Improvement In Mental Functioning Research Articles

Does Preoperative Back Pain Impact Patient-reported Outcomes in Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion for Isthmic Spondylolisthesis?

Retrospective review. To determine postoperative clinical outcomes in patients undergoing minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) for isthmic spondylolisthesis (IS). Few studies have examined the postoperative clinical trajectory in patients undergoing MIS-TLIF specifically for IS. Patients were separated into two cohorts based on the previously defined Visual Analog Scale (VAS) back pain (BP) for severe pain: VAS-BP <7 and VAS-BP ≥7. Patient-reported outcome measures (PROMs) of Patient-Reported Outcomes Measurement Information System-physical function (PF), 12-item Short Form (SF-12) Physical/Mental Component Score, Patient Health Questionnaire-9, VAS-BP, VAS leg pain, and Oswestry Disability Index were collected preoperatively and up to 2-year postoperatively. Minimum clinically important difference (MCID) was calculated through previously defined thresholds. A total of 160 patients were recorded, with 58 patients in the VAS-BP <7 cohort. The VAS-BP <7 cohort demonstrated significant improvement in all PROMs at one or more postoperative time points. The VAS-BP ≥7 demonstrated significant improvement at 3 or more postoperative time points in all PROMs except for SF-12 Mental Component Score. The VAS-BP <7 cohort reported significantly superior preoperative and postoperative PROMs in all domains, except for SF-12 Physical Component Score. The VAS-BP ≥7 cohort had higher MCID achievement rates at one or more time points in multiple PROMs. Patients undergoing MIS-TLIF for IS demonstrated significant postoperative improvement in PF, mental function, pain, and disability outcomes independent of preoperative severity of BP. Patients with lower preoperative BP demonstrated superior outcomes in PF, mental function, pain, and disability. However, patients with greater preoperative BP achieved higher rates of MCID in mental function, BP, and disability outcomes. Patients with greater severity of preoperative BP undergoing MIS-TLIF for IS may experience greater rates of clinically relevant improvement in mental function, BP, and disability outcomes.

Long-Term Change and Predictors of Change in Physical and Mental Function after Rehabilitation: A Multi-Centre Study

To investigate changes and predictors of change in physical and mental function over a 3-year period after rehabilitation. Prospective cohort. Patients, across diseases, living in western Norway, accepted for somatic specialized interprofessional rehabilitation (n = 984). Physical and mental function were assessed at admittance (baseline), and after 1 and 3 years using the Medical Outcome Study Short Form 36 (SF-36). Associations between changes in SF-36 component summary scores and sense of coherence, pain, disease group (musculoskeletal, neoplasm, cardiovascular, neurological, other), exercise habits and demographic variables were analysed using linear mixed modelling. In the total group, mean (standard deviation) physical component summary scores improved by 2.9 (8.4) and 3.4 (9.3) points at 1 and 3 years, respectively. Mental component summary scores improved by 2.1 (9.7) and 1.6 (10.8) points. Improvement in physical component summary was significantly greater for patients with higher sense of coherence (b = 0.09, p = 0.001) and for the neoplasm disease group (b = 2.13, p = 0.046). Improvement in mental component summary was significantly greater for patients with low sense of coherence (b = -0.13, p = < 0.001) and higher level of education (b = 3.02, p = 0.0302). Interaction with age (physical component summary: b = 0.22, p = 0.039/mental component summary b = 0.51, p = 0.006) indicated larger effect at 1 year than at 3 years. Physical and mental function improved in the total study group over the 3-year period. Sense of coherence at baseline was associated with improved physical and mental function, suggesting that coping resources are important in rehabilitation.

Influence of Preoperative Disability on Clinical Outcomes in Patients Undergoing Anterior Lumbar Interbody Fusion

