generally used to indicate that a patient has AD in association with another disease process that could by itself cause dementia. There are no studies describing how these criteria should be applied, and there are no descriptions of functional and cognitive progression or survival in possible AD.

METHODS

The authors examined the clinical characteristics of 267 patients diagnosed with possible AD at the AD Research Center of Pittsburgh from 1983 to 2000 and the likelihood of arriving at four endpoints: Mini-Mental State Examination score of </= 9, Blessed Dementia Rating Scale for activities of daily living score of >/= 12, nursing home admission, and death.

RESULTS

The possible AD classification has been simplified in six categories: possible AD with cerebrovascular disease (CVD) (69%), with history of alcohol abuse (15%), with history of depression (7%), with thyroid disease (4%), with history of head trauma (6%), with vitamin B12 deficiency (6%), and with other disease process that may have affected the clinical presentation of AD (4%). The presence of CVD, history of alcohol abuse, and history of depression concomitant with the onset of dementia were associated with time to death. Neither thyroid disease, history of head trauma, nor vitamin B12 deficiency were associated with any of the four endpoints.

CONCLUSION

This cohort showed that comorbid conditions that can affect cognition delineate clearly defined subgroups in AD. The presence of environmental or other brain disorders sufficient to produce dementia appears to affect physical survival in patients with AD, but not functional and cognitive decline or institutionalization.

Normative data on the Boston Naming Test and two equivalent 30-item short forms

Because of the significance of the Boston Naming Test (BNT) in the differential diagnosis of the dementias, especially Alzheimer's disease, adequate norms from community-dwelling elderly individuals are essential. The present study describes the development of two new empirically derived equivalent short forms (30 items each) of the test. Normative data for the total BNT and the two equivalent 30-item halves based on item difficulty are presented using the performance of 314 community-dwelling individuals aged 65 and over. Age and education norms are presented using an overlapping midpoint interval strategy.

Cognitive test performance and presence of subclinical cardiovascular disease in the cardiovascular health study

The purpose of the present study was to investigate the relationship between performance on a comprehensive battery of neuropsychological tests and the presence of clinical, subclinical or no cardiovascular disease in an elderly community-dwelling population. The results confirm previous reports of significant associations of age, education and gender with test performance. When performance was examined controlling for these variables, significant associations of disease group were seen with five measures emphasizing speed of performance; Parts A and B of the Trail Making Test, the WAIS-R Digit Symbol and Block Design subtests and category verbal fluency. These results add to the evidence that, in addition to other health implications, cardiovascular disease is related to cognitive functioning in the elderly even at subclinical levels.

The neuropsychological consequences of abstinence among older alcoholics: a cross-sectional study

BACKGROUND

The older alcoholic has been distinguished from the younger alcoholic with regard to both the acute effects of alcohol and also the recovery of functioning with abstinence. Few studies, however, have included samples of exclusively older subjects. In this investigation we examined the recovery of functioning in an older cohort of recovering alcoholics (age range 55-83) to determine which neuropsychological functions improve and which remain impaired with abstinence.

METHODS

We used a cross-sectional design, comparing three demographically matched groups on a battery of neuropsychological tests: (a) older alcoholics who had been abstinent for greater than 6 months, (b) older alcoholics who had been abstinent for less than 6 months, and (c) a control group of older subjects without alcohol abuse histories.

RESULTS

In almost all tasks, the alcoholics who were abstinent for less than 6 months performed worse than the control group. In contrast, the alcoholics who had been abstinent for more than 6 months differed from the control group on learning and recall of a word list, immediate and delayed recall of a complex figure, initial letter fluency, and clock drawing.

CONCLUSIONS

Memory and executive skills appear to be resistant to recovery or at least slower to recover with abstinence in the older alcoholic. The impairment with visuospatial skills reported in prior investigations of alcoholics may be related to compromised executive functions, which interfere with the encoding of more complex visuospatial information and thus affect recall of such information. Studies that involve larger samples of older alcoholics are needed to understand their ability to recover cognitive functioning with abstinence.

