Stroke location, characterization, severity, and outcome in mitral vs aortic valve endocarditis.

OBJECTIVE: To characterize the incidence and clinical features of patients with infective endocarditis (IE) and stroke. METHODS: The authors reviewed the records of 707 patients diagnosed with definite or possible IE between January 1984 and November 1999. Stroke was confirmed by application of strict definitions and classified by type, pathophysiology, vascular territory, and severity. The authors determined mortality rates for the initial hospitalization and 12 months after admission. RESULTS: Strokes occurred in 68 (9.6%) of 707 patients with IE, 38 (17%) of 218 patients with mitral valve endocarditis (MVE), 14 (9%) of 149 patients with aortic valve endocarditis (AVE), and 16 (5%) of 340 patients with other forms of IE (OR for MVE vs AVE = 2.0, 95% CI 1.1 to 3.9). Among the patients with MVE or AVE and stroke, there were no significant relationships between site of vegetation and length of hospitalization, stroke severity, mortality during the initial hospitalization, or 12-month mortality. Fifty-two percent of patients with stroke and IE died within 1 year of admission. CONCLUSIONS: The overall incidence of stroke in patients with IE (9.6%) is lower than previous reports (21 to 39%). Patients with MVE had a greater risk of stroke than patients with AVE. Fifty-two percent of patients died within 1 year of admission for IE.

Dose-response relations of azimilide in the management of symptomatic, recurrent, atrial fibrillation.

We evaluated the efficacy and safety of azimilide, a new class III antiarrhythmic agent that blocks both the slow and fast components of the cardiac-delayed rectifier potassium currents in 4 randomized, double-blind, placebo-controlled trials with similar protocols. The purpose of this study was to assess the relation between dose and effect. A total of 1,380 patients with a documented history of symptomatic atrial fibrillation (AF), atrial flutter, or both, were enrolled. After a 3-day loading period during which the assigned dose was given twice a day, subjects received placebo or azimilide (35, 50, 75, 100, or 125 mg once a day) for the duration of the study period. The primary end point of the studies was the time to symptomatic arrhythmia recurrence with a transtelephonic electrocardiogram typical of AF, atrial flutter, or paroxysmal supraventricular tachycardia. For each study, Kaplan-Meier estimates of the median time to recurrence were computed for placebo and for each azimilide dose. Cox proportional-hazards modeling was used to estimate hazard ratios for each active dose. Each of the 2 highest azimilide doses (100 and 125 mg/day) significantly prolonged the time to recurrence of arrhythmia. For the 100 mg/day dose, the hazard ratio was 1.34, 95% confidence interval 1.05 to 1.72; p = 0.02. For the 125 mg/day dose, the hazard ratio was 1.32, 95% confidence interval 1.07 to 1.62; p = 0.01. Patients with a history of either ischemic heart disease or congestive heart failure had a significantly greater treatment effect from azimilide than those without it. Torsades de Pointes occurred in 0.9% of patients receiving either of the 2 effective doses. Thus, doses of azimilide <100 mg/day are not effective for control of AF, whereas doses of 100 and 125 mg/day are effective with an acceptable risk of serious toxicity.

The effects of intravenous doxycycline therapy for rheumatoid arthritis: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To determine the feasibility, safety, and potential clinical efficacy of intravenous (IV) doxycycline therapy for rheumatoid arthritis (RA), as well as its possible effects on serum and urinary markers of collagen breakdown. METHODS: The exploratory trial was designed as a 16-week, single-center, randomized, double-blind, placebo-controlled trial. Eligible subjects with active seropositive or erosive RA were randomly allocated into 3 treatment groups: doxycycline 200 mg IV, azithromycin 250 mg orally, or placebo. The blinded IV study drug was administered once daily for the first 3 weeks by home self-infusion and then weekly for the next 8 weeks, concurrent with the blinded oral study drug at the prescribed doses. The primary end points were the change between baseline and week 4 in the tender joint count, erythrocyte sedimentation rate, and urinary excretion of pyridinoline. RESULTS: The trial was stopped prematurely after enrollment of 31 patients. Three subjects were withdrawn because of worsening arthritis, and 1 patient was withdrawn when newly diagnosed with breast cancer. Infusion-related events occurred in 13 (42%) of 31 patients, but none were serious. There were 4 serious adverse events unrelated to the study drug, including a new diagnosis of breast cancer in 3 cases and hospitalization for abdominal pain in 1 case. No significant differences were observed across treatment groups in any of the 3 primary clinical end points. CONCLUSION: Although IV doxycycline therapy was generally well-tolerated by patients in this trial, it did not show any evidence of reducing disease activity or collagen crosslink production.