Few studies have examined the influence of preoperative disability through the Oswestry Disability Index (ODI) on clinical outcomes in patients undergoing anterior lumbar interbody fusion (ALIF). Patients undergoing ALIF were separated into 2 groups based on ODI<41 (lower disability) versus ODI≥41% (higher disability). Patient-reported outcomes (PROs) were collected at preoperative and postoperative 6-week/12-week/6-month/1-year/2-year time points. Physical function PROs were Patient-Reported Outcomes Measurement Information System Physical Function and 12-item Short Form Physical Component Score. Mental function PROs were 12-item Short Form Mental Component Score and Patient Health Questionnaire-9. Pain PROs were visual analog scale back and visual analog scale leg. ODI was the disability PRO. A total of 148 patients were identified, with 52 patients with lower disability. Higher disability patients demonstrated significant improvement in mental function (P ≤ 0.010, all). Lower disability patients demonstrated superior postoperative PROs in physical function, mental function, back pain, and disability outcomes (P ≤ 0.034, all). Minimum clinically important difference achievement ratesfor lower disability patients were higher for back pain andlower for mental function and disability outcomes (P ≤ 0.041, all). Independent of preoperative disability, patients undergoing ALIF reported significant postoperative improvement in physical function, pain, and disability outcomes. Patients with lower preoperative disability continued to report superior PROs in mental function, back pain, and disability postoperatively. Minimum clinically important difference achievement rates for lower disability patients were higher for back pain and lower in mental function and disability outcomes. Patients undergoing ALIF with higher preoperative disability may experience greater clinically meaningful improvement in mental function and disability.

Post-Traumatic Growth and Quality of Life among World Trade Center Health Registry Enrollees 16 Years after 9/11.

A recent study of World Trade Center Health Registry enrollees found that about one-third experienced post-traumatic growth (PTG) in the wake of the 9/11 attacks and that PTG was associated with social support and social integration. However, the implications of PTG for the enrollees’ overall quality of life are unknown. The present study investigated the prevalence of PTG and its association with the SF-12 physical and mental functioning quality of life scales in a sample of 4760 enrollees from the Registry’s Health and Quality of Life Study (HQoL) who completed the first four surveys, were older than 18 on 9/11, reported English as their primary spoken language, and provided consistent self-report of 9/11 physical injury at the Registry’s baseline and HQoL surveys. We employed multivariable linear regression to evaluate the association between PTG and the SF-12 physical and mental scales, controlling for sociodemographic and other variables. We found that 31% of the sample enrollees experienced PTG and that PTG exhibited a clinically and statistically significant association with the SF-12 mental scale but not the physical scale (physical: b = 0.15 (−0.45, 0.75), mental: b = 3.61 (2.85, 4.37)). Those who were physically injured during 9/11 showed larger improvements in mental functioning than those who were not. PTG has implications for the overall mental quality of life that should be further investigated.

Therapeutic effects of mirror therapy in patients after stroke

To evaluate the effect of mirror therapy on the regression of motor disorders in the paretic arm, functional and psychological disorders, the patient's functioning and quality of life, risk factors for recurrent stroke in the early recovery period of stroke. We examined 219 patients after stroke, including 154 patients after ischemic stroke (IS) and 65 patients after hemorrhagic stroke (HS) in the early recovery period (21 days to 6 months). All patients received a standard medical rehabilitation course including medications, physical rehabilitation, and physiotherapeutic treatment. Patients were divided into four groups depending on the stroke type and the medical rehabilitation course received: two study treatment groups (post-IS and post-HS groups), which consisted of patients receiving the standard medical rehabilitation course and mirror therapy, and two comparison groups (post-IS and post-HS), in which patients received only the standard medical rehabilitation course. All patients before and after the medical rehabilitation course were evaluated for neurological disorders (NIHSS, Ashworth scale of muscle spasticity, Medical Research Council (MRC) Scale and handgrip test), functional limitations (Frenchay Arm Test, Hauser Ambulation Index, Rivermead Mobility Index, Functional Independence Measure (FIM), ICF), mental status («Visual Memory» and «10 Word Memory» methods, Schulte-Platonoff tables, Lüscher color test, Hospital Anxiety and Depression Scale (HADS), Locus of Control Recovery Questionnaire), quality of life (EQ-5D), arterial hypertension (Arterial Hypertension in Adults. Clinical Guidelines, 2020). Addition of the mirror therapy to the standard course provided additional therapeutic effects: in patients with IS, the high tone of the paretic muscles of the arm significantly decreased (by 46%); the target blood pressure was achieved in 96% of patients; severe disorders of functional independence and depression regressed; significant changes of mental functions parameters (visual memory, shifting attention); improvement of activity and participation parameters (carrying in the hands, self-care, housekeeping). In patients with HS, the muscle strength of the paretic arm significantly increased (by 35%); the target blood pressure was achieved in all patients; improvement of mental functions (motivation, shifting attention, visual memory), activity and participation parameters (objects moving and manipulation, self-care), and decreased level of depression were observed. The addition of mirror therapy to the standard of care for patients after stroke resulted in regression of neurological deficit, motor disorders in the paretic arm, improvement of emotions and motivation, mitigation of recurrent stroke risk factors, as well as significant impact on the cognitive functions and enhancement of patients' capabilities of self-care.

