Work rehabilitation in schizophrenia: does cognitive impairment limit improvement?

Cognitive impairments may be an important contributor to disability in schizophrenia and may limit the rate of improvement in work rehabilitation. Thirty-three outpatients with schizophrenia or schizoaffective disorder who participated in a 6-month work rehabilitation program were assessed for symptom severity and administered neuropsychological testing at intake. Their work performance was evaluated biweekly using the Work Behavior Inventory. On each of five domains of work performance, 76 to 91 percent of subjects reached proficiency or improved significantly over 26 weeks. Individual differences in rate of improvement were robustly predicted by neuropsychological variables: Work Habits, r2 = 0.79; Personal Presentation, r2 = 0.73; Cooperativeness, r2 = 0.67; Work Quality, r2 = 0.56; Social Skills, r2 = 0.27; Total, r2 = 0.44. Neuropsychological measures had differential relationships to work domains. Individual differences in improvement were not predicted by symptom measures. These findings link cognitive impairment to disability and suggest that remediating or accommodating such deficits may be necessary for successful rehabilitation.     

Gliosarcoma with areas of primitive neuroepithelial differentiation and extracranial metastasis

We report a case of gliosarcoma with areas of primitive neuroepithelial differentiation arising in the temporal lobe of a 53-year-old man. The sarcomatous component of this tumor was perivascular in its distribution and showed expression of factor VIII-related antigen, smooth muscle actin and CD34. The primitive neuroepithelial component possessed a small cell morphology and showed expression of neuronal antigens. Strong expression of p53 was demonstrated throughout the tumor with only focal weak expression of epidermal growth factor receptor. The tumor developed widespread extraneural metastases 5 months after surgical resection of the primary tumor. Histological examination of the liver metastases showed them to consist predominantly of the primitive neuroepithelial component. We believe this to be a novel pattern of differentiation in a gliosarcoma which in this case was associated with an aggressive metastatic potential.     

Drugs for cardiovascular risk reduction in the diabetic patient

The diabetic patient is at increased risk for cardiac events. Lowering hemoglobin A1c levels even within the normal range is associated with less cardiac risk. Oral agents for diabetes that reduce insulin resistance and its associated cardiac risk factors in addition to lowering glucose should be used. Energetic reduction of blood pressure with an emphasis on the use of angiotensin-converting enzyme inhibitors and b blockers will further reduce cardiac risk. Reduction of low-density lipoprotein and triglyceride levels and elevation of high-density lipoprotein levels through judicious use of statins and other anti-lipid agents is essential and will lower the rate of cardiac events in the diabetic patient even more than in the nondiabetic patient. In addition, aspirin and folic acid supplementation should be utilized. Use of a multiple risk factor management strategy with these drugs will lower morbidity and mortality, improve quality of life, and save cost for the diabetic patient.     

Dual Tobacco use among Native American adults in southeastern North Carolina

OBJECTIVE: While patterns of smokeless tobacco (ST) use and cigarette smoking are well documented, the epidemiology of simultaneous use of both tobacco products is less well studied, particularly among Native American populations. This study examines correlates of dual tobacco use among Lumbee Indian adults in southeastern North Carolina. METHODS: A telephone survey among 400 adult Lumbee Indians in Pembroke, North Carolina, collected information on demographics, current tobacco use, amounts of tobacco used, and tobacco related attitudes. RESULTS: Total of 241 (60.3%) individuals did not currently use tobacco, 104 (26%) currently smoked, 74 (18.5%) currently used ST, and 19 (4.8%) used both products. Thus, 19 of 104 (18.3%) current smokers and 19 of 74 (25.7%) current ST users reported dual tobacco use. Compared to exclusive users of either tobacco product, dual tobacco users were intermediate in age and frequency of church attendance, had lower levels of education, and were the highest proportion of subjects reporting no friends and few close relatives. There was no difference by gender or marital status by tobacco use categories. While exclusive cigarette smokers reported smoking more cigarettes per day than dual tobacco users, overall, dual tobacco users had higher estimated daily nicotine exposure levels. Logistic regression analysis showed that younger age and infrequent church attendance predicted exclusive cigarette smoking, while older age and less education predicted exclusive ST use. Dual tobacco use was predicted only by less education. CONCLUSIONS: Simultaneous use of ST and cigarettes is comparatively more common among Lumbee Indian adults than the general population and has an epidemiology distinct from either exclusive cigarette smoking or ST use. These data are the first to explore social support as well as tobacco-related attitudes among dual tobacco users in a Native American population. Recognition of these patterns of dual tobacco use would be important in any future tobacco intervention among Lumbee Indian adults.     

