Teleneuropsychology: evidence for video teleconference-based neuropsychological assessment.

The use of videoconference technology to deliver health care diagnostics and treatment continues to grow at a rapid pace. Telepsychiatry and telepsychology applications are well-accepted by patients and providers, and both diagnostic and treatment outcomes have generally been similar to traditional face-to-face interactions. Preliminary applications of videoconference-based neuropsychological assessment (teleneuropsychology) have yielded promising results in the feasibility and reliability of several standard tests, although large-scale studies are lacking. This investigation was conducted to determine the reliability of video teleconference (VTC) - based neuropsychological assessment using a brief battery of standard neuropsychological tests commonly used in the evaluation of known or suspected dementia. Tests included the Mini-Mental State Examination (MMSE), Hopkins Verbal Learning Test-Revised, Digit Span forward and backward, short form Boston Naming Test, Letter and Category Fluency, and Clock Drawing. Tests were administered via VTC and in-person to subjects, counterbalanced using alternate test forms and standard instructions. Two hundred two adult subjects were tested in both rural and urban settings, including 83 with cognitive impairment and 119 healthy controls. We found highly similar results across VTC and in-person conditions, with significant intraclass correlations (mean=.74; range: 0.55-0.91) between test scores. Findings remained consistent in subjects with or without cognitive impairment and in persons with MMSE scores as low as 15. VTC-based neuropsychological testing is a valid and reliable alternative to traditional face-to-face assessment using selected measures. More VTC-based studies using additional tests in different populations are needed to fully explore the utility of this new testing medium.

Association of depressive symptoms with functional outcome after traumatic brain injury.

OBJECTIVE: To test whether improved functional status correlates with more depressive symptoms after traumatic brain injury (TBI). This is based on the concept that increasing awareness of deficits may exacerbate depression, even while survivors are making functional improvements. PARTICIPANTS: A total of 471 individuals with TBI (72% white; 71% men; median Glasgow Coma Scale (GCS) score = 11) enrolled during acute care or inpatient rehabilitation and followed up at a median of 6 months. MAIN MEASURE: Beck Depression Inventory-II (BDI-II), Glasgow Outcome Scale-Extended, and Functional Status Examination (FSE). RESULTS: We found significant Spearman rank order correlations between BDI-II scores and the total FSE as well as all domains of the FSE. Lower functional levels correlated with more depressive symptoms. Modeling of predictive factors, including subject characteristics, injury-related characteristics, and outcome measures, resulted in 2 models, both containing age and GCS along with other factors. CONCLUSION: The relation between depressive symptoms and functional outcomes is complex and a fertile area for further research. The authors would encourage clinicians to monitor patients for depressive symptoms to help to prevent the detrimental impact on recovery.

The 5-D itch scale: a new measure of pruritus.

BACKGROUND: Itching is a subjective and multidimensional experience which is difficult to quantify. Most methodologies to assess itching suffer from being unidimensional, for example only measuring intensity without impact on quality of life, or only measuring scratching activity. None has actually been demonstrated to be able to detect change over time, which is essential to using them as an outcome measure of response to an intervention. The 5-D itch scale was developed as a brief but multidimensional questionnaire designed to be useful as an outcome measure in clinical trials. The five dimensions are degree, duration, direction, disability and distribution. OBJECTIVES: To study the 5-D with respect to validity, reliability and response to change. METHODS: The 5-D was administered to 234 individuals with chronic pruritus due to liver disease (n = 63), kidney disease (n = 36), dermatological disorders (n = 56), HIV/AIDS (n = 28) and burn injuries (n = 51). The 5-D was administered at baseline and after a 6-week follow-up period. A subset of 50 untreated patients was retested after 3 days to assess test-retest reliability. RESULTS: The 5-D score correlated strongly with a visual analogue score: r = 0.727 at baseline (P < 0.0001), r = 0.868 at the 3-day repeat (P < 0.0001), and r = 0.892 at the 6-week follow-up (P < 0.0001). There was no change in mean 5-D score between day 1 and day 3 in untreated individuals (intraclass correlation coefficient = 0.96, P < 0.0001). The 5-D did, however, detect significant changes in pruritus over the 6-week follow-up period (P < 0.0001). Subanalysis of the different patient groups revealed similar response patterns and scores, with the exception of lower total scores for the burn victims due to lower scores on the distribution domain because they itched only at the site of their burn. CONCLUSIONS: The 5-D, therefore, is a reliable, multidimensional measure of itching that has been validated in patients with chronic pruritus to able to detect changes over time. The 5-D should be useful as an outcome measure in clinical trials.

Denture cream: an unusual source of excess zinc, leading to hypocupremia and neurologic disease.