Dynamic control and conventional strength ratios of the quadriceps and hamstrings in subjects with anterior cruciate ligament deficiency

The hamstrings:quadriceps muscle strength ratio has been used as an indicator of normal balance between the knee flexors and extensors. A more functional approach to this strength ratio would be to compare opposite muscle actions of antagonistic muscle groups. The dynamic strength control ratio (DSCR) should give a more appropriate measure relating to knee function. There is a lack of normative data relating to DSCR for anterior cruciate ligament (ACL) deficient subjects. Effects of ACL deficiency on isokinetic peak torque for eccentric and concentric muscle actions of the quadriceps and hamstrings, in conjunction with isometric peak torque, were examined in 10 patients awaiting reconstructive surgery (male = 8, female = 2 ; age = 32.8 +/- 8.3 years; height = 1.77 +/- 0.08 m; mass = 72.1 +/- 12.5 kg). These variables were assessed using an isokinetic dynamometer. The results were considered in terms of the conventional ratio and DSCR. Anterior tibial drawer was measured using a knee ligament arthrometer to confirm clinical diagnosis of ACL rupture. The isokinetic peak torque data analysed were for angular velocities of 1.05 rad s(-1) (60 degrees s(-1)). Significant strength deficits were apparent between normal and injured sides for: concentric isokinetic quadriceps action (p < 0.05); isometric quadriceps action at 70 degrees of knee flexion (p < 0.05); isometric quadriceps action at 40 degrees of knee flexion (p<0.01); eccentric isokinetic hamstrings action (p < 0.05). With bilateral comparison, the conventional strength ratios showed no significant difference, as did the DSCR. The bilateral comparison of isometric strength ratios revealed significant losses in quadriceps strength for the injured side (p < 0.05) but no significant losses in hamstring strength (p > 0.05). Thus, differences can be seen in conventional ratios and DSCR for ACL-deficient subjects. This is an area of clinical interest with the increasing frequency of ACL reconstruction using hamstrings tendons.

Does paclitaxel improve the chemoradiotherapy of locoregionally advanced esophageal cancer? A nonrandomized comparison with fluorouracil-based therapy

PURPOSE

A phase II trial of accelerated fractionation radiation with concurrent cisplatin and paclitaxel chemotherapy was performed to investigate the role of the paclitaxel, when substituted for fluorouracil (5-FU), in the chemoradiotherapy of esophageal cancer.

PATIENTS AND METHODS

Patients with an esophageal ultrasound stage of T(3) or N(1) or M(1) (nodal) esophageal cancer were treated with two courses of a cisplatin infusion (20 mg/m(2)/d for 4 days) and paclitaxel (175 mg/m(2) over 24 hours) concurrent with a split course of accelerated fractionation radiation (1.5 Gy bid to a total dose of 45 Gy). Surgical resection was performed 4 to 6 weeks later followed by a single identical postoperative course of chemoradiotherapy (24 Gy) in patients with significant residual tumor at surgery. Toxicity and results of this treatment were retrospectively compared with our previous 5-FU and cisplatin chemoradiotherapy experience.

RESULTS

Between September 1995 and July 1997, 40 patients were entered onto this study. Although dysphagia proved worse in our 5-FU-treated patients, profound leukopenia and a need for unplanned hospitalization were significantly more common in the paclitaxel group. Thirty-seven patients (93%) proved resectable for cure. The 3-year projected overall survival is 30%, locoregional control is 81%, and distant metastatic disease control is 44%. When compared with a similarly staged cohort of 5-FU-treated patients, there was no advantage for any survival function studied.

CONCLUSION

This paclitaxel-based treatment regimen for locoregionally advanced esophageal cancer produced increased toxicity with no improvement in results when compared with our previous 5-FU experience. Paclitaxel-based treatments must be carefully and prospectively studied before their incorporation into the standard management of esophageal cancer.

Neuropsychological assessment of the severely impaired elderly patient: validation of the Italian short version of the Severe Impairment Battery (SIB). Gruppo di Studio sull'Invecchiamento Cerebrale della Società Italiana di Gerontologia e Geriatria

One hundred and sixty-nine severely demented patients were tested in a multicenter study with the short version of the Severe Impairment Battery which was translated into Italian with the purpose of adapting and validating it for an Italian population. Patients were enrolled in Italian geriatric centers participating in the Study Group on Aging Brain of the Italian Society of Gerontology and Geriatrics. Following thorough clinical and instrumental examinations, they were evaluated with the Mini Mental State Examination, the Clinical Dementia Rating, the Severe Impairment Battery (SIB), the Gottfries-Bråne-Steen Rating Scale for Dementia, the Activity of Daily Living index, and the Bedford Alzheimer Nursing Severity scale (BANS.s). The inter-rater reliability of the SIB was highly significant for the total score and its subtests; test-retest reliability showed the same significance in all items. Also concurrent validity, performed comparing the total SIB score with the total BANS.s score, was significant. The short Italian version of the SIB proved to be a very reliable tool for the evaluation of severely demented patients; it has the advantage of being easy to administer, it evaluates more cognitive domains that, are typically assessed in dementia, and has a wide enough range of scores to detect even small differences in the examined abilities.

