Teleneuropsychology: evidence for video teleconference-based neuropsychological assessment.

The use of videoconference technology to deliver health care diagnostics and treatment continues to grow at a rapid pace. Telepsychiatry and telepsychology applications are well-accepted by patients and providers, and both diagnostic and treatment outcomes have generally been similar to traditional face-to-face interactions. Preliminary applications of videoconference-based neuropsychological assessment (teleneuropsychology) have yielded promising results in the feasibility and reliability of several standard tests, although large-scale studies are lacking. This investigation was conducted to determine the reliability of video teleconference (VTC) - based neuropsychological assessment using a brief battery of standard neuropsychological tests commonly used in the evaluation of known or suspected dementia. Tests included the Mini-Mental State Examination (MMSE), Hopkins Verbal Learning Test-Revised, Digit Span forward and backward, short form Boston Naming Test, Letter and Category Fluency, and Clock Drawing. Tests were administered via VTC and in-person to subjects, counterbalanced using alternate test forms and standard instructions. Two hundred two adult subjects were tested in both rural and urban settings, including 83 with cognitive impairment and 119 healthy controls. We found highly similar results across VTC and in-person conditions, with significant intraclass correlations (mean=.74; range: 0.55-0.91) between test scores. Findings remained consistent in subjects with or without cognitive impairment and in persons with MMSE scores as low as 15. VTC-based neuropsychological testing is a valid and reliable alternative to traditional face-to-face assessment using selected measures. More VTC-based studies using additional tests in different populations are needed to fully explore the utility of this new testing medium.

George Riddoch: the man who found Ludwig Guttmann.

STUDY DESIGN: This is a review article. OBJECTIVES: To evaluate the role played by George Riddoch in the setting up of spinal units in the UK and the appointment of Ludwig Guttmann. SETTING: Wendover, UK. METHODS: Review of the literature and the public records. RESULTS: Not applicable. CONCLUSIONS: George Riddoch's contribution to our understanding of the treatment for spinal injuries by means of his research on the patho-physiology, treatment and the setting up of spinal injury units in World Wars I and II was outstanding, especially his role in finding, appointing and supervising Ludwig Guttmann at the National Spinal Injuries Centre.

The contribution to our understanding of spinal disorders by the great Windmill Street School of Anatomy.

STUDY DESIGN: This is a review article. OBJECTIVES: The aim of this study is to investigate the contribution of the private school of anatomy, the Great Windmill Street School, in our understanding of the physiology, anatomy and pathology of the spine and spinal cord and its role in the treatment of spinal diseases in the eighteenth century. Much has been written about the Hunter brothers and Sir Charles Bell and their contribution to anatomy and medical teaching but the significant role of the Great Windmill Street School of Anatomy in our understanding of the spinal cord and the treatment of spinal disorders had not been previously explored. SETTING: Wendover, UK. METHODS: Review of the literature. RESULTS: Not applicable. CONCLUSION: The Great Windmill Street School of Anatomy was unique and fundamental in our understanding of the spine and the spinal cord and the treatment of spinal diseases. What is remarkable is that this work emanated from a private school and not a hospital or a university and it allowed an outstanding school of surgeons and physicians to carry out their work unfettered.

Spinal institutions in post-Revolutionary France.

STUDY DESIGN: Literature review. SETTING: Europe with special reference to France. OBJECTIVES: To describe the first known orthopaedic rehabilitation units founded in France in the first half of the nineteenth century for the treatment of spinal curvature and deformity and analyse their impact on the future provision of rehabilitation treatment in Europe. CONCLUSION: Despite the pioneering work of a few French orthopaedic surgeons and doctors, no long-lasting legacy remains from the establishment of innovative and holistic institutes for the treatment of spinal curvature and deformity as early as the 1830 s.

Paralysis as a result of traction for the treatment of scoliosis: a forgotten lesson from history.