BACKGROUND: Chronic, excess zinc intake can result in copper deficiency and profound neurologic disease. However, when hyperzincemia is identified, the source often remains elusive. We identified four patients, one previously reported, with various neurologic abnormalities in the setting of hypocupremia and hyperzincemia. Each of these patients wore dentures and used very large amounts of denture cream chronically. OBJECTIVE: To determine zinc concentration in the denture creams used by the patients as a possible source of excess zinc ingestion. METHODS: Detailed clinical and laboratory data for each patient were compiled. Tubes of denture adhesives were analyzed for zinc content using dynamic reaction cell-inductively coupled plasma-mass spectrometry. Patients received copper supplementation. Copper and zinc levels were obtained post-treatment at varying intervals. RESULTS: Zinc concentrations ranging from about 17,000 to 34,000 mug/g were identified in Fixodent and Poli-Grip denture creams. Serum zinc levels improved in three patients following cessation of denture cream use. Copper supplementation resulted in mild neurologic improvement in two patients who stopped using denture cream. No alternative source of excess zinc ingestion or explanation for hypocupremia was identified. CONCLUSION: Denture cream contains zinc, and chronic excessive use may result in hypocupremia and serious neurologic disease.

Outcome of noninvasive ventilation in children with neuromuscular disease.

OBJECTIVE: To assess the effect of institution of noninvasive ventilation (NIV) on clinical outcome and quality of life (QOL) in a cohort of children with severe neuromuscular disorders. METHODS: We reviewed records and obtained clinical data from the year prior to commencing NIV and annually thereafter. Data obtained included diagnosis, patient symptoms, mortality, NIV adverse effects, pulmonary function tests, polysomnographic data, length of hospitalizations, and health care costs. Patients and parents completed questionnaires assessing QOL with NIV and recalling QOL before NIV. RESULTS: Fourteen of 17 (82%) suitable patients were enrolled. Follow-up ranged from 6 to 84 months (median 30). Symptoms of daytime sleepiness (p = 0.003) and headache (p = 0.046) improved after initiation of NIV. Sleep quality assessed by polysomnography also improved. Hospitalization rates (p = 0.002) and health care costs (p = 0.003) decreased. QOL remained stable after NIV, despite disease progression. CONCLUSION: Treatment of respiratory failure, in children with neuromuscular disease, with noninvasive ventilation results in a reduction in symptoms, hospitalizations, and health care costs without adverse effects on quality of life.

Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior.

OBJECTIVES: To evaluate the effectiveness of an educational program for improving medical event reporting attitude and behavior in the ambulatory care setting among graduate medical trainees. DESIGN: One group pre- and post-test study. SETTING: The University of Texas Southwestern Medical Center at Dallas Family Medicine Residency Program. PARTICIPANTS: All family practice residents (n = 30). INTERVENTION: Patient safety educational program implemented through an introductory lecture and 6 monthly conferences, June to December 2002, involving medical events that occurred in the ambulatory care setting. OUTCOME MEASURES: Medical event reporting attitude and behavior at baseline and at 6 month follow up, and barriers to medical event reporting at the 6 month follow up. RESULTS: Program attendance was significantly correlated with medical event reporting attitude and behavior change (rho = 0.525, p = 0.003). The median change in medical event reporting attitude and behavior was zero and not statistically significant (p = 0.566). Major barriers to medical event reporting were lack of time, extra paper work, and concern about career and personal reputation. CONCLUSIONS: Attending the patient safety educational program was key for promoting a positive medical event reporting attitude and behavior change among graduate trainees. Major barriers to medical event reporting were lack of time, extra paper work, and concern about career and personal reputation. Future research will need to focus on reducing these barriers and to evaluate the effectiveness of such a program over longer periods of time, since making a positive change in medical event reporting attitude and behavior must be made at the individual and organizational levels.

Subscores of the FAB differentiate frontotemporal lobar degeneration from AD.

OBJECTIVE: To determine the clinical utility of the Frontal Assessment Battery (FAB), a short test of frontal lobe functions, in differentiating frontotemporal lobar degeneration (FTLD) from Alzheimer disease (AD). METHODS: FAB total scores and subscores for 23 subjects with FTLD and 31 subjects with AD were compared for sensitivity, specificity, and positive predictive value. Concurrent validity of the FAB with the Mini-Mental State Examination (MMSE) and other scales was also assessed. RESULTS: The FAB did not have positive predictive value for FTLD. Total FAB scores did not differ between the FTLD and AD groups. However, three subtests of the FAB (mental flexibility, motor programming, and environmental autonomy) demonstrated significant differences between the two groups. Total FAB scores correlated with scores on the MMSE, a more general test of cognition. CONCLUSION: The Frontal Assessment Battery did not discriminate subjects with frontotemporal lobar degeneration from those with Alzheimer disease, though certain subtests may be helpful in differential diagnosis.

