A cross-sectional study of non-attendance among patients at a US hemophilia treatment center 2010-2014.

INTRODUCTION: Among patients with chronic disease, non-attendance at scheduled healthcare visits is associated with poor outcomes. The impact of non-attendance among patients with bleeding disorders is unknown. METHODS: Scheduling and medical record data over a 5-year period for all individuals with at least one scheduled appointment during 2010-2014 at a US Hemophilia Treatment Center (HTC) were analysed. Non-attendance rates were calculated as the number of non-attended visits divided by the number of years as a patient during the time period. Consistent non-attenders were patients who did not attend more than one scheduled appointment per person-year on average. Logistic regression determined characteristics associated with consistent non-attendance and Poisson regression estimated adjusted incidence rate ratios (aIRRs) describing associations between non-attendance and emergency department (ED) visits and hospitalizations. RESULTS: There were 8028 appointments scheduled for 950 individuals; 12% were not attended. Consistent non-attenders (n = 62; 7% of the HTC patient population) accounted for over one-third of non-attended appointments and over one-quarter of hospitalizations. Characteristics associated with consistent non-attendance included public health insurance and black race. Higher non-attendance rates were associated with more ED visits (aIRR 1.78; 95% CI: 1.37-2.30) and hospitalizations (aIRR 2.73; 95% CI: 2.18-3.42). Consistent non-attenders had more ED visits (aIRR 2.49; 95% CI: 1.56-3.96) and hospitalizations (aIRR 4.73; 95% CI: 2.96-7.57) compared with patients who never missed appointments. CONCLUSIONS: Frequent non-attendance identified a small but at-risk population. Interventions to improve disease management that target them may have an impact on health outcomes and healthcare utilization.

Distress in patients with bleeding disorders: a single institutional cross-sectional study.

INTRODUCTION: Distress may affect a patient's ability to cope with and manage disease. AIM: To report distress prevalence in adult patients with bleeding disorders and determine whether specific clinical and health characteristics, including disease severity and employment status, are associated with distress. METHODS: Patients who visited a Haemophilia Treatment Centre (HTC) between January 1st, 2012 through February 28th, 2014 and who completed a distress screen, pain screen and questionnaire were evaluated cross sectionally. Distress was measured by the National Comprehensive Cancer Network Distress Management Tool, which allowed patients to rate recent distress on a 0-10 point scale. A rating of five or more was categorized as high distress. Pain was measured by the Brief Pain Inventory Short Form, which asked patients to rate pain types on 0-10 point scales. Patients reported employment and other demographic and behavioural information on the questionnaire. Primary diagnosis, age, HIV and HCV status were abstracted from medical records. Adjusted logistic regression was used to identify distress associations. RESULTS: High distress prevalence among 152 patients with bleeding disorders was 31.6%. Unemployment, disability, greater depressive symptoms and higher pain were associated with high distress in multivariable models. Bleeding disorder diagnosis, race/ethnicity, HIV/HCV status and on-demand treatment regimen were not associated with high distress. CONCLUSION: Distress among patients with congenital bleeding disorders followed at a comprehensive HTC was high and similar to that reported among patients with cancer. Future research should determine whether distress impacts clinical outcomes in patients with bleeding disorders as demonstrated in other chronic disorders.

Randomized trial of hypotensive epidural anesthesia in older adults.

BACKGROUND: Data are sparse on the incidence of postoperative cognitive, cardiac, and renal complications after deliberate hypotensive anesthesia in elderly patients. METHODS: This randomized, controlled clinical trial included 235 older adults with comorbid medical illnesses undergoing elective primary total hip replacement with epidural anesthesia. The patients were randomly assigned to one of two levels of intraoperative mean arterial blood pressure management: either to a markedly hypotensive mean arterial blood pressure range of 45-55 mmHg or to a less hypotensive range of 55-70 mmHg. Cognitive outcome was assessed by within-patient change on 10 neuropsychologic tests assessing memory, psychomotor, and language skills from before surgery to 1 week and 4 months after surgery. Prospective standardized surveillance was performed for cardiovascular and renal outcomes, delirium, thromboembolism, and blood loss and replacement. RESULTS: The two groups were similar at baseline in terms of age (mean, 72 yr), sex (50% women), comorbid conditions, and cognitive function. After operation, no significant differences in the incidence of early or long-term cognitive dysfunction were observed between the two blood pressure management groups. There were no significant differences in the rates of other adverse consequences, including cardiac, renal, and thromboembolic complications. In addition, no differences occurred in the duration of surgery, intraoperative estimated blood loss, or transfusion rates. CONCLUSIONS: Elderly patients can safely receive controlled hypotensive epidural anesthesia with this protocol. There was no evidence of greater risks, or early benefits, with the use of the more markedly hypotensive range.

