Feasibility and Acceptability of Computerised Cognitive Training of Everyday Cognition in Parkinson's Disease.

OBJECTIVES: We piloted a computerised cognitive training battery in a group of participants with Parkinson's disease without dementia to investigate the relevance of the training to daily life and the feasibility and the acceptability of the tasks. Previous studies of CT have had limited success in the benefits of training, extending to improvements in everyday function. By taking a pragmatic approach and targeting training to the cognitive skills affected by Parkinson's disease (planning, attention, and recollection), whilst using tasks that emulated real-life scenarios, we sought to understand whether participants perceived the training to be effective and to identify the elements of the training that elicited beneficial effects. METHODS: Four participants completed a cognitive training session comprising three distinct tasks 5 days a week over two weeks. Participants completed baseline questionnaires examining health-related quality of life, everyday cognition, and apathy before the training period, after the last session, and two weeks after the last session. An interview was held after participants had completed the training. RESULTS: The findings indicated that participants felt the training was acceptable, enhanced their awareness, and encouraged them to monitor their thinking abilities. The group interview indicated that the training was feasible; participants felt the tasks had potential to improve everyday performance, but more supporting information should be provided to facilitate this transfer. Responses to the questionnaires reflected these findings, indicating improvement for some participants' cognition and quality of life. Objective measures supported the subjective reports; there were improvements in some but not all domains. Performance on the planning and recollection tasks improved over the training period, and the evidence for improvement on the attention task was mixed. CONCLUSION: This study has found that pragmatic computer-based training with real-life outcomes is both feasible and acceptable and should be evaluated more extensively using controlled methods.

Colour thresholds in a coral reef fish.

Coral reef fishes are among the most colourful animals in the world. Given the diversity of lifestyles and habitats on the reef, it is probable that in many instances coloration is a compromise between crypsis and communication. However, human observation of this coloration is biased by our primate visual system. Most animals have visual systems that are 'tuned' differently to humans; optimized for different parts of the visible spectrum. To understand reef fish colours, we need to reconstruct the appearance of colourful patterns and backgrounds as they are seen through the eyes of fish. Here, the coral reef associated triggerfish, Rhinecanthus aculeatus, was tested behaviourally to determine the limits of its colour vision. This is the first demonstration of behavioural colour discrimination thresholds in a coral reef species and is a critical step in our understanding of communication and speciation in this vibrant colourful habitat. Fish were trained to discriminate between a reward colour stimulus and series of non-reward colour stimuli and the discrimination thresholds were found to correspond well with predictions based on the receptor noise limited visual model and anatomy of the eye. Colour discrimination abilities of both reef fish and a variety of animals can therefore now be predicted using the parameters described here.

Internal carotid artery occlusion: its natural history including recanalization and subsequent neurological events.

OBJECTIVE: To determine the incidence of recanalization of the occluded internal carotid artery (ICA) and establish its natural history. METHODS: Patients with duplex-confirmed ICA occlusions were identified, and a subgroup offered repeat scanning. The antemortem condition and cause of death of patients who died were recorded. RESULTS: Of 153 patients identified, 77 underwent follow-up at a median of 35 months (interquartile range [IQR]: 14-61).In all, 8 (10.3%) demonstrated recanalization at a median of 53 months (IQR: 35-114). Of 8, 7 underwent carotid endarterectomy with histopathological confirmation of recanalization. Of the 153 patients, 45 (29%) had further neurological events, and 38 (25%) were within the territory of the occluded ICA. In all, 76 patients died, and of the 53 with a confirmed cause of death, 12 (23%) were attributed to a cerebrovascular accident corresponding to the territory of the occluded artery. CONCLUSION: Recanalization of ICA occlusion is common and leads to significant neurological events. Duplex ultrasound follow-up appears mandatory.

Is primary endocrine therapy effective in treating the elderly, unfit patient with breast cancer?

INTRODUCTION: Elderly patients with oestrogen receptor (ER)-positive breast cancer wishing to avoid surgery or those who are considered unsuitable for a general anaesthetic may be treated with primary endocrine therapy. We have reviewed all patients with ER-positive breast cancer who were initially treated with primary hormone therapy (PHT) at a district general hospital in south Wales and investigated their outcome in order to evaluate the appropriateness of this method of managing breast cancer. MATERIALS AND METHODS: All patients with breast cancer who were initially treated with PHT between January 2002 and December 2008 were identified from a single consultant's prospectively maintained database. For each patient the Charlson co-morbidity index was calculated to give an estimate of ten-year survival. Patients who had died during the study period were identified from hospital and cancer registries. RESULTS: A total of 83 cancers in 82 patients with a median age of 81 years (range: 62-93 years) were included. All cancers were ER-positive. Six patients (7%) had a greater than 50% chance of surviving ten years, calculated using the Charlson index. The median follow-up period was 24 months (range: 6-72 months). Twelve patients (15%) had disease progression while taking PHT. Twenty-three patients (28%) have died (median time from diagnosis to death of 10.5 months, range: 1-77 months). Two patients (2%) experienced disease progression within six months of starting PHT and the number of patients whose cancer progressed increased with increasing length of follow up. Fourteen patients (17%) eventually underwent a wide local excision under local anaesthetic. CONCLUSIONS: PHT can be considered an effective treatment in this elderly, unfit population with the aim of stopping disease progression so that these patients die with their breast cancer, not of it.