A total score for the CERAD neuropsychological battery.

OBJECTIVE: To develop a total or composite score for the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery. METHOD: CERAD total scores were obtained by summing scores from the individual CERAD subtests (excluding the Mini-Mental State Examination [MMSE]) into a total composite (maximum score = 100). The method of tabulating the total score was constructed using normal controls (NCs; n = 424) and patients with AD (n = 835) from the CERAD registry database. The utility of the total score was further tested in independent samples of mild AD (n = 95), mild cognitive impairment (MCI; n = 60), and NC (n = 95) subjects. RESULTS: The CERAD total score was highly accurate in differentiating NC and AD subjects in the CERAD registry. Age, gender, and education effects were observed, and demographic correction scores were derived through multiple regression analysis. Demographically corrected CERAD total scores showed excellent test-retest reliability across samples (r = 0.95) and were highly correlated with the MMSE (r = 0.89) and Clinical Dementia Rating Scale (r = -0.83) in mixed AD and NC samples and with the Blessed Dementia Rating Scale in an AD sample (r = -0.40). The CERAD total score was highly accurate in differentiating independent samples of NC, MCI, and AD subjects. CONCLUSION: Results provide support for the validity of a Consortium to Establish a Registry for Alzheimer's Disease (CERAD) total score that can be used along with the normative data to provide an index of overall level of cognitive functioning from the CERAD neuropsychological battery.

Early behavioral symptoms and course of Alzheimer's disease.

OBJECTIVE: To determine if behavioral symptoms detected at initial evaluation relate to cognitive or functional status or survival time in Alzheimer's disease (AD) patients. method: Review, in 100 cases of autopsy-proven AD, of the relationship of behavioral symptoms detected at initial evaluation to cognitive and global function measures and survival time. RESULTS: Behavioral symptoms had occurred in 74% of patients, including apathy (51%), hallucinations (25%), delusions (20%) and depressed mood (6.6%). Verbal aggression was common (36.8%); physical aggression less so (17%). The symptomatic group was more functionally (but not cognitively) impaired and had shorter median survival time (8 years: 95% CI: 7-9 years vs. 10 years: 95% CI: 8-12 years; P = 0.002) than the asymptomatic group. The presence of any one symptom at initial evaluation accounted for 6.1% of the variance in duration of illness. CONCLUSION: Presence of behavioral symptoms at initial evaluation of AD patients is associated with greater functional impairment and shorter survival time.

Perforated appendicitis in children: is there a best treatment?

PURPOSE: This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors' hospital. METHODS: This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital. RESULTS: The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management. CONCLUSIONS: Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm3. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.

Correlation of statin-increased platelet APP ratios and reduced blood lipids in AD patients.

Platelets, like neurons, contain 120- to 130- and 110-kd amyloid precursor proteins (APPs). Their ratio is reduced in AD, further reductions correlating with reduced Mini-Mental Status Examination scores [r(11) = 0.69, p < 0.05]. As statins alter APP processing, platelet APPs were analyzed in patients with AD given anticholesterol drugs for 6 weeks. APP ratios increased [t(37) = -3.888, p = 0.0004], proportionally with reduced cholesterol [r(36) = -0.45, p = 0.005]. Longer trials may reveal slowed cognitive loss, validating this index.

Synapse loss is greater in presenile than senile onset Alzheimer disease: implications for the cognitive reserve hypothesis.

In the past, 'Alzheimer disease' (AD) referred to pathologic AD with clinical onset of dementia in the presenium, while 'senile dementia of the Alzheimer type' (SDAT) referred to senile onset AD. Because AD appears clinically homogeneous regardless of age of onset, the two subtypes in more recent years have not been distinguished. Pathologic differences have been noted, but synapse loss has not previously been compared between the two groups. Hypothesizing that synapse loss would be greater in presenile onset than senile onset AD, we compared synapse loss, as well as Alzheimer pathology in presenile and senile onset AD, using an ELISA method to quantify synaptophysin. Synaptophysin was significantly lower in presenile than senile AD in right frontal and bilateral parietal lobes. Neuritic plaque counts were significantly higher in presenile than senile AD in bilateral frontal and parietal lobes. Semi-quantitative evaluation of neurofibrillary tangles revealed significantly more tangles in bilateral frontal and parietal lobes in presenile than senile AD. Brain weight was significantly lower in presenile than senile AD. The differences in synapse loss and Alzheimer-type pathology in presenile and senile onset AD support the hypothesis that 'cognitive reserve' protects the human brain from neurodegenerative disease.