Children's cognitive responses to the somatic symptoms of panic.

The purpose of this study was to test Nelles and Barlow's (1988) hypothesis that spontaneous panic attacks are rare or nonexistent prior to adolescence as children lack the ability to make the internal, catastrophic attributions (i.e., thoughts of losing control, going crazy, or dying) characteristic of panic according to the cognitive model (Clark, 1986). Conceptions of panic attacks, including the understanding of symptoms and causes, and cognitive interpretations of the somatic symptoms of panic were examined in children from Grades 3, 6, and 9. A significant main effect for grade was found for conceptions of panic attacks, with third graders receiving significantly lower scores than sixth and ninth graders. However, the majority of all children, regardless of age, tended to employ internal (e.g., "I'd think I was scared or nervous") rather than external (e.g., "I'd think I was feeling that way because of the temperature or the weather") explanations of panic attacks. No significant grade differences were found for the tendency to make internal versus external and catastrophic versus noncatastrophic attributions in response to the somatic symptoms of panic. When presented with panic imagery in a panic induction phase, children, regardless of age, made more internal and noncatastrophic attributions. Finally, internal attributional style in response to negative outcomes and anxiety sensitivity were found to be significant predictors of internal, catastrophic attributions. The challenge that these findings pose to Nelles and Barlow's hypothesis, and their relevance for understanding children's cognitive interpretations of panic symptomatology are discussed.

Impulsive Homicide Associated With an Arachnoid Cyst and Unilateral Frontotemporal Cerebral Dysfunction.

A 65-year-old man with no past history of violent or criminal behavior abruptly strangled his wife after she scratched his face during a domestic argument. He appeared emotionally blunted and lacked insight into the motivations for his violent actions. The presence of left-sided cerebral dysfunction was initially suggested by subtly decreased dexterity of his dominant right hand. A magnetic resonance image (MRI) revealed a large arachnoid cyst centered in his left Sylvian fissure that effaced ventral frontal, anterior temporal and insular cortical gyri. The left middle cerebral artery was displaced relative to an earlier study, providing indirect evidence that the cyst had enlarged during his adult life. Neuropsychological testing indicated generally intact cognitive abilities except for mild impairment on tests of prospective memory and executive functions. He was found to have intermittently decreased EEG amplitude in the left fronto-temporal region. Positron emission tomography (PET) revealed significantly reduced resting glucose metabolism in the left frontal and temporal lobes. He was also found to have pathological diminution of autonomic responses to affectively charged visual stimuli, a phenomenon previously reported in patients with ventromedial frontal lobe injury and acquired disturbances of social conduct. In light of these findings, we suggest that his violent behavior represents stimulus-bound aggression, triggered by a novel physical threat and unchecked by learned social restraints owing to the presence of ventral prefrontal dysfunction.

Psychiatric complications in a patient with complex partial seizures.

This case highlights the complexities of evaluating and treating psychiatric symptoms that are concurrent with a seizure disorder. Interictal and postictal psychoses, affective disorders, personality changes, and cognitive deficits are common problems that require modified psychiatric treatments.

Cognitive effects after epidural vs general anesthesia in older adults. A randomized trial.

OBJECTIVE: To compare the effect of epidural vs general anesthesia on the incidence of long-term cognitive dysfunction after total knee replacement surgery in older adults. DESIGN: Randomized controlled clinical trial. SETTING: Orthopedic specialty academic hospital. PATIENTS: A total of 262 patients undergoing elective primary total knee replacement with a median age of 69 years; 70% women. INTERVENTION: Random assignment to either epidural or general anesthesia. MAIN OUTCOME MEASURES: A thorough neuropsychological assessment was performed preoperatively and repeated at 1 week and 6 months postoperatively. Cognitive outcome was assessed by within-patient change on 10 tests of memory, psychomotor, and language skills. Prospective standardized surveillance for cardiovascular complications was performed to allow simultaneous assessment of anesthetic effects on cognitive and cardiovascular outcomes. RESULTS: The two groups were similar at baseline in terms of age, sex, comorbidity, and cognitive function. There were no significant differences between the epidural and general anesthesia groups in within-subject change from baseline on any of the 10 cognitive test results at either 1 week or 6 months. Overall, 5% of patients showed a long-term clinically significant deterioration in cognitive function. There was no difference between the anesthesia groups in the incidence of major cardiovascular complications (3% overall). CONCLUSIONS: The type of anesthesia, general or epidural, does not affect the magnitude or pattern of postoperative cognitive dysfunction or the incidence of major cardiovascular complications in older adults undergoing elective total knee replacement. This is the largest trial of the effects of general vs regional anesthesia on cerebral function reported to date, with more than 99% power to detect a clinically significant difference on any of the neuropsychological tests.

