Progressive atrophy of the frontal lobes in first-episode schizophrenia: interaction with clinical course and neuroleptic treatment

OBJECTIVE: This prospective study examined the interaction of clinical course of disease and brain structure with time in schizophrenic patients. METHOD: A total of 21 first-episode schizophrenic patients, 10 patients with other psychiatric disorders and a control group of 9 healthy volunteers had CT at first admission and at reinvestigation 5 years later. RESULTS: At first admission all of the patients had enlarged cortical fissures and sulci compared to controls, and the duration of untreated psychosis was significantly correlated with sulcal enlargement. At reinvestigation, frontal and central brain atrophy had progressed in schizophrenic patients. CONCLUSION: The study indicated that ongoing psychosis and lifetime dose of classical antipsychotics were the main candidates accounting for the finding of progressively disturbed brain structure during the first 5 years of schizophrenia.     

Borna disease virus-induced hippocampal dentate gyrus damage is associated with spatial learning and memory deficits

In neonatally inoculated rats, Borna disease virus (BDV) leads to a persistent infection of the brain in the absence of an inflammatory response and is associated with neuroanatomic, developmental, physiologic, and behavioral abnormalities. One of the most dramatic sites of BDV-associated damage in the neonatal rat brain is the dentate gyrus, a neuroanatomic region believed to play a major role in spatial learning and memory. The absence of a generalized inflammatory response to neonatal BDV infection permits direct effects of viral damage to the dentate gyrus to be examined. In this report, neonatally BDV-infected rats at various stages of dentate gyrus degeneration were evaluated in the Morris water maze, a swimming test that assesses the rats' capacity to navigate by visual cues. Our data demonstrate progressive spatial learning and memory deficits in BDV-infected rats that coincided with a gradual decline in the estimated hippocampal dentate gyrus neuron density.     

Service use by elderly patients after psychiatric hospitalization

The extent and source of services used by older adults discharged to a community setting after a psychiatric hospitalization were examined in a prospective follow-up study. Patients were asked about service use in structured telephone interviews one month after hospital discharge. Subjects had comorbid medical conditions and high levels of functional impairment. Service use was low, highly skewed, and spread across three sectors of care-mental health specialty care (38 percent of the services), general medical care (35 percent), and social services and formal aging services (27 percent). Most service episodes were related to mental disorder.     

Evolving trends in liver transplantation: an outcome and charge analysis

BACKGROUND: Due to the limited supply and increased demand for donor livers, waiting times are progressively lengthening, which may lead to transplantation at more advanced and less cost-effective stages of disease. The purpose of this study was to evaluate the outcomes and hospital charges of liver transplantation during two recent eras to identify areas for providing more cost-effective care. METHODS: A total of 144 primary liver allografts were performed from 1991 to 1996. Patient characteristics, outcome measures, and hospital charges were compared for patients receiving allografts between 1991 and 1993 (group A) versus those receiving grafts between 1994 and 1996 (group B) using unpaired Student t tests for continuous data and chi-squared tests for categorical data. RESULTS: In comparing groups A and B, no significant differences in patient demographics, relative contraindications, or indication for transplantation existed; median waiting time from date of listing until transplant increased from 88 days to 159 days; and a shift in UNOS priority status at time of transplantation occurred, as the percentage of patients requiring inpatient care increased from 58% to 75% (P=0.034). Despite this, patient hospital and 1-year survival significantly improved from 75.0% to 90.3% (P=0.016), and from 68.1% to 88.9% (P=0.002), respectively. Total hospital charges, without correction for inflation, were $174,908+/-16,388 in A and $193,525+/-14,444 in B (P=0.288). The increased charges were associated with longer inpatient length of stay (LOS) before transplant, resulting in increased pretransplant charges from $24,088+/-4134 (A) to $39,490+/-6,196 (B) (P=0.011). Room and service (54%) was the largest pretransplant contributor to charges, while blood products (23%), room and service (21%), organ acquisition (13%), and operating room charges (11%) contributed the most after transplant. CONCLUSIONS: Longer waiting times resulting in transplantation at later stages of disease have occurred, leading to longer pretransplant LOS and its associated charges. Despite more advanced disease, patient survival rates have significantly improved with fewer infection-related deaths. LOS pretransplant, blood products, and operating room services represent potential areas for providing more cost-effective care.     

