How helpful are the European AIDS Clinical Society cognitive screening questions in predicting cognitive impairment in an aging, well-treated HIV-positive population?

OBJECTIVES: Diagnosing neurocognitive impairment (NCI) in HIV infection requires time-consuming neuropsychological assessment. Screening tools are needed to identify when neuropsychological referral is indicated. We examined the positive and negative predictive values (PPVs and NPVs, respectively) of the three European AIDS Clinical Society (EACS) screening questions in identifying NCI. METHODS: The Neurocognitive Assessment in the Metabolic and Aging Cohort (NAMACO) study recruited patients aged ≥45 years enrolled in the Swiss HIV Cohort Study between 1 May 2013 and 30 November 2016. NAMACO participants (1) answered EACS screening questions, (2) underwent standardized neuropsychological assessment and (3) completed self-report forms [Center for Epidemiologic Studies Depression Scale (CES-D)] rating mood. NCI categories were defined using Frascati criteria. PPVs and NPVs of the EACS screening questions in identifying NCI categories were calculated. RESULTS: Of 974 NAMACO participants with complete EACS screening question data, 244 (25.1%) expressed cognitive complaints in answer to at least one EACS screening question, of whom 51.3% had NCI (26.1% HIV-associated and 25.2% related to confounding factors). The PPV and NPV of the EACS screening questions in identifying HIV-associated NCI were 0.35 and 0.7, respectively. Restricting analysis to NCI with functional impairment or related to confounding factors, notably depression, the NPV was 0.90. Expressing cognitive complaints for all three EACS screening questions was significantly associated with depression (P < 0.001). CONCLUSIONS: The EACS screening questions had an NPV of 0.7 for excluding patients with HIV-associated NCI as defined by Frascati criteria. The PPV and NPV may improve if NCI diagnoses are based on new criteria.

The Neurocognitive Assessment in the Metabolic and Aging Cohort (NAMACO) study: baseline participant profile.

OBJECTIVES: The aim of the study was to examine baseline neurocognitive impairment (NCI) prevalence and factors associated with NCI among patients enrolled in the Neurocognitive Assessment in the Metabolic and Aging Cohort (NAMACO) study. METHODS: The NAMACO study is an ongoing, prospective, longitudinal, multicentre and multilingual (German, French and Italian) study within the Swiss HIV Cohort Study. Between 1 May 2013 and 30 November 2016, 981 patients ≥ 45 years old were enrolled in the study. All underwent standardized neuropsychological (NP) assessment by neuropsychologists. NCI was diagnosed using Frascati criteria and classified as HIV-associated or as related to other factors. Dichotomized analysis (NCI versus no NCI) and continuous analyses (based on NP test z-score means) were performed. RESULTS: Most patients (942; 96.2%) had viral loads < 50 HIV-1 RNA copies/mL. NCI was identified in 390 patients (39.8%): 263 patients (26.8%) had HIV-associated NCI [249 patients (25.4%) had asymptomatic neurocognitive impairment (ANI)] and 127 patients (13%) had NCI attributable to other factors, mainly psychiatric disorders. There was good correlation between dichotomized and continuous analyses, with NCI associated with older age, non-Caucasian ethnicity, shorter duration of education, unemployment and longer antiretroviral therapy duration. CONCLUSIONS: In this large sample of aging people living with HIV with well-controlled infection in Switzerland, baseline HIV-associated NCI prevalence, as diagnosed after formal NP assessment, was 26.8%, with most cases being ANI. The NAMACO study data will enable longitudinal analyses within this population to examine factors affecting NCI development and course.

The human insulin analog insulin lispro improves insulin binding on circulating monocytes of intensively treated insulin-dependent diabetes mellitus patients.

The rapidly absorbed analog of human insulin, insulin lispro (LP), is characterized by a faster onset of action, a higher peak insulin level, and a shorter duration of action compared with regular insulin (RI). The aim of this study was to investigate whether intensified treatment with either LP or RI influences insulin receptor status. Twelve patients with insulin-dependent diabetes mellitus (IDDM) participating in a multicenter randomized cross-over trial were allocated to this study. Four patients began with LP, whereas eight patients started with RI. Each patient was switched to the other insulin after a 3-month treatment period. Competitive [125I]A-14-insulin binding studies were performed with isolated monocytes. Treatment with insulin lispro increased the total number of insulin binding sites from 9,400 +/- 2,200 (RI) to 20,300 +/- 3,000 (LP)/monocyte (P < 0.001). The insulin concentration required for a 50% competition of [125I]insulin binding (IC50) decreased from 0.6 +/- 0.2 (RI) to 0.1 +/- 0.03 (LP) nmol/L, indicating significantly higher affinity of insulin binding sites during LP treatment (P < 0.001). In additional experiments, the time course of insulin binding was determined after an oral meal. In LP-treated IDDM patients, the affinity and capacity of insulin binding showed a nadir 1 h after insulin injection and a regained binding affinity and capacity 5 h later. These changes observed after LP treatment were comparable to the effect of endogenous insulin secretion in healthy control subjects. In contrast, the IDDM patients who injected RI showed a decreasing insulin binding affinity and capacity, most markedly expressed after 5 h. The corresponding serum levels of insulin were inversely correlated with the affinity and capacity of insulin-binding sites. Pretreatment of cultured human IM-9 lymphoblasts with LP or RI yielded no difference in the down-regulation of insulin binding. In summary, intensified conventional insulin therapy with LP increased the number and affinity of insulin receptors on circulating monocytes to a level similar to that observed in healthy subjects. We conclude that the improved insulin receptor status observed during LP treatment is caused by its more physiological pharmacokinetic profile.