Reducing medication regimen complexity: a controlled trial.

OBJECTIVE: To determine if a visual intervention (medication grid) delivered to physicians can reduce medication regimen complexity. DESIGN: Nonrandomized, controlled trial. SETTING: Veterans Affairs medical center. PATIENTS/PARTICIPANTS: Eight hundred thirty-six patients taking at least 5 medications at the time of admission and the 48 teams of physicians and students on the general medicine inpatient service. INTERVENTION: For intervention patients, a medication grid was created that displayed all of the patients' medicines and the times of administration for 1 week. This grid was delivered to the admitting resident soon after admission. MEASUREMENTS AND MAIN RESULTS: For the patients of each team of physicians, we calculated the change in the average number of medications and doses from admission to discharge. The number of medications in the intervention group decreased by 0.92 per patient, and increased by 1.65 in the control group (P <.001). The mean number of doses per day in the intervention group decreased by 2.47 per patient and increased by 3.83 in the control group (P <.001). CONCLUSIONS: This simple intervention had a significant impact on medication regimen complexity in this population. Apparently, physicians were able to address polypharmacy when the issue was brought to their attention.

Antiarrhythmic effects of azimilide in atrial fibrillation: efficacy and dose-response. Azimilide Supraventricular Arrhythmia Program 3 (SVA-3) Investigators.

OBJECTIVES: The purpose of this study was to assess the effectiveness of azimilide, a class III antiarrhythmic drug, in reducing the frequency of symptomatic arrhythmia recurrences in patients with atrial fibrillation, atrial flutter or both. BACKGROUND: Atrial fibrillation is an increasingly common disorder of the heart rhythm, and most patients with this problem are identified because they have symptoms associated with their arrhythmia. New antiarrhythmic therapies are needed to treat patients with this problem. METHODS: A total of 384 patients with a history of atrial fibrillation, atrial flutter or both were randomly assigned to receive once daily doses of placebo or azimilide; recurrent symptomatic arrhythmias were documented using transtelephonic electrocardiogram (ECG) recording. Azimilide 50 mg, 100 mg or 125 mg was tested; the primary efficacy analysis compared the time to first symptomatic recurrence in the combined azimilide 100 mg and 125 mg dose groups with that in the placebo group using the log-rank test. RESULTS: In the primary efficacy analysis, the time to first symptomatic arrhythmia recurrence was significantly prolonged in the combined azimilide 100 mg and 125 mg daily dose group compared with the placebo group (chi-square 7.96, p = 0.005); the hazard ratio (placebo: azimilide) for this comparison was 1.58 (95% confidence interval [CI] = 1.15, 2.16). In comparisons between individual doses and placebo, the hazard ratio for the 50 mg daily dose was 1.17 (95% CI = 0.83, 1.66; p = 0.37); for the 100 mg group, dose was 1.38 (95% CI = 0.96, 1.98; p = 0.08), and for the 125 mg group, dose was 1.83 (95% CI = 1.24, 2.70; p = 0.002). CONCLUSIONS: Azimilide significantly lengthened the symptomatic arrhythmia-free interval in patients with a history of atrial fibrillation, atrial flutter or both.

Observations on the transition from intermittent to permanent atrial fibrillation.