Case report on energy drink consumption among Health Sciences University students in Gauteng Province, South Africa

BackgroundThere are claims that energy drink (ED) consumption can bring about an improvement in mental functioning in the form of increased alertness and enhanced mental and physical energy. These claims address the lifestyle of a student of sleep deprivation and academic pressure with ED consumption becoming a popular practice amongst students. The study’s objectives were to determine the prevalence, reasons for, and patterns of ED and alcohol mixed with ED (AmED) consumption amongst university students.Case presentationRegistered students of the Health Sciences University, Gauteng Province, South Africa, formed the study population where this quantitative cross-sectional survey conveniently collected data by means of previous validated self-administered questionnaires from 490 students representing the diverse demographics of the university. Questions on the socio-demographic profile of the participants; pattern of alcohol use; reasons, pattern, and preferred types of EDs use; and the pattern, reason, and experience of AmED use during the past 12 months were asked. Frequency and percentages of distributions were determined, and the possible factors contributing to ED consumption were computed using the chi-square test. Results indicated that a total of 58% of students were consuming EDs mainly to stay awake (31%), to be more alert (14%), and to help with concentration (15%), 69% were consuming alcohol, and 16% were consuming AmEDs.ConclusionThere is an urgent need for an appropriate public health prevention intervention so that ED consumers can make informed choices when indulging in these health behaviors before the seemingly harmless consumption of ED amongst students becomes a public health issue.

BACE Inhibitors and Tau Protein Targeting Drugs in Prevention of Alzheimer's Disease.

Alzheimer's disease (AD) is a common disease in the United States with almost 10% of people older than 65 suffering from the disease. A few drugs provide some improvement in mental function in mild-to-moderate disease, but no treatments are available to prevent the development of AD. Two new classes of drugs being investigated for the treatment or prevention of AD include drugs to decrease beta amyloid accumulation and Tau protein aggregation inhibitors. After disappointing results for treatment of AD, both classes are being tested in prevention trials.

The Effects of a Health Partner Program on Improving Health Status Among Overweight/Obese Individuals With and Without Prediabetes.

The purpose of this study was to compare baseline health status in overweight/obese adults with and without prediabetes and to determine whether a health partner program improved health status at 1-year follow-up from 2010 to 2011. Sociodemographic information, body composition, blood work, and health status were obtained from both baseline and 1-year follow-up visit. Healthy overweight/obese participants with prediabetes were likely to self-report poorer physical functioning compared with those without prediabetes at baseline. At the 1-year follow-up visit, compared with participants without prediabetes, participants with prediabetes had the greatest improvements in physical functioning. Although participants without prediabetes had a significant improvement in mental functioning, there were no significant differences in changes in mental functioning between those with and without prediabetes. Early interventions to improve health status are important, and provider advice and preventive measures aimed at improving health status should be integrated into clinical practice.

One-year trajectories of mental and physical functioning during and after rehabilitation among individuals with disabilities

PurposeFirst, to evaluate the trajectories of physical and mental functioning in individuals with chronic disabilities receiving adapted physical activity-based rehabilitation. Second, to determine whether demographic factors, disability group, pain, fatigue and self-efficacy at baseline influenced these trajectories.Research designA prospective intervention study.MethodsThe study included 214 subjects with chronic disabilities who were admitted to a four-week adapted physical activity-based rehabilitation stay at Beitostølen Healthsports Centre. The subjects completed written questionnaires eight and four weeks before the rehabilitation, at admission to and discharge from the rehabilitation centre and again four weeks and 12 months after discharge. Multilevel models were performed to examine the trajectories of SF-12 physical and mental functioning with possible predictors.ResultsTime yielded a statistically significant effect on physical and mental functioning (p < 0.001). Low age (p = 0.002), no more than 2 h of personal assistance per week (p = 0.023), non-nervous system disability (p = 0.019), low pain level (p < 0.001) and high chronic disease-efficacy (p = 0.007) were associated with higher physical functioning. There was a greater improvement in physical functioning for subjects with lower chronic disease-efficacy at baseline (p = 0.036) and with a disability not associated with the nervous system (p = 0.040). Low fatigue (p = 0.001) and high chronic disease-efficacy (p = 0.004) predicted higher mental functioning. There was also a greater improvement in mental functioning for subjects with high fatigue (p =0.003) and low chronic disease efficacy at baseline (p = 0.032).ConclusionIndividuals with chronic disabilities who participated in an adapted physical activity-based intervention showed statistically significant increases in both physical and mental functioning across the 12 months after the intervention. The greatest improvement was among subjects with a high level of fatigue and low chronic disease-efficacy, as well as disabilities not associated with the nervous system, which has implications for the target groups in future rehabilitation.