Panic in children and adolescents: a review.

Based on our review of the available data, we conclude that panic attacks are common among adolescents, while both panic attacks and Panic Disorder appear to be present, but less frequent, in children. Furthermore, it is evident that both adolescents and children who report panic attacks describe the occurrence of cognitive symptoms, although with less frequency than physiological ones. Consistent with the cognitive model of panic, it seems that at least some youngsters are capable of experiencing the physiological symptoms of panic accompanied by the requisite catastrophic cognitions. However, a more complete understanding of the cognitive manifestation of panic attacks/disorder among children awaits further investigation. Future research should aim to explore the developmental progression in children's cognitive responses to specific panic symptomatology. Risk factors (e.g. anxiety sensitivity, depression) which may contribute to the likelihood of misinterpreting physiological sensations in a catastrophic manner throughout the course of development should also be assessed: Finally, we are in general agreement with Abelson and Alessi (1992) who argue that we must begin to ask ourselves how panic disorder may be manifested in children. That is, rather than assessing the frequency with which children experience symptoms of adult panic, we should explore what panic would look like in children. They propose that the study of panic in children would be facilitated by a reformulation of separation anxiety as a childhood expression of panic disorder. Although this reformulation makes intuitive sense and is appealing from a developmental perspective, we would insert a strong caveat. Although the research is yet to be conducted, it is probable that childhood separation anxiety is only one of many routes to panic disorder outcome. It is improbable that such direct and continuous pathways are present for the majority of children, adolescents and adults who experience panic disorder. More probably, the pathways are multiple, complex, and discontinuous (Robbins & Rutter, 1990). Much work remains to be done before we are able to ferret out the linkages between developmental processes and clinical outcomes for panic disorder in children and adolescents.

The course of geriatric depression with "reversible dementia": a controlled study.

OBJECTIVE: The goals of this longitudinal investigation were 1) to study the rate of development of irreversible dementia in elderly depressed patients with a dementia syndrome that subsided after improvement of depression and 2) to compare it with that of depressed, never-demented patients. METHOD: The subjects were 57 elderly patients consecutively hospitalized for major depression. At entry into the study, 23 subjects also met criteria for "reversible dementia," while 34 were without dementia. After a systematic clinical evaluation, the subjects were followed up at approximately yearly intervals for an average of 33.8 months. RESULTS: Irreversible dementia developed significantly more frequently in the depressed group with reversible dementia (43%) than in the group with depression alone (12%). Survival analysis showed that the group with reversible dementia had a 4.69-times higher chance of having developed dementia at follow-up than the patients with depression alone. No clinical characteristics at entry into the study were found to discriminate the subjects who developed irreversible dementia during the follow-up period from those who remained nondemented. CONCLUSIONS: These findings suggest that geriatric depression with reversible dementia is a clinical entity that includes a group of patients with early-stage dementing disorders. Therefore, identification of a reversible dementia syndrome is an indication for a thorough diagnostic workup and frequent follow-ups in order to identify treatable neurological disorders.

Gender differences in cognition in schizophrenia.

Gender differences in cognition were investigated in schizophrenic inpatients and outpatients using the Dementia Rating Scale. Females displayed greater impairment on Attention and Conceptualization than males. Gender interacted with patient group for construction: females performed worse than males among inpatients and better among outpatients. Results may be related to the atypically early age of onset of females relative to males; attention to sampling and selection biases is needed in evaluating gender differences in cognition in schizophrenia.

Pain perception in self-injurious patients with borderline personality disorder.

Pain ratings during the cold pressor test were significantly lower in female inpatients with borderline personality disorder who report that they do not experience pain during self-injury (BPD-NP group, n = 11), compared with similar patients who report that they do experience pain during self-injury (BPD-P group, n = 11), and normal female subjects (n = 6). Pain ratings were not significantly different in the BPD-P and normal control groups. Self-report ratings of depression, anger, anxiety, and confusion were significantly lower, and ratings of vigor significantly higher following the cold pressor test in the BPD-NP group, but not in the BPD-P group. Only anxiety was significantly lower in the normal control group following the cold pressor test. The implications and limitations of these preliminary findings are discussed.