BACKGROUND: Quantitative data on the frequency with which transition from intermittent to permanent atrial fibrillation occurs are lacking. We conducted this study to determine the proportion of patients with intermittent atrial fibrillation who progress to permanent atrial fibrillation and to investigate baseline clinical characteristics that might predict such a progression. METHODS: This retrospective cohort study included 231 patients who were seen with intermittent atrial fibrillation at a university hospital-based clinic from January 1978 through December 1997. Patients' medical records and electrocardiograms were reviewed and data were collected for all clinic visits through May 1998. The proportion of patients who remained free of transition from intermittent to permanent atrial fibrillation was calculated by the Kaplan-Meier method. A Cox proportional hazards model was used to determine the effect of some baseline characteristics on this transition. RESULTS: The number of patients who remained free of transition from intermittent to permanent atrial fibrillation was 92% (95% confidence interval 88%-96%) at 1 year and 82% (95% confidence interval 75%-88%) at 4 years. Among 5 baseline characteristics (age, sex, structural heart disease, atrial fibrillation at presentation, and use of an antiarrhythmic medicine before presentation), the 2 significant predictors of progression from intermittent to permanent atrial fibrillation were age (P =.0003) and being in atrial fibrillation at presentation (P =.0006). The hazard ratio associated with 10 years of advancing age was 1.82 (95% confidence interval 1.31-2.51), and the hazard ratio associated with atrial fibrillation at presentation was 3.56 (95% confidence interval 1.73-7.34). CONCLUSIONS: Approximately 18% of patients who had intermittent atrial fibrillation were permanently in atrial fibrillation after 4 years of follow-up. Age and being in atrial fibrillation at presentation were the only 2 important clinical variables identified in predicting such a progression.

Effect of highly active antiretroviral therapy and thymic transplantation on immunoreconstitution in HIV infection.

The purpose of this study was to determine whether thymic transplantation in addition to highly active antiretroviral therapy (HAART) will restore T cell function in HIV infection. Eight treatment-naive HIV-infected patients with CD4+ T cell counts of 200-500/mm3 were randomized into thymic transplantation and control arms. All patients received HAART (zidovudine, lamivudine, and ritonavir) for 6 weeks prior to transplantation. Thymic transplantation was done without immunosuppression, using postnatal HLA-unmatched cultured allogeneic thymus tissue. Patients were immunized every 6 months with the neoantigen keyhole limpet hemocyanin (KLH) and the recall antigen tetanus toxoid (TT). T cell phenotype and function and T cell receptor rearrangement excision circles (TRECs) were assessed. Thymic allografts were biopsied at 2 months. Six HIV-infected patients completed the study. Four patients received cultured allogeneic postnatal thymic grafts, two others were controls. CD4+ T cell counts increased and T cell-proliferative responses to Candida antigen and TT normalized in all patients. Proliferative responses to KLH developed in three of four transplant recipients and one of two controls. Patients responding to KLH after secondary immunization had greater TREC increases compared with the patients who did not respond. All thymic allografts were rejected within 2 months. In summary, four of six patients developed T cell-proliferative responses to the neoantigen KLH over the first 2 years of HAART. The transplanted thymus tissue, however, was rejected. There was no clear difference in restoration of T cell function in the transplant recipients compared with the controls. Increases in TRECs after initiation of HAART may correlate with improved immune function.

The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.

OBJECTIVE: To determine mortality, morbidity, and costs attributable to surgical-site infections (SSIs) in the 1990s. DESIGN: A matched follow-up study of a cohort of patients with SSI, matched one-to-one with patients without SSI. SETTING: A 415-bed community hospital. STUDY POPULATION: 255 pairs of patients with and without SSI were matched on age, procedure, National Nosocomial Infection Surveillance System risk index, date of surgery, and surgeon. OUTCOME MEASURES: Mortality, excess length of hospitalization, and extra direct costs attributable to SSI; relative risk for intensive care unit (ICU) admission and for readmission to the hospital. RESULTS: Of the 255 pairs, 20 infected patients (7.8%) and 9 uninfected patients (3.5%) died during the postoperative hospitalization (relative risk [RR], 2.2; 95% confidence interval [CI95], 1.1-4.5). Seventy-four infected patients (29%) and 46 uninfected patients (18%) required ICU admission (RR, 1.6; CI95, 1.3-2.0). The median length of hospitalization was 11 days for infected patients and 6 days for uninfected patients. The extra hospital stay attributable to SSI was 6.5 days (CI95, 5-8 days). The median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected patients. The excess direct costs attributable to SSI were $3,089 (CI95, $2,139-$4,163). Among the 229 pairs who survived the initial hospitalization, 94 infected patients (41%) and 17 uninfected patients (7%) required readmission to the hospital within 30 days of discharge (RR, 5.5; CI95, 4.0-7.7). When the second hospitalization was included, the total excess hospitalization and direct costs attributable to SSI were 12 days and $5,038, respectively. CONCLUSIONS: In the 1990s, patients who develop SSI have longer and costlier hospitalizations than patients who do not develop such infections. They are twice as likely to die, 60% more likely to spend time in an ICU, and more than five times more likely to be readmitted to the hospital. Programs that reduce the incidence of SSI can substantially decrease morbidity and mortality and reduce the economic burden for patients and hospitals.