Consistency in the observation of features used to classify duct carcinoma in situ (DCIS) of the breast.

AIM: To determine interobserver and intra-observer agreement in the assessment of cytological grade and intraduct necrosis in pure duct carcinoma in situ (DCIS) of the breast. METHODS: Sixty unselected cases with illustrated diagnostic criteria were circulated to 19 practising histopathologists. RESULTS: Overall agreement was moderate for cytological grade in three categories: 71% agreement; weighted kappa (kappa w), 0.36; intraduct necrosis in three categories (absent, present, extensive): 76% agreement; kappa w, 0.57; and the Van Nuys classification system: 73% agreement; kappa w, 0.48. Agreement was no better among observers participating in the National External Quality Assurance Programme. Intra-observer agreement for cytological assessment (69.6% agreement; kappa w, 0.52) and intraduct necrosis (68.3% agreement; kappa w, 0.48) was moderate, suggesting that individual variation rather than precision of criteria contributes to the lack of agreement. CONCLUSIONS: Moderate agreement on observations can be achieved by non-specialist pathologists, with better agreement on necrosis than cytological grade. There was evidence of consistent individual bias towards over or under scoring cytological grade, which could be corrected with adequate and prompt feedback.

Pulmonary thromboembolism and unexpected death in infancy.

Review of the Department of Histopathology autopsy files over a 30 year period from 1962 to 1991 revealed only three cases in which unexpected death occurred in infants under 1 year of age due to massive pulmonary thromboemboli. Predisposing factors included necrotizing enterocolitis with gut perforation and sepsis, a ventriculoatrial shunt and idiopathic arterial calcification. Diagnosis of the latter autosomal recessive condition was only made at autopsy. These cases demonstrate that pulmonary thromboembolism is a possible, although exceedingly rare, cause of sudden infant death, that some predisposing factors are unique to infancy and that the source of the pulmonary thromboembolus may be difficult to determine at autopsy. Massive pulmonary thromboembolism in infancy may point to the presence of other significant, clinically-unsuspected, disorders.

Sudden death in asthma in childhood.

Death from asthma in childhood is rare, occurring in approximately 1 in 10,000 affected children. While most deaths occur in hospitalised children with severe asthma, it has been reported that sudden and unexpected death may occur in children with only mild disease. In this study the clinicopathological features of 11 cases of sudden death taken from the files of the Adelaide Children's Hospital over a 30-year period are reported. Children were aged between 3 years 10 months and 15 years 2 months (average = 9 years 9 months), with a male to female ratio of 5:6. Deaths occurred either at home, in an ambulance or within minutes of arriving in the Emergency Department. Viral respiratory tract infections were common associated findings. While one child was considered to have only mild disease, most children had long histories of asthma and had required prolonged medication or hospitalisation. The demonstration of growth retardation (i.e. height or weight < 3rd percentile) in 73% of cases is also supportive of long-standing severe asthma being present. Thus, in this series, sudden and unexpected death occurred only in children with significant chronic disease. In formulating the diagnosis of sudden death due to asthma in children, delaying growth parameters may, therefore, be an additional useful morphological marker indicating an at-risk child.

Behçet's disease: activated T lymphocytes in retinal perivasculitis.

A 38-year-old man who died from systemic Behçet's disease had previously suffered from severe, recurrent bilateral retinal vasculitis, and anterior uveitis for 10 years. Immunopathological examination of the eyes postmortem revealed marked hyaline thickening of the retinal and optic nerve vessels. The vessels had an intramural and perivascular infiltrate of T lymphocytes which stained positively for CD4 and IL2 receptor surface markers. Small numbers of cells in the optic nerve head, retinal vascular endothelium, and retinal pigment epithelium were HLA DR positive.

Diagonal earlobe creases and atheromatous disease: a postmortem study.