Changes in indices of antioxidant status, lipid peroxidation and inflammation in human skeletal muscle after eccentric muscle actions

This study investigated the effects of chronic muscle inflammation on indices of antioxidant status and muscle injury after eccentric exercise. Eight subjects each performed 70 maximal voluntary eccentric muscle actions on an isokinetic dynamometer, using the knee extensors of a single leg. Venous blood samples were collected into serum and EDTA tubes 5 and 3 days before exercise, immediately before exercise, and then again on days 3, 4, 5, 6, 7, 10 and 12 after the bout. Needle biopsies were taken from the vastus lateralis of six subjects, a week before exercise (baseline), and again on days 4 and 7 post-exercise. The concentrations of malondialdehyde in plasma and muscle were used as markers of lipid peroxidation. Creatine kinase activity, beta-glucuronidase activity and total antioxidant capacity were determined in serum. In muscle, aqueous and bound total antioxidant capacity, the aqueous sulphydryl concentration, and beta-glucuronidase and glucose-6-phosphate dehydrogenase activity were determined. No changes were detected in serum total antioxidant capacity, serum creatine kinase and beta-glucuronidase after the baseline biopsy. After exercise serum creatine kinase and beta-glucuronidase were elevated although other serum measures were unchanged. In muscle, aqueous and bound total antioxidant capacity, sulphydryls, glucose-6-phosphate dehydrogenase and beta-glucuronidase were all elevated. Despite evidence of inflammation in this study, muscle antioxidant status was not compromised, and malondialdehyde was unaltered in muscle and plasma. Therefore, this study provides no evidence that chronic muscle inflammation compromises antioxidant status or increases lipid peroxidation.

Maintenance of mobility in residents of an Alzheimer special care facility

The cognitive and functional decline of demented residents in a specialized Alzheimer's facility was compared to that of demented residents living in a traditional nursing home. All residents met DSM-III-R criteria for dementia. The evaluation consisted of a clinical interview with patients and collateral assessments of cognition, general health, problem behaviors, depression, and a broad range of activities of daily living (ADLs) including mobility. Residents were evaluated at baseline and 6-month intervals over 18 months. Similar rates of decline were found in cognition and overall ADLs in both groups. However, the most striking finding was preserved mobility in residents of the Alzheimer's facility. This finding suggests that specialized facilities do not halt or slow the overall progression of cognitive and functional decline seen in Alzheimer's disease; however, residents of such facilities may show slower decline in mobility.

Changes in the secretion and glycosylation of fibronectin by human skin fibroblasts associated with tuberous sclerosis

Fibroblasts from skin and skin lesions of patients with tuberous sclerosis (TS) and from skin of normal individuals were grown in culture. ELISA showed that the spent medium of those derived from TS skin lesions contained significantly more fibronectin (FN) than spent medium from the other cells. Amino acid compositional analysis of the FN from TS and normal sources revealed no substantial differences. However the FN of fibroblasts from TS-skin lesions was shown by HPAEC to contain a two- to three-fold increased content of carbohydrate. The changed monosaccharide composition was consistent with an increased content of N- and O-linked glycans and with the former containing polylactosamine chains. Fibroblasts from a normal individual were shown to proliferate more slowly and to produce larger cells when grown on FN from a TS skin lesion compared to growth on FN from normal skin.

The severe impairment battery: concurrent validity and the assessment of longitudinal change in Alzheimer's disease. The Alzheimer's Disease Cooperative Study

Measurement of cognitive dysfunction in the early stages of Alzheimer's disease (AD) has been well studied and there are many objective tests in use for this purpose. However, with the exception of clinical rating scales, such as the Clinical Dementia Rating Scale, Global Deterioration Scale, and Functional Assessment Staging, there are few objective measures of cognition in the more advanced stages of AD. Given a renewed interest in potential AD therapies, objective measures of mental functioning are needed to adequately assess change in more advanced AD patients. As part of an effort by the NIA-Alzheimer's Disease Cooperative Study to evaluate new measures of efficacy for their utility in treatment studies, the Severe Impairment Battery (SIB) was examined in a 1-year evaluation of change across a wide range of AD severity. The data suggest that the SIB is a reliable and valid measure of progression, particularly in persons with moderate to severe AD. The SIB may therefore be a useful outcome measure in clinical trials that include patients with more advanced stages of AD.