Characteristics of discrepancies between self-reported visual function and measured reading speed. Salisbury Eye Evaluation Project Team

PURPOSE: Visual impairment is a risk factor for morbidity in the elderly and is often screened for by self-report. This study evaluates whether there are subsets for whom there is a discrepancy between self-reported and measured function. METHODS: The prevalence of a discrepancy between self-reported difficulty reading a newspaper and measured reading speed was determined in 2520 community-based men and women, aged 65 to 84 years, and the discrepant group characterized by polychotomous regression. RESULTS: Of subjects who reported minimal difficulty reading a newspaper, 10.8% (227/2107) read newsprint-sized text (0.21 degrees) more slowly than 80 words/min, a level previously shown to be necessary for sustained reading. Poor visual acuity, presence of psychiatric symptoms, and less satisfaction with vision were associated with being in the group that read slowly and reported difficulty with reading. Better cognition, better visual acuity, more years of education, white race, and fewer psychiatric symptoms were associated with being in the group that read more quickly and reported minimal difficulty. When reading the text size at which subjects read their fastest, only 2.6% of those with minimal difficulty remained discrepant. These individuals were more likely to have less education, be male, be African American, and have poorer cognitive status than those who did not remain discrepant. CONCLUSIONS: A subset of the elderly population have a substantial discrepancy between self-reported reading difficulty and measured reading speed. In some, this discrepancy may be based on underlying expectations and experiences, and in others it may represent a transition from no visual impairment to visual impairment.     

Effects of cataract and scotoma on visual acuity: a simulation study.

Central field loss (CFL) and cataract both decrease visual acuity. For patients with CFL, visual acuity is further reduced when the acuity target is more visually complex. We tested visual acuity for targets of varying complexity (letters alone, letters flanked by one or two x's on each side, and words) in subjects with normal vision and in the presence of a simulated cataract, simulated scotoma, and their combination (scotoma + cataract). Visual acuity was best with normal vision and worst with scotoma + cataract for all of the acuity targets. There was little difference in visual acuity between the letters alone and flanked letters, and visual acuity was best for words under all vision conditions. The cataract had a greater impact on visual acuity when the subject's central visual field was clear (normal vision) than when it was occluded by the simulated scotoma.     

Pharmacokinetic consequences of a citalopram treatment discontinuation.

In this pilot study, the pharmacokinetics of citalopram (CIT) were examined in five hospitalized depressed patients after an abrupt discontinuation of a treatment with 40 mg/d of this selective serotonin reuptake inhibitor (SSRI). During the 8-day study period, clinical ratings were regularly carried out. Between days 5 and 8, the patients were treated with clomipramine (75 mg/d). The enantiomers of CIT and its metabolites, demethyl-CIT (DCIT) and CIT-propionic acid derivative (CIT-PROP), were measured repeatedly from day 0 to day 8 by a stereoselective high-performance liquid chromatography (HPLC) procedure. The following drug plasma half-lives were measured (means +/- SD): R-CIT: 66+/-11 h; S-CIT: 42+/-13 h; R-DCIT: 228+/-148 h; S-DCIT: 93+/-35 h; R-CIT-PROP: 82+/-31 h; S-CIT-PROP: 186+/-93 h.     

Leucovorin, 5-fluorouracil,and gemcitabine: A phase I study

Gemcitabine is a chemotherapy agent with efficacy in the treatment of lung, pancreas, bladder and breast cancer. It inhibits DNA synthesis by interfering with cytidine triphosphate production and also inhibits the activity of ribonucleotide reductase. Gemcitabine may potentiate fluorouracil's inhibition of thymidylate synthase. This inhibition would be expected to be sequence dependent, occurring only if gemcitabine were administered following fluorouracil (5FU).The combination of leucovorin, 5-FU, and gemcitabine was assessed in this phase I trial. Eligibility requirements included refractory solid tumor malignancy; adequate hematologic, renal and hepatic reserve; no prior therapy with the combination of leucovorin and 5FU, or with gemcitabine; ECOG performance status 0–2, and signed informed consent.Eleven men and nine women were eligible. The median age was 52.5 years and the median performance status was 1. All but three patients had prior chemotherapy. The starting doses were leucovorin 20 mg/m², 5FU 255 mg/m² and gemcitabine 600 mg/m². 5FU and gemcitabine were escalated in tandem to 340 mg/m² and 800 mg/m² and thereafter to 425 mg/m² and 1000 mg/m², respectively. Gemcitabine administration always followed that of 5FU by 30 minutes. The median number of cycles was 2 (range 1–32). Two patients at the starting dose had disease progression within the first cycle with one death on day 28. One patient with cholangiocarcinoma had a partial response and remained on study for 40 months. There were no other responses.The maximum tolerated dose is leucovorin 20 mg/m², 5FU 340 mg/m², and gemcitabine 800 mg/m². The impact of drug sequence remains undetermined.     

Reliability of medical audit in quality assessment of medical care

Medical audit of hospital records has been a major component of quality of care assessment, although physician judgment is known to have low reliability. We estimated interrater agreement of quality assessment in a sample of patients with cardiac conditions admitted to an American teaching hospital. Physician-reviewers used structured review methods designed to improve quality assessment based on judgment. Chance-corrected agreement for the items considered more relevant to process and outcome of care ranged from low to moderate (0.2 to 0.6), depending on the review item and the principal diagnoses and procedures the patients underwent. Results from several studies seem to converge on this point. Comparisons among different settings should be made with caution, given the sensitivity of agreement measurements to prevalence rates. Reliability of review methods in their current stage could be improved by combining the assessment of two or more reviewers, and by emphasizing outcome-oriented events.