Lapse of consciousness and automatisms in temporal lobe epilepsy: a videotape analysis.

Videotape analysis of 76 attacks in 14 epileptics showed two electro-clinical types of psychomotor attacks. The first and most common type had three clinical phases, consisting of an initial motionless stare, stereotyped movements, and reactive automatisms during impaired consciousness. The second and less common type started with stereotyped and reactive automatisms. In the first type, focal temporal or lateralizing features were common. In the second type, there were only diffuse changes in the electroencephalogram. The value of recording attacks with nasopharyngeal electrodes was emphasized by a high yield for focal-lateralizing electroencephalographic features.

Correlation between the clinical picture, the EEG and cerebral blood flow after partial occlusion of the middle cerebral artery in man.

Quantitative measurements of global and regional cerebral blood flow were performed in 18 patients 1 to 3 days after the onset of symptoms of acute cerebral ischemia due to partial occlusion of the middle cerebral artery and were repeated 21 days thereafter. The first rCBF measurement revealed either an extensive ischemic focus or an ischemic focus with simultaneous reduction of the global blood flow within the corresponding hemisphere in all patients. The later measurements indicated no change in blood flow in the ischemic focus in any case, but there was a slight increase of global cerebral blood flow in 1/3 of the cases. The measurements of cerebral blood flow were correlated with the neurological, psychopathological and EEG findings and in spite of an unaltered cerebral blood circulation, all patients showed a distinct clinical imrovement. Various hypotheses for the return of neurological functions in patients with persistent cerebral ischemia are discussed.

[Blood pressure awareness in Austria: indicators of an increasing information deficit]. / Blutdruckbewusstein in Osterreich: Hinweise auf ein zunehmendes Informationsdefizit.

Attitudes and knowledge of the Austrian population concerning hypertension have been investigated on a regular basis for 15 years (1978-1993). In 1978 a public campaign of information on hypertension was conducted all over Austria. Between 1978 and 1993 four representative population surveys, based on random samples, were performed (1978, 1984, 1990, 1993). The four surveys showed that maximal blood pressure awareness after the campaign was followed by a decrease of awareness between 1984 and 1993. Above all, lack of knowledge of personal blood pressure increased markedly over the observation period. The determinant "don't know my blood pressure" was self reported by 10% in 1978, 7% in 1984, rising to 17% and 18% in 1990 and 1993, respectively. This increase was significant in females and males younger than 50 years. Nearly no differences were found in self-reported high blood pressure and antihypertensive drug intake between 1978 and 1993 (1978, 1984, 1990: 14%, 1993: 12% with respect to the former; 1978: 10%, 1990: 11%, 1993: 8% with respect to the latter). In 1993 significantly less people than in 1978 reported that their blood pressure had been measured within the past three months (1978: 49%; 1993: 34%). People estimated overweight, alcohol, mental stress, and cigarette smoking as the most important risk factors for hypertension (89%, 89%, 88%, 83%, respectively). The importance of these risk factors in the eyes of the questioned population increased between 1978 and 1993, significantly in the case of cigarette smoking. Primarily a lack of information was found in knowledge of personal values, whereas knowledge of risk factors for hypertension was considerably higher. The results of the four surveys lead to the conclusion that the population should be informed about the health hazards of high blood pressure more intensively and people should be motivated to take an interest in their blood pressure.

Alternative nicotine delivery systems (ANDS)--public health-aspects.