Do we have to leave obesity treatment to the surgeons?

The comparison of the largest bariatric surgery study (Swedish Obese Subjects, SOS) with almost 4000 surgical and conservatively treated patients and its conservative counterpart, the LookAHEAD study (Action for Help in Diabetes) with more than 5000 obese patients (average BMI 36 kg/m(2)) with type 2 diabetes showed that although both studies resulted in improved cardiovascular risk factors (bodyweight, HbA1c, HDL/LDL, blood pressure, sleep apnoe syndrome) only the SOS study and subsequent obesity surgery studies could verify their primary outcome hypothesis (significant reduction of the incidence of both cardiovascular deaths, non-fatal infarctions and strokes and hospitalization angina). Furthermore the SOS study could demonstrate a decreased mortality compared to the Look-AHEAD study. Despite a high psychological co-morbidity of obesity surgery patients the majority of studies also with follow-ups of more than 5 years demonstrates an improvement in mental functioning and quality of life. In contrast, there seems to be an increased risk for suicide about 3-4 years after the surgical intervention. Thus, while the majority of obesity surgery patients seems to benefit both physically and mentally, there is a minority that risks to take at least psychologically serious damage.

Mindfulness-Based Cognitive Therapy for Patients with Medically Unexplained Symptoms: A Randomized Controlled Trial

Background: Patients with medically unexplained symptoms make heavy demands on the health care system. An offer for psychological treatment is often declined. There is a need for acceptable and effective treatments. We assessed the acceptability and effectiveness of mindfulness-based cognitive therapy (MBCT) for patients with persistent medically unexplained symptoms. Method: A randomized controlled trial comparing MBCT (n = 64) to enhanced usual care (EUC; n = 61). Participants were the 10% most frequently attending patients in primary care. The primary outcome measure was general health status at the end of treatment. Secondary outcome measures were mental and physical functioning. Assessments took place at the end of treatment and at the 9-month follow-up. Results: Health status and physical functioning did not significantly differ between groups. However, participants in the MBCT group reported a significantly greater improvement in mental functioning at the end of treatment (adjusted mean difference, 3.9; 95% CI, 0.24-7.6), in particular with regard to vitality and social functioning. In addition, at 9 months of follow-up, the mindfulness skills ‘observing' and ‘describing' were significantly higher in the MBCT group. Within the MBCT group, almost half of the outcome measures had significantly improved at the end of treatment, whereas in the EUC group none had. Conclusions: MBCT was feasible for frequently attending patients with persistent medically unexplained symptoms in primary care. Although MBCT did not lead to a significant difference in general health status between the two groups, it did result in a significant improvement in mental functioning.

Perceived wellbeing of patients one year post stroke in general practice - recommendations for quality aftercare