Effect of dofetilide on survival in patients with supraventricular arrhythmias.

OBJECTIVES: This study compared survival between patients taking dofetilide and patients taking placebo in a pooled analysis of randomized clinical trials of patients with supraventricular arrhythmias. BACKGROUND: Clinical trials of antiarrhythmic drugs used to treat supraventricular arrhythmias rarely include enough patients to assess whether the drug being tested has an effect on survival. Pooling data from many trials provides useful information on safety. METHODS: Data from randomized clinical trials of antiarrhythmic drug therapy of supraventricular arrhythmias were pooled to assess the effect on survival of dofetilide (n = 1346) compared with placebo (n = 677) in this patient population. RESULTS: The unadjusted hazard ratio for risk of death (dofetilide/placebo) was 1.4 with 95% confidence interval 0.4-5.1. After adjusting for effects of arrhythmia diagnosis, age, sex, and structural heart disease, the hazard ratio was 1.1 (confidence interval 0.3-4.3). CONCLUSIONS: The pooled survival analysis provided reassurance regarding the safety of dofetilide in patients with supraventricular arrhythmias.

A cross sectional analysis of 5 different markers of collagen degradation in rheumatoid arthritis.

OBJECTIVE: To compare 5 different assays measuring collagen degradation in rheumatoid arthritis (RA). METHODS: Daily serum samples and 3 consecutive 24 h urine samples were obtained from 25 patients with RA and 20 control subjects. Levels of pyridinoline (PYD), deoxypyridinoline (DPYD), n-telopeptide (NTx), CrossLaps (XL), and carboxy-terminal peptide of type I collagen (ICTP) were determined by ELISA or radioimmunoassay. PYD, DPYD, NTx, and XL were measured in urine and expressed as a ratio of the amount of crosslink to mmoles of creatinine (Cr). ICTP was determined in serum. The day-to-day variability of urinary collagen crosslink levels and serum ICTP was assessed over 3 day hospitalization. RESULTS: Four of the 5 markers were significantly elevated in the RA cohort compared to controls: PYD (nmol)/Cr (median 33.8 vs 19.3; p = 0.0001), NTx (nmol)/Cr (median 22.5 vs 13.8; p = 0.01), XL (microg)/Cr (median 191.4 vs 126.1; p = 0.01), and ICTP (microg/l) (median 5.8 vs 3.7; p = 0.001). In the RA group, higher levels of the markers were associated with concomitant prednisone therapy. The levels of the 4 urine markers and of ICTP in serum exhibited little day-to-day variability. CONCLUSION: Biochemical evidence of increased collagen degradation can be readily observed in RA using simple quantitative assays. These measures have minimal short term, day-to-day variability and hence may be useful to assess the effect of potentially disease modifying therapies.

Initial experience with a high-impedance tined endocardial pacemaker lead: evidence for increased lead failure.

We report our initial clinical experience with a new tined ventricular endocardial pacemaker lead, the Medtronic model 5034. This lead has a reduced electrode tip size, which provides a higher impedance. Based on early evidence of elevation of pacing lead threshold, we compared our clinical experience with the performance of this lead with that of other similar models with larger surface area (Medtronic models 4024 and 5024). Of 17 implant procedures performed at our institution with the model 5034 lead, two (11.2%) developed high thresholds, versus 0% in 121 implant procedures with models 4024 or 5024 leads (p = 0.014). We conclude that there is evidence of increased failure caused by elevation of pacing threshold in this lead. This increased failure rate needs to be confirmed in a multicenter observational study or randomized trial.

Evaluation of the effect of transthoracic cardioversion from ventricular tachycardia to sinus rhythm on left atrial mechanical function.

We measured left atrial function during sinus rhythm before and after ventricular tachycardia was induced in an electrophysiology laboratory, using peak transmitral A-wave velocity from pulsed-Doppler transthoracic echocardiography as a marker of left atrial mechanical function. The results of this prospective study do not support the hypothesis that a transthoracic shock of mild to moderate energy diminishes atrial mechanical function.

Increased expression of blood mononuclear cell nitric oxide synthase type 2 in rheumatoid arthritis patients.