The association between the grade of earlobe creases and degree of atheromatous disease was investigated in 376 postmortem examinations. Each earlobe crease was individually graded from 0 to 3. The risk of atherosclerosis as a cause of death was nearly doubled in men with grade 3 creases in both earlobes, and more than trebled in women with bilateral high-grade creases. The risk of death from myocardial infarction was 2.50 in men with high-grade creases and 3.70 in women. The earlobe crease is an important sign of atheromatous disease and it may be useful to include it in the clinical examination of patients.

Improve your hospital autopsy rate to 40-50 per cent, a tale of two towns.

In the light of medical audit, all pathology departments are scrutinizing their hospital autopsy rate. In most countries, the rate has fallen over the last few decades to between 10 and 20 per cent. However, it is still possible to achieve a much higher rate. We compare two neighbouring District General Hospitals (DGHs): Northampton, with the more usual autopsy rate of 11 per cent, and Kettering, with a higher rate of 40-50 per cent. These hospitals are comparable in almost every way except for the system used to request permission for an autopsy. These differences were evaluated and the following factors were found to be of importance in achieving a high rate: (1) centralization of death certificates within the mortuary and personal contact between the certifying doctor and the relatives within the bereavement room; (2) mortuary pathology technicians are designated as bereavement officers and act as coordinators between relatives, clinicians, and pathologists; and (3) regular clinico-pathological meetings and a positive attitude to autopsies by clinicians.

A perspex grid for localization of non-palpable mammographic lesions in breast biopsies.

The examination of excised, non-palpable mammographic lesions in breast biopsies is a recognized problem for the pathologist. There may be difficulties in identifying the lesion macroscopically and in subsequent sampling. This paper describes a simple method for resolving these problems. The breast biopsy is attached to a perspex grid and then radiographed. Use of the grid co-ordinates assists appropriate sampling of the specimen. Advantages over previously described methods are discussed.

Quantitation of 'junctional feet' content in two types of muscle fiber from hind limb muscles of the rat.

1. Transverse tubules in fibers from rat soleus and extensor digitorum longus (EDL) muscles of the rat were infiltrated with silver dichromate (black reaction of Golgi). This provides a faithful, high-contrast outline of the tubules, which allows distinction between segments involved in junction formation with the sarcoplasmic reticulum and segments that are free. 2. Electron micrographs of semithin transverse sections were used to quantitate T tubule parameters and to measure cross-sectional area and perimeter of individual fibers. Thin sections and data from the literature were used to obtain the contribution of caveolae to external surface area and the frequency of junctional feet along the junctional T tubule membrane. 3. From the above data we calculate the ratio of number of feet to total external surface area for a given fiber segment. The ratio is compared with data in the literature on the total amount of 'charge movement' (in nC/uF of total external surface area). 4. The average feet/surface area ratio is twice as large in EDL than in soleus fibers, while the charge movement is up to five-fold larger. Probably some of the total charge movement is not directly associated with events related to the turning on of the SR permeability to calcium.

Discrimination between fast- and slow-twitch fibres of guinea pig skeletal muscle using the relative surface density of junctional transverse tubule membrane.

The black reaction of Golgi was used to infiltrate transverse (T) tubules in fast-twitch glycolytic (FW), fast-twitch oxidative-glycolytic (FR) and slow-twitch (S) type fibres in muscles of guinea pigs. Non-junctional (fT) and junctional (jT) segments of the T-tubule network are clearly demarcated by this technique. Digitized planimetry and direct measurements were used to determine the proportion of T-tubule network forming junctions with the sarcoplasmic reticulum (%LjT) and to estimate the surface density (surface area per fibre volume) of total and junctional T membrane. From these data, the volume density (number per fibre volume) of junctional feet was calculated. All three types of fibres have approximately equal surface density of T tubules, but the FW and FR fibres have a much higher proportion of jT. The calculated volume density of feet is twice as high in fast-twitch as in slow-twitch fibres.

Sudden death from perforation of a benign oesophageal ulcer into a major blood vessel.

Two cases of sudden death due to perforation of a benign oesophageal ulcer into a major blood vessel are reported. In one man, anaemia and aspiration pneumonitis dominated the clinical picture. He had an oesophageal stricture and a chronic peptic ulcer associated with an incarcerated hiatus hernia. Death was due to haemorrhage caused by perforation of the ulcer into the thoracic aorta. The second patient presented with confusion and falls, backache and indigestion. She had a hiatus hernia and a large benign chronic oesophageal ulcer. Death was due to perforation of the ulcer into the left pulmonary vein. The cases are presented for their rarity, to illustrate the complex and late presentation of problems in geriatric medicine, and as a reminder that reflux oesophagitis can be dangerous.