BackgroundAnnually, 41,000 people in the Netherlands have strokes. This has multiple physical and psychosocial consequences. Most patients return home after discharge from hospital. Quality aftercare by general practitioners is important to support patients at home. The purpose of this study is to examine the wellbeing of patients who returned home immediately after discharge from hospital, one year post stroke, in comparison with the general Dutch population of the same age and to determine factors that could influence wellbeing.MethodsAll the stroke patients from the Department of Neurology, Martini Hospital Groningen in the period November 2006 to October 2007 were included. People aged under 65 years or with haemorrhaging were excluded. All the patients (N = 57) were interviewed at home using the following questionnaires: Barthel Index, SF-36, HADS, CSI and a questionnaire about their way of life.Results31% of the patients in this study experienced a decrease in functional status after one year. Nevertheless, there was no significant difference between the median Barthel Index value at discharge from hospital and one year post stroke. ADL independence correlated with a better quality of life. The health-related quality of life was high. Stroke patients have almost the same quality of life as the 'average' Dutch elderly population. Where patients can no longer fully participate in society, their perceived quality of life is also lower. In this study there is an indication of a high prevalence of depression and anxiety disorders in stroke patients. This negatively affects the quality of life a year after stroke. Although caregiver strain was low for the partners of stroke patients, a reduced quality of life is correlated to greater burden.ConclusionsThis study provides valuable insight into the wellbeing of patients living at home one year post stroke. Physical functioning and quality of life are comparable to the general population of the same age, but improvements in mental functioning can be envisaged. In addition, more attention should be paid to maintaining the patients' activities. The wellbeing of these stroke patients could be increased further if greater attention is paid to these aspects of life. This seems to be applicable to general practice.

Comprehensive rehabilitation at Beitostølen Healthsports Centre: Influence on mental and physical functioning

To characterize the mental and physical functioning of subjects admitted to Beitostølen Healthsports Centre, and evaluate whether functioning was improved during rehabilitation. A total of 228 subjects admitted for rehabilitation completed the Medical Outcome Study Short Form 12 (SF-12) on admission and on discharge after approximately 4 weeks. A total of 174 subjects also completed SF-12 3 months after discharge. The physical and mental sum scores and the scores for the 8 subscales of SF-12 were calculated. In a stepwise backward multiple regression model, demographic and medical factors influencing improvement during rehabilitation were explored. Physical, as well as mental, functioning was reduced on admission. Bodily pain and emotional factors represented the most dominant components. Both physical and mental functioning improved during the stay, and the improvement in physical functioning remained stable 3 months after discharge. The improvement in physical functioning was greatest for those subjects living in urban areas and having a painful musculoskeletal diagnosis. The improvement in mental functioning was greatest for females. This approach to rehabilitation appears to be effective for improving physical functioning in the relevant group of individuals. However, carefully controlled studies with longer follow-up periods are required.

Carbohydrates and mental function: feeding or impeding the brain?

Summary Despite over 25 years of research into carbohydrates and mental function, findings have, if anything, become more divergent in recent years, and no clear mechanistic model that satisfactorily explains such variability has been produced. At best, there is some consensus that individuals with poor regulation of glucose, and who find the tests of cognitive performance particularly challenging, may benefit from some improvement in mental function after a specific dose of carbohydrate. Even then, this is mainly limited to hippocampally mediated verbal memory.Recent developments in understanding the regulation of energy supply (principally glucose) for neuronal function suggest that it is too simplistic to assume that ingesting carbohydrates will inevitably improve cognitive function. There is a damping or buffering seen between glucose changes in blood and brain extracellular fluid, and even evidence for an acute dissociation of these glucose changes during task performance in specific brain regions. This may be mainly owing to the role of astrocytes, which are large, star‐shaped cells within the central nervous system that can store glucose as glycogen, and when needed, release energy to neurones ‘on demand’.Variables such as age, effort, personality, glucoregulation, time of day, task demand, task domain, and nature and amount of the carbohydrate, can all affect the outcome. One factor that could be involved in all of these variables is the limbic–hypothalamic–pituitary–adrenal axis, which controls release of glucocorticoid hormones such as cortisol, and is believed to be a major route by which the brain regulates its energy supply. Moreover, rapidly absorbed carbohydrate provokes a greater cortisol release during stressful tasks and, like glucose, cortisol is known to have dose‐dependent, and bidirectional, effects on cognitive function, especially memory. This process might help explain recent findings that carbohydrate‐rich foods with lower glycaemic indices provide more benefit to mental function than high‐glycaemic foods.The challenge now is to identify characteristics of both susceptible individuals and the carbohydrate manipulations that can best predict improvements in selective cognitive functions. This should be aided by a better understanding of the regulation of energy supply to the brain, together with knowledge of the relevant nutritional, neuronal, physiological and psychological parameters that would consistently promote improvements in cognitive function by carbohydrates.