Contribution of family, cognitive and clinical dimensions to long-term outcome in schizophrenia.

A multivariate approach incorporating both biological and psychosocial factors was used in a cross-sectional study of schizophrenic inpatients and outpatients selected to represent opposite ends of the outcome spectrum. Twenty-six RDC-diagnosed chronic schizophrenic patients hospitalized continuously for 18 months or longer, and 26 patients with a history of at least three years of community tenure without rehospitalization were matched for sex, age, ethnicity, SES and chronicity, and assessed on a structured family interview (Social Behavior Assessment Schedule), neuropsychological test battery, Brief Psychiatric Rating Scale and Premorbid Asociality Scale. Stepwise discriminant function analysis was performed; family ratings of patients' problem behaviors was the most powerful discriminator between the two groups and a composite measure of neuropsychological functioning ranked second. Other significant discriminators were BPRS scores, availability of social support to the family and age of onset. Family ratings of patient behavior were related to ratings of family burden and to BPRS scores. Further research is needed to understand the complex interactions between the diverse sets of social, clinical and neurobiological factors that determine long-term outcome in schizophrenia.

Neuropsychological discriminators of long-term inpatient or outpatient status in chronic schizophrenia.

This study investigates specific neuropsychological functions discriminating schizophrenic patients with hospitalization beyond 18 months from patients residing in the community without rehospitalization beyond 3 years. Twenty-six Research Diagnostic Criteria-diagnosed chronic schizophrenic outpatients and 26 inpatients matched for sex, ethnicity, socioeconomic status, and chronicity completed a comprehensive neuropsychological battery and responded to an inventory of psychopathology. Discriminant function analyses showed that measures of motor coordination, preservation, memory, and attention discriminated between patient groups. Bilateral simultaneous fine motor coordination was the most potent discriminator between patient groups, independent of psychopathology. Implications for treatment and research on course and outcome in schizophrenia are discussed.

Diagnosing cognitive dysfunction in the elderly: primary screening tests.

The recognition of cognitive disturbances in geriatric patients has important clinical implications for the primary care physician. Commonly seen cognitive dysfunctions include dementia, pseudodementia, delirium, and frontal lobe syndrome; these may be confounded by overlapping depression. The cognitive examination covers such intellectual and behavioral functions as attention, memory, and language. As many psychiatric disorders result from neurologic brain disease, a psychiatric examination is essential. Mental status questionnaires are useful for screening of high-risk populations for dementia and to quantify the degree of cognitive dysfunction for purposes of management planning and surveillance.

Verbal memory and plasma drug concentrations in elderly depressives treated with nortriptyline.

Performance on a verbal memory task and affective state were assessed in geriatric major depressives before and during 6 weeks of treatment with nortriptyline (NT) in a fixed-dose design study. Higher plasma NT concentration was associated with poorer free recall but better affective outcome. In contrast, higher plasma Z-10-hydroxynortriptyline (Z-10-OH-NT) concentration was associated with more efficient free recall. Concentration-effect relationships were noted in patients later classified as cognitively unimpaired using the Dementia Rating Scale after optimal treatment, rather than in those with residual cognitive impairment.

Effects of nortriptyline on memory self-assessment and performance in recovered elderly depressives.

The effects of nortriptyline (NTL) on memory were compared with those of placebo (PBO), in elderly subjects after recovery from a major depression. Subjective and objective memory was assessed using a repeated-measures discontinuation design. Average immediate, but not delayed, free recall, on a 20-item selective reminding test was adversely affected by medication. Free recall on placebo was stable over four learning trials and at delay. A different pattern of responses occurred on nortriptyline: Performance dropped off significantly on learning Trial 2, remained worse than placebo through Trial 4, but improved after a 15-min delay. Performance on measures of immediate and delayed recognition memory were comparable on nortriptyline and placebo. Discontinuation of nortriptyline resulted in significant improvement on a subset of nine memory self-assessment items. On questions addressing ability to retrieve recently learned information, subjects reported the greatest improvement while on placebo compared with nortriptyline.

A reticulo-frontal disconnection syndrome.

Persistent executive deficit, usually seen following prefrontal damage, is reported in a patient recovering from head trauma. Repeated neuroradidological examinations failed to reveal a lesion within the frontal lobes, but a circumscribed lesion in the ventral mesencephalic tegmentum was found. It is proposed that the observed syndrome was caused by damage to mesencephalic reticular nuclei and their projections into prefrontal cortex. The concept of a "reticulo-frontal disconnection syndrome" is introduced and its possible role in head trauma and schizophrenia discussed.