Memory training combined with the use of oral physostigmine.

Impaired memory function is one of the most frequent and disabling symptoms observed after brain injury. A number of studies have examined the efficacy of using cholinergic agonists, such as physostigmine, in treating memory impairment resulting from various neurologic conditions. Few studies, however, have either combined the drug treatment with a memory training programme or monitored serum cholinesterase levels to increase the likelihood of achieving a therapeutic dose of the medication. The current study addresses both of these issues. Two single-case studies are reported in this investigation. In each case, a double-blind, placebo-controlled, single-subject, A-B-A design was used with A representing the base-line phases, B constituting the memory training combined with medication phase and A representing the return to base-line condition. Both patients sustained anoxia as a result of carbon monoxide poisoning. In the first case, a clinically significant improvement was seen in the patient's performance of both standardized and non-standardized measures of memory function as a result of the combined treatment regimen. No significant changes, however, were seen in the patient's performance on measures of attention and concentration, cognitive flexibility or motor speed. These findings were then replicated with the second anoxic patient. The results from this study point out the potential benefit of combining cholinergic agonists with specific memory training strategies in improving memory function after brain injury.

Assessing the risk of diabetic retinopathy.

We used multiple logistic regression to analyze cross-sectional data on 1,006 patients with diabetes mellitus who were examined in a rural diabetic screening program. The factors found to have independent and significant associations with the presence of retinopathy were duration of diabetes, albuminuria, serum creatinine, glycosylated hemoglobin, and plasma glucose levels, blood pressure, and percentage of desirable weight. By comparing the contribution of each significant factor to the deviance from the regression models, we estimated the relative importance of each. Duration of diabetes was by far the most important predictive factor. The logistic model provided a good fit to the observed prevalence rates in various risk groups but was less satisfactory for predicting the presence or absence of retinopathy in individual patients. The discovery of presently unknown risk factors may improve this situation.

Wheelchair transfer training for right cerebral dysfunctions: an interdisciplinary approach.

A 44-year-old patient with cerebrovascular accident and resulting total occlusion of the right internal carotid artery and severe cognitive impairments was seen as an inpatient. Impulsivity, general inattention, left side neglect, decreased concentration and visual-spatial-perceptual difficulties were clinically evident. A conventional approach to training this patient in wheelchair transfer skills met with little success. An individualized training program based on the patient's specific cognitive strengths and deficits was developed. The major elements of the program were (a) careful observation of task performance, (b) task analysis of the skill to be taught, (c) utilization of the patient's learning strengths to guide performance, (d) small step hierarchical programming to meet the desired goal, (e) intense repetition of the skill and (f) data collection procedures to monitor change and program adjustments. Six weeks after the program was implemented the patient was able to complete safe transfers, and was discharged home. At follow-up, two weeks after discharge, inconsistency in transfers was noted; the written program was immediately reestablished, and the patient continued safe wheelchair transfers at every subsequent check. This study suggests that treatment outcome in patients with right hemisphere damage may not be as bleak as has been previously suggested. A treatment strategy that includes an optimal utilization of a patient's verbal skills to cue and monitor performance and judgment, along with systematic data collection to guide program modifications, can lead to a more successful rehabilitation outcome.

Medical correlates and diabetic retinopathy screening.

A systematic ophthalmological, medical, and biochemical screening of a rural population of diabetics in Western Australia is being carried out. A team of ophthalmologists, physicians, and paramedical personnel establish regional screening centres on a voluntary basis at weekends. Every attempt is made to locate and examine all known diabetics. All patients are given a thorough ophthalmic examination including standard multiple field colour fundus photography. Thorough physical examination includes assessment of cardiovascular and neurological status. Biochemical parameters include random blood sugar, urine analysis, serum creatinine, glycosylated haemoglobin, cholesterol, and high density lipoprotein. A detailed questionnaire and interview is carried out to assess the historical degree of control and the patient's knowledge of the control and management of diabetes. The sample now comprises an unselected population of 400 diabetics living in rural areas and allows comparison of areas which have scarce medical services with centres that are well supplied with medical practitioners. Incidence of retinopathy varies from 25 to 36 per cent of the diabetic population. Positive correlations of retinopathy have been found with duration, age, hypertension, level of control assessed biochemically at the time of examination, presence of ischaemic heart disease, peripheral neuropathy, and renal disease. Smoking also correlates positively. The data provide a baseline by which attempts to alter diabetic knowledge, management, and control may be measured in follow-up studies.