Patient characteristics can predict improvement in functional health after elective coronary artery bypass grafting

Background Despite many patients undergoing coronary artery bypass grafting (CABG) to improve their functional status, literature in this area is limited. The purpose of this study is to determine the effect of CABG on the functional health of an elective population and to identify preoperative patient characteristics associated with improved functional health after surgery. Methods Physical and mental functional health was assessed before and 6 months after surgery with the Short-Form Health Survey (SF-36) in 1,061 consecutive patients undergoing elective, isolated CABG. Survey data were complete in 529 patients (49.9%). Preoperative information on patient demographics, severity of cardiovascular illness, and disease comorbidities was also prospectively collected. Results Six months post-CABG the mean summary score for physical function improved by 31.9% over baseline (45.1 versus 34.2, p < 0.0001). The mean summary score for mental function improved by 7.3% over baseline (51.3 versus 47.8, p < 0.0001). Overall 73.2% of patients showed improvement in physical function and 41.6% showed improvement in mental function. Multivariate logistic regression identified certain preoperative characteristics as negative correlates of a significant improvement in physical functioning: body mass index 35 kg/m 2 or greater, diabetes with sequelae, chronic obstructive pulmonary disease, peripheral vascular disease, and baseline physical function. Baseline mental function and chronic obstructive pulmonary disease were identified as negative correlates and older age as a positive correlate of significant improvement in mental functioning. Conclusions Patient characteristics exist that impact functional health after elective CABG. Knowledge of these characteristics may be helpful when counseling patients about expected improvement in functional health with CABG.

Invited commentary

This paper reports prospective assessment of pre- and postoperative functional status (measured with the by now familiar SF-36 health status survey) in a consecutive series of patients undergoing elective coronary artery bypass surgery. Although the study is marred by the fact that only half of the patients completed both surveys, the authors were able to identify improvements in both physical and mental functions after operations for myocardial ischemia. In addition, the data highlighted several patient factors that affected the likelihood that improvement would be realized. Negative correlates of improvement in physical status included obesity, diabetes with sequelae, chronic lung disease, peripheral vascular disease, and baseline physical function. Baseline mental function and lung disease were negative correlates, and, interestingly, older age was a positive correlate of postoperative improvement in mental function.This is an important paper. First, it provides data to counter the recent contention, much publicized in the lay press, that cardiac operations for myocardial revascularization inevitably lead to, and perhaps cause, a decline in physical and especially cognitive performance. This paper bolster the surgeon’s objective of using sophisticated science and meticulously developed art to help restore patients afflicted by the scourge of atherosclerosis to more functional and productive life. Second, this report provides evidence that certain patient characteristics may operate independently of the quality of the operation to limit the potential rehabilitative benefit of coronary artery bypass surgery.Finally, the assessment of functional improvement, especially after elective coronary bypass surgery, is critical in the current environment of cost containment and competing, nonsurgical revascularization strategies. This paper provides another means to evaluate those therapies as well. While the authors have identified the limitations of their study accurately, their data are provocative. This type of analysis might well be a useful additional approach in future, prospective, comparative assessments of surgical and catheter-based myocardial revascularization. This paper reports prospective assessment of pre- and postoperative functional status (measured with the by now familiar SF-36 health status survey) in a consecutive series of patients undergoing elective coronary artery bypass surgery. Although the study is marred by the fact that only half of the patients completed both surveys, the authors were able to identify improvements in both physical and mental functions after operations for myocardial ischemia. In addition, the data highlighted several patient factors that affected the likelihood that improvement would be realized. Negative correlates of improvement in physical status included obesity, diabetes with sequelae, chronic lung disease, peripheral vascular disease, and baseline physical function. Baseline mental function and lung disease were negative correlates, and, interestingly, older age was a positive correlate of postoperative improvement in mental function. This is an important paper. First, it provides data to counter the recent contention, much publicized in the lay press, that cardiac operations for myocardial revascularization inevitably lead to, and perhaps cause, a decline in physical and especially cognitive performance. This paper bolster the surgeon’s objective of using sophisticated science and meticulously developed art to help restore patients afflicted by the scourge of atherosclerosis to more functional and productive life. Second, this report provides evidence that certain patient characteristics may operate independently of the quality of the operation to limit the potential rehabilitative benefit of coronary artery bypass surgery. Finally, the assessment of functional improvement, especially after elective coronary bypass surgery, is critical in the current environment of cost containment and competing, nonsurgical revascularization strategies. This paper provides another means to evaluate those therapies as well. While the authors have identified the limitations of their study accurately, their data are provocative. This type of analysis might well be a useful additional approach in future, prospective, comparative assessments of surgical and catheter-based myocardial revascularization.