Nitric oxide (NO) is an important inflammatory mediator in nonhuman animal models of rheumatoid arthritis (RA). The purpose of the present study was to determine whether blood mononuclear cells from patients with active RA (as compared to control subjects) have higher levels of NO synthase type 2 (NOS2) and produce more NO in vitro. Leukocytes from 25 RA patients and 20 normal subjects were examined. Arthritis activity was assessed by tender and swollen joint counts, duration of morning stiffness, patient assessment of pain, physician and patient global assessment of disease activity, the modified Stanford Health Assessment Questionnaire, and by blood levels of acute phase reactants. Blood mononuclear cell NOS enzyme activity/antigen content and nitrite/nitrate formation in vitro were measured. Blood mononuclear cells from RA patients had increased NOS activity and increased NOS2 antigen content as compared to those from normal subjects, and responded to interferon-gamma with increased NOS expression and nitrite/nitrate production in vitro. NOS activity of freshly isolated blood mononuclear cells correlated significantly with disease activity, as assessed by render and swollen joint counts. Our results demonstrate that patients with RA have systemic activation for NOS2 expression, and that the degree of activation correlates with disease activity. Increased NOS2 expression and NO generation may be important in the pathogenesis of RA.

Heart rate during spontaneous and induced paroxysmal supraventricular tachycardia.

It is generally assumed that paroxysmal supraventricular tachycardia (PSVT) induced during invasive electrophysiological study reproduces the patient's spontaneous, clinical arrhythmia. Even in the absence of antiarrhythmic drugs, however, there may be significant differences in characteristics of the induced and spontaneous arrhythmias. We compared the heart rate of PSVT in 38 patients who had undergone electrophysiological study with induction of PSVT who also had a spontaneous episode of PSVT documented by transtelephonic ECG monitoring during a period when all antiarrhythmic drugs were withheld. The heart rate during spontaneous PSVT was faster than the heart rate of PSVT induced during electrophysiological study; the mean difference was 16 beats/min (P < 0.001). We conclude that heart rate of PSVT induced during electrophysiological study generally underestimates the heart rate of spontaneous PSVT in the antiarrhythmic drug-free state. This may be due to differences in the autonomic and hemodynamic states during spontaneous and induced arrhythmias.

Shoulder range of motion in patients with osteoporosis.

OBJECTIVE: To determine the degree of loss of shoulder flexion in patients with osteoporosis, and to determine whether this was correlated with functional disability and pain as measured by the modified Health Assessment Questionnaire. METHODS: Two different exercise regimens, one using traditional extension exercises of the spine (group A) and the other using both the extension exercises and exercises to stretch and strengthen scapular musculature (group B), were compared to determine their effects on range of motion, pain, and disability in 33 women with osteoporosis. RESULTS: A significant improvement in shoulder flexion occurred in both exercise groups compared to controls; however, there were no statistically significant differences either within or between exercise groups from baseline to study end. A decrease in pain correlated with an increase in shoulder flexion in group A (r = 0.56), while an improvement in functional disability scores correlated with an increase in shoulder flexion in group B (r = 0.46). CONCLUSION: Traditional spinal exercises along with exercises that target scapular mobility help to improve shoulder flexion, pain, and function in women with osteoporosis.

Therapeutic delay and mortality in cases of Rocky Mountain spotted fever.

We conducted a retrospective cohort study of patients with Rocky Mountain spotted fever (RMSF) at a university hospital in order to assess the relationship between delay in treatment and mortality and to identify predictors of delay in initiating therapy. Patients with RMSF who received antirickettsial therapy within 5 days of the onset of symptoms were significantly less likely to die than were those who received treatment after the 5th day of illness (6.5% vs. 22.9%, respectively; P < .03). Ninety percent of patients were seen by a physician during this 5-day period, yet less than one-half of them received treatment before day 6. Three factors were independent predictors of failure by the physician to initiate therapy the first time a patient was seen: absence of a rash, presentation between 1 August and 30 April, and presentation within the first 3 days of illness. Until reliable early diagnostic tests become available, physicians may be able to decrease the mortality associated with RMSF by instituting empirical treatment of suspected cases within the first 5 days of illness.

Incidence of symptomatic atrial fibrillation in patients with paroxysmal supraventricular tachycardia.