Purification and partial characterization of the high and low molecular weight form (S- and F-form) of invertase secreted by Aspergillus nidulans

Two forms of secreted invertase have been purified from Aspergillus nidulans by ion-exchange and gel-filtration chromatography. S-invertase gave a single, broad, glycoprotein band on PAGE and SDS-PAGE corresponding in size to 185 and 78 kDa, respectively, compared with 94 and 110 kDa for F-invertase. The carbohydrate of S-invertase contained mainly mannose (14%) and less galactose (5%) whereas the F-form yielded mainly galactose (29%) and less mannose (12%). Three sharp bands of enzymically active glycoprotein for both the S-form (pI 4.9-5.2) and the F-form (pI 3-4.2) were observed after isoelectric focusing. Deglycosylation with Endo H simplified this pattern to one enzymically active protein band (pI 5.2). The aglycoenzymes gave narrow bands on PAGE and SDS-PAGE corresponding to 115 kDa and 60 kDa respectively for both S- and F-forms. The specific activity of S-invertase was three-fold higher than that of F-invertase both before and after deglycosylation. The Km values of the two forms of invertase were very similar. Significant homology existed between the N-terminal amino-acid sequences of S-invertase (and of internal peptides derived from it) and sequences of invertase from other species. It is suggested that the higher carbohydrate content in F-invertase results in the native enzyme existing as a monomer and having a greater negative charge and lower specific enzyme activity compared with the dimeric S-enzyme.

[Validation of the Spanish version of the Severe Impairment Battery]

We examine the cognitive ability of 58 demented patients who were evaluated with the Spanish version of the Severe Impairment Battery (SIB). The SIB is composed of multiple simple subtests for memory, language, orientation, attention, visual perception and ability to construct. The battery also assesses social skills, praxis and the ability to respond appropriately to name. The mean SIB scores (72.55 +/- 17.99; range 8-99) correlated with mean scores (10.76 +/- 6.41; range 0-31) on the Spanish version of Folstein's Mini-Mental State Examination (MMSE). The SIB detected deterioration in the nine cognitive areas examined, even in the most severely impaired patients (MMSE = 0-6). These results indicate that the Spanish version of the SIB is a useful instrument for examining severely demented patients.

The natural history of Alzheimer's disease. Description of study cohort and accuracy of diagnosis

OBJECTIVE

We describe the sampling, initial evaluation, and final diagnostic classification of subjects enrolled in a natural history study of Alzheimer's disease (AD).

DESIGN

Volunteer cohort study.

SETTING

Multidisciplinary behavioral neurology research clinic.

PATIENTS OR OTHER PARTICIPANTS

Three-hundred nineteen individuals were enrolled in the Alzheimer Research Program between March 1983 and March 1988. Of these, 204 were originally classified with AD, 102 were normal elderly control subjects, and 13 were considered special cases.

MAIN OUTCOME MEASURES

Final consensus clinical diagnosis, final neuropathologic diagnosis, and death.

RESULTS

Of the 204 patients enrolled in the study, re-review after as many as 5 years of follow-up resulted in a final clinical classification of 188 with probable AD. Seven patients were believed to have a significant vascular component to the dementia, three were found to have developed depression, and six were excluded on other clinical grounds. Neuropathologic examination of 50 brains indicated definite AD in 43. After removing these seven misdiagnosed patients, the final group of probable/definite AD totaled 181 individuals. Accuracy of the baseline clinical diagnosis relative to neuropathology was 86%, and when follow-up clinical data were considered, 91.4%. Detailed neuropsychological testing yielded high sensitivity (0.988) and specificity (0.983) to dementia. Analyses of survival time from study entry until death revealed that older patients were significantly more likely to die during follow-up, but neither sex, years of education, nor pattern of cognitive impairment were related to survival.

CONCLUSIONS

These data provide the descriptive basis for future studies of this cohort. They indicate that longitudinal follow-up of demented cases increases accuracy of diagnosis, and that detailed cognitive testing aids in early classification.