Screening for abuse: barriers and opportunities

Domestic abuse is the leading cause of injuries and death among women of childbearing age in the United States. The broad purpose of this research is to discover how pregnant women's psychological and behavioral responses to abuse affect birth outcomes. To select a diverse sample of women, we identified 8 prenatal care sites and completed the human subjects approval process with each. Rates of screening for abuse range from all but 12 women over a 2-1/2-year period at one site to no screening for abuse at another site. In this article, we will review pertinent literature and discuss the supports and barriers we observed when implementing an abuse screening program using the Abuse Assessment Screen, a well-tested and valid clinical instrument. Suggestions will be made for improving the screening rates at those sites where screening is absent or inconsistent.     

Apparent confined placental mosaicism of trisomy 16 and multiple fetal anomalies: case report

Trisomy 16 is frequently found confined to the placenta (confined placental mosaicism (CPM)), with a structurally normal fetus. In some cases of trisomy 16, the fetus has uniparental disomy for chromosome 16 (UPD16) which is associated with intrauterine growth restriction (IUGR) and fetal anomalies. We report a case of apparent confined placental mosaicism for trisomy 16, using standard cytogenetic techniques, but with multiple fetal abnormalities including congenital diaphragmatic hernia in which there was no evidence of UPD in the disomic tissues examined. Subsequent examination of fetal tissues using fluorescent in situ hybridization (FISH) demonstrated low levels of mosaicism for trisomy 16 in all the tissues examined. The use of FISH permits identification of mosaicism which conventional techniques may not identify.     

The association between caregiver burden and caregiver health-related quality of life in Alzheimer disease

The burden experienced by family caregivers of individuals with Alzheimer disease (AD) affects the caregivers' overall health-related quality of life (HRQOL). Assessing the influence on HRQOL is an integral part of determining the efficacy and economic attractiveness of interventions for AD. Generic preference-weighted instruments such as the Health Utilities Index Mark 2 (HUI2) are recommended for measuring HRQOL for cost-effectiveness studies. However, these instruments focus on physical attributes and have not been tested in an AD caregiver population. We administered the HUI2 to a population of 679 caregivers to people with AD at 13 community and institutional sites in the United States. We also administered the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), a caregiver time questionnaire, and a caregiver burden instrument. The mean global HUI2 utility score for caregivers was 0.87 and varied little by the affected person's setting of care and AD stage (range, 0.86-0.89; p > 0.2). The caregiver burden scales all varied by the affected person's setting of care, and some also varied by disease severity. The mental health component summary score of the SF-36 for caregivers varied across both disease stage and setting. Caregiver time increased for caregivers of AD-affected persons with more severe cognitive impairment. Generic preference-weighted instruments may not adequately capture differences in the burden of caregivers of those with AD. The development of condition-specific preference-weighted instruments may provide the means to better estimate HRQOL in AD caregivers.     

The utility of computed tomography in acute small bowel obstruction

Small bowel obstruction is a significant cause of acute surgical admissions. Surgeons are tending to favour an initial trial of conservative management. Due to the unreliability of clinical signs to predict accurately those patients requiring early intervention there is an increasing tendency to utilize imaging investigations, particularly computed tomography (CT), to help define the severity, cause and complications of acute small bowel obstruction. The aim of this pictorial review is to demonstrate the contribution CT can make to the management of these patients. Burkill, G. J. C., Bell, J. R. G. & Healy, J. C. (2001). Clinical Radiology56, 350-359.