STUDY DESIGN: Literature review. SETTING: Europe with special reference to France. OBJECTIVES: To review the treatment of spinal deformity in nineteenth century Europe and explain the high incidence of paralysis as a result of forceful traction of the spinal column to treat scoliosis in France as compared with other European countries. CONCLUSION: Although well described in the nineteenth century French medical literature, the dangers of forceful traction on the spinal column to correct spinal deformity were not recognized in Europe or the USA until the halofemoral traction method of treatment was used in the 1970s.

Urtication (flogging with stinging nettles) and flagellation (beating with rods) in the treatment of paralysis.

Urtication and flagellation were used as a last resort in the treatment of paralysis when all other means were exhausted, and very few cases are reported in the literature. Two cases were identified and reviewed, one of urtication (flogging with nettles) and one of flagellation (beating with rods). In both cases the symptoms were alleviated, but there was insufficient detail to evaluate the therapeutic value of each treatment.

Edward Harrison and the treatment of spinal deformities in the nineteenth century.

At the beginning of the nineteenth century, doctors and lay practitioners became interested in the treatment of spinal deformity, but it took two centuries for the specialty to become established. The provision of care was fragmented, and treatment was in the hands of physicians, surgeons, mechanics, masseurs and bonesetters. In 1837, Dr Edward Harrison founded the first infirmary for spinal diseases in London with only six beds. Harrison was a forceful character who had trained in Scotland. He held no voluntary hospital appointment and faced great opposition from the London Royal Colleges and the orthodox establishment, including Sir Charles Bell and John Shaw. This paper describes Harrison's treatment of patients afflicted by spinal deformity and analyses the medical environment of the time as well as Harrison's legacy.

George Riddoch (1888-1947): the driving force behind the treatment of spinal injuries in the UK during the Second World War.

The development of the successful treatment of spinal injuries has been inextricably linked to Sir Ludwig Guttmann and Stoke Mandeville Hospital. The role of George Riddoch has largely been ignored or mentioned merely in relation to Ludwig Guttmann and his appointment as the first Resident Medical Officer at Stoke Mandeville Hospital. Riddoch's contribution was far more significant. New material, comprising Riddoch's letters and memoranda written between 1939 and 1944, reveals his paramount involvement in the setting up of spinal injury units across the UK between 1941 and 1944, and his skill as an administrator and a clinician. Riddoch must be given credit for finding and appointing Ludwig Guttmann.

St Hugh's Military Hospital (Head Injuries), Oxford 1940-1945.

Despite being open for only five years, St Hugh's Military Hospital (Head Injuries) has a seminal place in the history of neurology, neurosurgery and rehabilitation medicine. At its peak, during the Normandy campaign of 1944, it provided 430 beds for the treatment of service personnel. Between 1940 and 1945, 13,000 patients were referred to St Hugh's providing a unique opportunity for ground-breaking research into the management of head injuries. The doctors at St Hugh's collaborated with research scientists at Oxford University in many areas of fundamental research including the treatment of infection, the mechanics of brain injury, brain surgery, neuropsychiatry and rehabilitation, and the use of electroencephalograms. This paper documents these scientific advances and considers their influence on the practice of neurology and neurosurgery in the UK.

Mary Riddoch (1901-1966), an extraordinary tale of survival.

In 1934 Mary Riddoch sustained a traumatic spinal injury as a result of a road traffic accident. Although a few surviving servicemen from the First World War have been recorded, this is the first account of a female paraplegic patient surviving a traumatic spinal injury. Her personal circumstances greatly contributed to her long survival: she was a qualified doctor, she was the sister of George Riddoch the neurologist who treated soldiers who had sustained spinal cord injuries during the First World War, and she was fortunate to have benefited from the dedicated care of nurse Dorothy Fiddes. Her great-nephew, Graeme Riddoch, is one of the authors of this paper and his recollections provide a unique perspective to this case report.

The privilege study.