OBJECTIVES: This study was performed to determine the incidence of symptomatic, sustained atrial fibrillation in a group of patients with paroxysmal supraventricular tachycardia. The effects of the mechanism of paroxysmal supraventricular tachycardia (atrioventricular [AV] node reentry vs. AV reentry through an accessory pathway) and heart rate during the tachycardia on the occurrence of atrial fibrillation were also assessed. BACKGROUND: There is a substantial incidence of atrial fibrillation in patients with paroxysmal supraventricular tachycardia, but the precise incidence and the factors that determine it are unknown. METHODS: One hundred sixty-nine patients with paroxysmal supraventricular tachycardia were followed up by regular clinic visits and transtelephonic electrocardiographic monitoring during symptomatic episodes of arrhythmia. The Kaplan-Meier product-limit method was used to estimate the proportion of patients remaining free of atrial fibrillation during the observation period. The Cox proportional hazards model was used to assess the effect of mechanism and heart rate during paroxysmal supraventricular tachycardia on the atrial fibrillation-free period. RESULTS: Thirty-two (19%) of the 169 patients had an episode of atrial fibrillation during a mean follow-up period of 31 months. The cumulative percent of patients experiencing an episode of atrial fibrillation was 6% within 1 month, 9% within 4 months and 12% within 1 year. The mechanism of paroxysmal supraventricular tachycardia was not associated with the time to occurrence of atrial fibrillation; the hazard ratio corresponding to classification in the AV node reentry group was 0.8 (p > 0.6). The heart rate during paroxysmal supraventricular tachycardia was not associated with the time to occurrence of atrial fibrillation; the hazard ratio associated with an increase in heart rate of 50 beats/min during the tachycardia was 1.15 (p > 0.5). CONCLUSIONS: This study suggests that atrial fibrillation will develop in approximately 12% of patients with paroxysmal supraventricular tachycardia during a 1-year follow-up period. The occurrence of atrial fibrillation is not related to the mechanism or heart rate of the paroxysmal supraventricular tachycardia.

Magnetic resonance imaging of the corpus callosum: predictors of size in normal adults.

Eighty normal adults were studied with MRI to investigate the relationship between regional morphology of the corpus callosum and characteristics such as age, gender, education, and cranial size. The variability coefficient was 20% in total callosal area and from 19% to 40% in regional callosal area. Increasing age and smaller cranial area were both associated with smaller total and regional callosal areas; there were no effects of gender and education. The relative effects of age and cranial size varied across regions and were most prominent for anterior subdivisions. However, age and cranial size together explained less than half the variance in regional callosal size. Further study is needed to identify additional correlates of regional callosal anatomy.

Discrimination between stages of Alzheimer's disease with subsets of Mini-Mental State Examination items. An analysis of Consortium to Establish a Registry for Alzheimer's Disease data.

OBJECTIVE: To identify minimal sets of Mini-Mental State Examination (MMSE) items that can distinguish normal control subjects from patients with mild Alzheimer's disease (AD), patients with mild from those with moderate AD, and those with moderate from those with severe AD. DESIGN: Two randomly selected equivalent half samples. Results of logistic regression analysis from data from the first half of the sample were confirmed by receiver operating characteristic curves on the second half. SETTING: Memory disorders clinics at major medical centers in the United States affiliated with the Consortium to establish a Registry for Alzheimer's Disease (CERAD). PARTICIPANTS: White, normal control subjects (n = 412) and patients with AD (n = 621) who met CERAD criteria; nonwhite subjects (n = 165) and persons with missing data (n = 27) were excluded. MAIN OUTCOME MEASURES: Three four-item sets of MMSE items that discriminate, respectively, (1) normal controls from patients with mild AD, (2) patients with mild from those with moderate AD, and (3) patients with moderate from those with severe AD. RESULTS: The MMSE items discriminating normal controls from patients with mild AD were day, date, recall of apple, and recall of penny; those discriminating patients with mild from those with moderate AD were month, city, spelling world backward, and county, and those discriminating patients with moderate from those with severe AD were floor of building, repeating the word table, naming watch, and folding paper in half. Performance on the first two four-item sets was comparable with that of the full MMSE; the third set distinguished patients with moderate from those with severe AD better than chance. CONCLUSIONS: A minimum set of MMSE items can effectively discriminate normal controls from patients with mild AD and between successive levels of severity of AD. Data apply only to white patients with AD. Performance in minorities, more heterogeneous groups, or normal subjects with questionable cognitive status has not been assessed.