Contribution of asymmetric synapse loss to lateralizing clinical deficits in frontotemporal dementias.

BACKGROUND: Synapse loss has been found to be the major correlate of cognitive decline in Alzheimer disease (AD), and prefrontal synapse loss has been found in patients with frontotemporal dementia (FTD). OBJECTIVE: To see if our hypothesis that within each FTD case, regional synapse loss would correlate with lateralizing neuropsychologic and neurobehavioral deficits would be correct. DESIGN: We analyzed synaptophysin as a marker for synapse loss in snap-frozen brain samples, using an enzyme-linked immunosorbent assay technique. Quantitative results were obtained by comparing patient data with a standard curve made by analyzing serial dilutions of a recombinant synaptophysin protein fragment. A board-certified neuropsychologist and a board-certified neurologist, both unaware of the synaptophysin results, determined areas of primary neuropsychologic and neurobehavioral dysfunction. Relationships between areas of primary dysfunction and synapse loss were analyzed using the binomial test. PATIENTS: Six cases of FTD, 28 cases of AD, and 16 nondemented control subjects. RESULTS: Five of 6 FTD cases had regional synaptophysins correlating with lateralizing frontal or temporal deficits. Three of 6 correlated in 2 or more regions. Although our results were higher than that expected based on a pure-chance mechanism (50% vs 34%), statistical significance was not attained. CONCLUSIONS: We found a trend for an association between synapse loss and lateralizing neuropsychologic and neurobehavioral deficits in FTD. Studies in larger numbers of FTD cases are planned with the goal of attaining statistically significant conclusions.

Cortical synapse loss in progressive supranuclear palsy.

Cortical synapse loss, the probable substrate of cognitive impairment in Alzheimer disease (AD), has not previously been evaluated in progressive supranuclear palsy (PSP). Hypothesizing that synapse loss would be greater in demented than non-demented PSP patients, we examined synaptophysin concentrations in 8 cases of PSP (5 demented and 3 nondemented cases). We found a decrease in mean synaptophysin concentration in these 8 cases in frontal, temporal, and parietal lobes, and in cerebellum, compared to the means in corresponding lobes of 16 controls. The decreases were similar to those in 28 cases of AD, but not as great. We determined synaptophysin concentration from motor cortex in only 4 of our PSP cases, 2 demented and 2 non-demented. The average concentrations in these 4 cases were lower than in AD motor cortex; both were lower than controls. When demented and non-demented PSP cases were compared, neocortical synaptophysin concentrations in non-demented PSP cases were lower than in demented cases. There appears to be a link between AD and PSP, in that synapse loss is found in both. However, the basis and significance of the prominent neocortical synapse loss in PSP, especially in non-demented subjects, remain to be explored.

Proliferative activity in craniopharyngiomas: clinicopathological correlations in adults and children.

BACKGROUND: Craniopharyngiomas are slow-growing, locally invasive intracranial tumors that can generate considerable morbidity, and recurrences are often difficult to manage. Because reliable morphologic criteria for accurately predicting the clinical outcome of these tumors are lacking, we evaluated the growth potential of craniopharyngiomas by measuring their proliferative activity based on MIB-1 immunostaining for the Ki-67 antigen, which is expressed during all phases of the cell cycle except G(0.) METHODS: Paraffin sections from 37 cases of craniopharyngiomas were immunostained with the monoclonal antibody MIB-1, and a labeling index was derived in each case from an the with the highest labeling. RESULTS: MIB-1 immunoreactivity was mainly confined to the peripheral palisaded epithelium of craniopharyngiomas. In adult craniopharyngiomas, MIB-1 labeling indices (MIB-LI) varied from 0.1% to 34.6% (mean 8.9%; SD 9. 8), and in pediatric tumors the indices ranged from 1.8% to 15.0% (mean 6.3%; SD 3.7). MIB-LI was not found to be an independent predictor of recurrence, although in all the pediatric cases that recurred, MIB-LI in the second specimen was greater. CONCLUSIONS: The actively proliferating compartment in craniopharyngiomas seems to be the peripheral palisaded epithelium. Low MIB-LI observed in the majority of tumors is in concordance with the slow growth and low-grade invasiveness associated with craniopharyngiomas. However, unlike other intracranial neoplasms, where Ki-67 labeling indices have been useful in predicting tumor behavior, a clear relationship could not be demonstrated between MIB-1 immunoreactivity, morphological features and clinical outcomes in adults or children with craniopharyngiomas.