We evaluated the impact of the Texas limited privilege statute, enacted in 1979, through a questionnaire study of 121 lay persons, 79 patients receiving psychiatric outpatient treatment, and 84 psychiatrists. An almost equal percentage of lay persons and patients knew or guessed correctly that the statute existed (26% v 27%), but only 45% of the psychiatrists knew or guessed correctly that it had been enacted. Lay persons indicated that they might disclose more to a psychiatrist or psychologist if they had statutory protection, but only a few of the patients said they would have sought treatment earlier or would have disclosed more had they known of a privilege statute. Patients reported that they relied more heavily on their psychiatrists' ethics than on the statute to protect their privacy.

Cortisol secretion and Alzheimer's disease progression: a preliminary report.

We report preliminary findings in a study of the relationship of plasma cortisol concentration (CORT) to the clinical progression of Alzheimer's disease (AD), testing the hypotheses that CORT predicts AD progression and that CORT increases as the disease advances. In 12 subjects with NINCDS/ADRDA probable AD, we performed cognitive testing and plasma cortisol determinations at baseline and again in 12 months. A modified Alzheimer's Disease Assessment Scale-Cognitive (ADAS-COG) measured disease progression. Plasma cortisol concentration CORT was determined at 12 AM and 1 PM, and an Afternoon Cortisol Test (ACT) was used to estimate average 24-hr CORT. Baseline 12 AM CORT correlated with the change in ADAS-COG from start of study to 12 months. No cortisol measure increased over the study period; estimated average 24-hr CORT and 12 AM CORT remained constant, whereas while 1 PM CORT declined. There was no relationship between age or duration of illness and any of the cortisol measures at baseline.

Cortisol secretion and Alzheimer's disease progression.

BACKGROUND: Mild hypercortisolemia is a frequent concomitant of Alzheimer's disease (AD). In an effort to ascertain the relationship between serum cortisol concentration (CORT) and disease progression, aging, and survival, we followed 9 persons with AD, ages from 56 to 84 years, from an original cohort of 19 enrollees with serial cognitive testing and CORT determinations. METHODS: The cognitive instrument was a modification of the Alzheimer's Disease Assessment Scale-Cognitive (mADAS-COG). Serum cortisol determinations were performed at noon, and an Afternoon Cortisol Test (ACT) was used to obtain an estimate of average CORT. RESULTS: Baseline 12:00 hours CORT but not ACT correlated significantly with the change in mADAS-COG (r = .90, p < .01). ACT levels increased as the mADAS-COG increased over time (p = .037), by 0.156 +/- 0.06 microgram/dL for each one-point increase (indicating greater impairment) in cognitive test score. ACT levels did not increase significantly simply with aging. For the entire cohort of 19 subjects, neither baseline ACT nor 12:00 hours CORT was significantly related to survival. CONCLUSIONS: Hypercortisolemia in AD appears related to the clinical progression of the disease, but not to aging or length of survival.

Apolipoprotein E epsilon 4, other risk factors, and course of Alzheimer's disease.

BACKGROUND: The epsilon 4 allele of apolipoprotein E (apoE epsilon 4) is associated with late-onset Alzheimer's disease (AD), but its relationship to various aspects of AD has become increasingly unclear. We studied the relationship of apoE genotype in AD to educational attainment, history of heart disease or head injury, age of onset, gender, severity of illness, depression, psychotic symptoms, rate of dementia progression, and time from initial evaluation to nursing home placement. METHODS: ApoE epsilon 4 genotype was determined for 97 clinically diagnosed AD patients and 61 neuropathologically confirmed cases of AD. RESULTS: Presence of one or more epsilon 4 alleles occurred in 66% of AD cases as compared with 27% in control subjects (allele frequency was .40 for AD, .15 for control subjects). Among AD subjects there was no significant relationship between epsilon 4 alleles and educational attainment, history of heart disease, head injury, age of onset, severity of illness, depression, history of depression, rate of dementia progression, or time to nursing home placement. Marginal correlations emerged between number of epsilon 4 alleles, and delusions (p = .05) and hallucinations (p = .05). There was a trend toward increased epsilon 4 homozygosity in patients with onset between ages 65 and 70 years. CONCLUSIONS: We did not find that individuals with one or two apoE epsilon 4 alleles differed significantly in clinical course of AD from those without epsilon 4 except for a trend toward increased psychotic symptoms in the group as a whole and an increase in epsilon 4 homozygosity in patients with reported symptom onset in the late 60s.