This paper deals with a relatively new category of pharmaceuticals, namely alternative nicotine delivery systems (ANDS). We do not refer to products like smokeless tobacco or other smoking devices. ANDS are designed to provide nicotine without the harmful substances contained in cigarette smoke. Several different nicotine replacement preparations exist, which are used in nicotine replacement therapy to obtain tobacco abstinence. There is a bulk of scientific literature on the clinical use of ANDS, but very little has been published on the public health aspects of the same. Nicotine dependence is associated with heavy consumption, tolerance, regulation of intake and withdrawal. We described a new symptom of extreme nicotine dependence, namely the nocturnal sleep disturbing nicotine craving (NSDNC), and developed a concept of a nicotine pre-abstinence syndrome (NPAS). Five nicotine replacement preparations are currently available: gum, patch, nasal spray, oral inhaler and sublingual tablet. As far as safety issues are concerned, scientific evidence shows that the use of ANDS involves almost no risk for consumers and patients, especially when compared with the consumption of tobacco products. New concepts developed by our group are the following: definition of possible endpoints of smoking control measures, reduced smoking, nicotine dependence and preventive oncology, chemoprevention of lung cancer by ANDS, public health impact by OTC availability of ANDS and the "let them choose approach" of ANDS focusing on the specific preferences and needs of the individual client. One may also speculate whether ANDS will, at some stage, replace cigarettes as the major source of nicotine for people who need this psychoactive drug.

[European Medical Association Smoking or Health (EMASH)--consensus on smoking cessation: guidelines for physicians]. / European Medical Association Smoking or Health (EMASH)--Konsensuspapier Rauchertherapie: Richtlinien für Arzte.

The present study summarizes the latest scientific findings on smoking cessation and the various therapeutic possibilities. The guidelines presented here were compiled by the experts of EMASH (European Medical Association Smoking or Health). Accurate diagnosis and adequate treatment of nicotine dependence is essential for achieving sustained abstinence. Diagnostic procedures including the Fagerström Test for Nicotine Dependence (FTND) and various modes of nicotine replacement therapy (chewing gum, plaster, nasal spray and inhaler) are described. New symptoms of nicotine dependence (nocturnal sleep disturbing nicotine craving, nicotine pre-abstinence syndrome), that permit a more precise diagnosis, are discussed.

Measurement of expired carbon monoxide among medical students to assess smoking behaviour.

CO-Measurement of medical students was taken during a compulsory public health training at the University of Vienna. The students were not informed previously, so a non-response bias was excluded. Measurements were done with Bedfont EC50-MICRO Carbon monoxide monitor. The cut off point was set at 11 ppM. One hundred and seventy-three students were measured. Define indication of active smoking was found in 9%. With exception of one student all the others with carbon monoxide over 10 ppM called themselves active smokers. CO measurement will replace at some stage the usual question regarding the number of cigarettes consumed. Students also had the opportunity to learn a new diagnostic technique.

[Diagnosis and therapy of nicotine dependence]. / Diagnostik und Therapie der Nikotinabhängigkeit.

The 1988 Report of the US-Surgeon General states very clearly, that the use of tobacco products is not a matter of free choice, but is the result of an addiction as scientifically valid as the addiction to heroin and other narcotics. Using the Fagerström Test for Nicotine Dependence (FTND) to assess nicotine dependence in a population 6,000 randomly selected Austrians were interviewed. 42% of men and 27% of women were found to be smokers. 3 groups of smokers differing in dependence can be described: 36.5% are nicotine addicted; 30.2% must be psychosocial dependent because they show nearly no sign of nicotine dependence; and there is a group between. The scientific literature provides informations on many methods and techniques for a smoking cessation, both pharmacological approaches have been tried to treat nicotine dependence in man. According to scientific standards and many controlled studies, nicotine has been the only drug found to be effective in treating nicotine dependence. Many techniques, ranging from self help to sophisticated combined therapeutic approaches including pharmacological interventions, are now available to deal with the nicotine addiction.

[Reduced smoking--a possible strategy for control of tobacco-associated illnesses?]. / Reduziertes Rauchen--eine mögliche Strategie zur Kontrolle tabakassoziierter Gesundheitsstörungen?

The aim of the publication is to discuss reduced smoking as a concept to control tobacco-related diseases. New scientific studies show that nicotine-replacement medications may be an untapped source in efforts to reduce smoking. This new indication for nicotine-replacement therapy was licensed for the first time in Denmark by the registration authority. Austrian data have shown that approximately 10 years after implementation, a 1% reduction in smoking could prevent 14 male cancers deaths each year. A 50% reduction could save 700 male lives. 100,000 lives (male and females) could be saved in the European Union annually by a reduction like this including other tobacco-related diseases. Even a 1% reduction would save 1,000 lives. These data are supplemented by the new hypothesis of longer induction time (of lung cancer): Even if this theory fails for the individual smoker, a remarkable gain in years of life will result for society if illness is a probability-based event. A new term of delayed and/or reduced incidence will be a result of this hypothesis. Nevertheless, primary abstinence will remain the most desirable goal in efforts to control tobacco-related diseases. However, most primary prevention campaigns failed, and it will take 30-40 years to translate primary prevention into major health benefits. Reduced smoking should be licensed as a valid method for those unwilling or unable to stop smoking.