Anorexia nervosa and depression: a dissenting view.

The frequency of depressive symptoms in anorexic patients, the response of some anorexic patients to antidepressants or ECT, the occurrence of comparable physiologic abnormalities in major depression and anorexia nervosa, and family studies of incidence increasingly link depression and anorexia in the literature. A review of the problems in making this linkage shows that the possibility of anorexia nervosa as a depressive equivalent or a depressive spectrum disorder must be seriously questioned.

Prevalence and incidence of major depression in Alzheimer's disease.

OBJECTIVE: This study examined the prevalence and incidence of major depressive disorder in Alzheimer's disease. METHOD: The authors retrospectively reviewed two large Alzheimer's disease databases, one at the University of Texas Southwestern Medical Center in Dallas and the other at the Consortium to Establish a Registry for Alzheimer's Disease (CERAD). The Dallas series contained 264 cases of Alzheimer's disease, of which 153 patients were followed up for an average of 3 years from initial evaluation. The CERAD database contained 1,095 cases and excluded patients with histories of depression at initial evaluation; 325 of these patients were followed up for at least 2 years. Alzheimer's disease was diagnosed according to the criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association; major depression was diagnosed according to the DSM-III-R criteria. Most of the patients in these series were dwelling in the community and had had Alzheimer's disease symptoms for approximately 4 years at the time of evaluation. RESULTS: In the Dallas series there was a 1.5% prevalence and a 0% incidence of major depression. In the CERAD series there was a 1.3% 2-year incidence of major depression. CONCLUSIONS: The low prevalence and incidence of DSM-III-R major depression in these patients suggest that for the period of time the patients were followed up, Alzheimer's disease did not predispose to major depression. However, major depression may herald the subsequent onset of dementia. Depression in dementia should perhaps be diagnosed by different criteria.

Influence of age and relative weight on cortisol suppression in normal subjects.

The authors examined the effects of certain nonpsychiatric variables on dexamethasone suppression test (DST) results. Sixty physically healthy, nondepressed, nondemented adults participated in a standard outpatient 1-mg DST. Postdexamethasone plasma cortisol concentrations were higher in older subjects and were lower in more obese subjects. The authors conclude that age and relative weight influence cortisol suppression in healthy subjects.

Alzheimer's disease and its Lewy body variant: a clinical analysis of postmortem verified cases.

OBJECTIVE: The authors compared clinical findings of Alzheimer's disease and the so-called Lewy body variant of Alzheimer's disease. METHOD: Available data were analyzed on the clinical features of 58 patients with Alzheimer's disease and 24 patients with the Lewy body variant of Alzheimer's disease who underwent postmortem examination. RESULTS: The proportion of men was significantly larger in the Lewy body variant group than in the Alzheimer's disease group (66.7% versus 34.5%), and, concordantly, the Lewy body variant group was slightly taller. The prevalence of hallucinations and delusions was significantly higher in Lewy body variant subjects than the Alzheimer's disease subjects, but there were no significant differences between the two groups in educational attainment, family history of dementia, age at onset, duration of illness, cognitive impairment, overall severity of illness, or neuropsychological findings. Patients with the Lewy body variant of Alzheimer's disease tended to experience more frequent extrapyramidal side effects of neuroleptics than did the patients with Alzheimer's disease, but for patients in the two groups who were not exposed to neuroleptics, there was little difference in frequency of extrapyramidal side effects. CSF concentration of homovanillic acid (HVA) was significantly lower in the Lewy body variant patients, even when correction was made for height. CONCLUSIONS: The Lewy body variant of Alzheimer's disease may be suspected in elderly male dementia patients who otherwise meet criteria for Alzheimer's disease but who manifest significant psychiatric symptoms and neuroleptic-induced extrapy-ramidal side effects and have low levels of CSF HVA.

The Behavior Rating Scale for Dementia of the Consortium to Establish a Registry for Alzheimer's Disease. The Behavioral Pathology Committee of the Consortium to Establish a Registry for Alzheimer's Disease.

OBJECTIVE: The purpose of the study was to develop a standardized instrument, the Behavior Rating Scale for Dementia, for rating psychopathology in patients with probable Alzheimer's disease and to conduct a multicenter pilot study of this instrument. METHOD: The rating scale was developed collaboratively on the basis of clinical experience and existing instruments. Items were scaled according to frequency of psychopathology and were administered to an informant who was familiar with the subject. The scale was administered in a standardized manner by trained examiners who had met predetermined certification standards. The study group consisted of 303 subjects with probable Alzheimer's disease who had undergone standardized clinical evaluations by the Consortium to Establish a Registry for Alzheimer's Disease. RESULTS: Subjects had an average of 15 problems rated as present in the preceding month. Wide variability in the nature of disturbances was found, with a number of items rated as present since the illness began but not in the past month. Interrater agreement was high. Factor analysis suggested eight preliminary factors that mapped onto clinically relevant domains: depressive features, psychotic features, defective self-regulation, irritability/agitation, vegetative features, apathy, aggression, and affective lability. CONCLUSIONS: The Behavior Rating Scale for Dementia provides a standardized, reliable measure that can be administered to caregivers of demented subjects. On the basis of the present study, the scale has been revised slightly. After additional studies in progress, the Behavior Rating Scale for Dementia will be available for general use in assessing a wide range of psychopathology in dementia.

Altered amyloid protein processing in platelets of patients with Alzheimer disease.

BACKGROUND: beta-Amyloid peptide, the core component of neuritic plaques in brain areas in patients with Alzheimer disease (AD), is 1 cleavage product of the beta-amyloid precursor protein (APP) in neurons and platelets. Alternate cleavage products of intact 140- to 150-kd APPs in platelets include nonamyloidogenic 120- to 130-kd and 110-kd isoforms. The possible differential significance of these 2 isoforms, structurally similar to protease nexin II, is unknown. OBJECTIVE: To determine whether the ratio of the 120- to 130-kd APP isoform to the 110-kd APP isoform as processed in platelets correlates with the presence of AD and/or the apolipoprotein E4 (ApoE4) allele, which is a major risk factor for AD. SETTING: The Alzheimer Disease Center at The University of Texas Southwestern Medical Center at Dallas. METHODS: The APP isoforms were quantitated with the use of 2 different Western blot detection methods in platelets from 15 patients with AD and 19 control subjects in whom genotyping of apolipoprotein E was performed. RESULTS: The mean ratio of the 120- to 130-kd APP isoform to the 110-kd APP isoform in the patients with AD was significantly lower than that of the control subjects (5.98 vs 7.64; P = .03 [method 1] and 5.98 vs 7.92; P = .01 [method 2]) after adjusting for age and the increased incidence of ApoE4 in patients with AD. The lower APP ratios were also associated with increased age and with the presence of an ApoE4 allele. CONCLUSIONS: The APP processing in platelets of patients with AD is different from that of control subjects. This difference, largely caused by factors other than the ApoE4 genotype, may reflect chronic platelet activation in patients with AD. The use of these data to estimate "AD risk," by using the APP isoform ratio, indicates an odds ratio of 1.75, suggesting possible utility as an adjunct in the diagnosis of AD. Moreover, these findings may relate to analogous alterations in APP processing that may occur in brain areas affected by AD.