Vagus nerve stimulation in children with therapy-resistant epilepsy diagnosed as Lennox-Gastaut syndrome: clinical results, neuropsychological effects, and cost-effectiveness.

We studied the clinical efficacy and tolerability, neuropsychological effects, and cost-effectiveness (direct medical costs, direct nonmedical costs, and indirect costs) of vagus nerve stimulation (VNS) in children with Lennox-like syndrome (n = 16). The situation 6 months before implantation of the device is compared with that 6 months after surgery. Seizure frequency and severity are significantly reduced during VNS: 25% of the patients show a reduction in seizure frequency of 50% or greater; overall seizure reduction is 26.9%. Measures of neuropsychological outcome show a moderate improvement in mental functioning, behavior, and mood. The scores for mood and mental age improve independently of seizure control. Side effects are minor and transient. There is a significant reduction in direct non-health care costs, ergotherapy, and the number of days of sub-optimal functioning of the child. The costs during the 6 postoperative months are 2,876.06 Euros less than the costs during the 6 months before VNS; the payback period is 2.3 years.

An inner city GP unit versus conventional care for elderly patients: prospective comparison of health functioning, use of services and patient satisfaction

GP units are generally nurse-led wards, where GPs have direct admitting rights and retain clinical responsibility for their patients. While GP-led wards are not new, they are relatively uncommon in urban areas. In addition, there has been little comparative evaluation of this type of service. The aim of the present study was to compare patients admitted to an inner city GP unit with comparable patients in conventional care (e.g. district nursing, nursing/residential homes, acute care of the elderly wards) in terms of mental and physical functioning, use of health and social services and patient satisfaction. Study group patients were those admitted to the GP unit; comparison group patients were identified by GP practices or conventional services who had agreed to participate in the study. Suitable patients were aged 65 years or over and fitted the eligibility criteria for the GP unit. Patients were interviewed at three time points: admission to either the GP unit or conventional care, and at 1 and 3 months after admission. Baseline comparability was assessed by demographic and medical data, cognitive function, mental state, social support, use of health and social services, and mental and physical functioning (SF-12). Mental and physical functioning and use of health and social services were compared between the groups over time. Patient satisfaction with their care was also compared between groups. Change in the mental and physical functioning between patients on the GP unit (n = 67) and those in conventional care (n = 60) did not differ when the groups were compared at any of the three time points. However, the mental function of patients in the GP unit significantly improved between admission and 1 month after admission (P: < 0.05). This effect was not sustained at 3 months after admission. GP unit patients were consistently more positive about the care they received than patients receiving conventional care; this included communication and information, staff, care and the facilities. Both groups of patients were high users of health and social services, with similar patterns of use in both groups, which did not alter over time. Patients who received care on the GP unit experienced a similar physical outcome to patients in conventional settings; however, they appeared to enjoy a short-term improvement in mental functioning and were consistently more positive about the quality of their care. This study has important policy implications with regard to planning future intermediate care services and will be of particular interest to health service planners and those responsible for clinical governance.

Liver transplantation for citrullinaemia improves intellectual function.

Arginosuccinic acid synthetase (ASA) (EC 6.3.4.5) deficiency (citrullinaemia) (McKusick 215700) is a well-recognized cause of neonatal hyperammonaemic coma with poor long-term intellectual function, despite good medical management. Cadaveric hepatic transplantation was performed in a 12-year-old boy with citrullinaemia under poor biochemical control. Subsequent development of fulminant hepatic failure necessitated a second cadaveric transplant. Psychometric assessments before and after transplantation were performed using a variety of age-appropriate tests. Normalization of plasma ammonium in our patient post transplantation has resulted in dramatic improvement in mental functioning and well-being and he now enjoys a normal diet. Psychometric assessment confirmed decline in his abilities prior to transplantation with particular post-transplantation improvement in perceptual organization and visuospatial abilities; these did not, however, return to normal. His family report considerable reduction in stress associated with the unpredictable nature of previous hyperammonaemic crises and recurrent hospitalization. Liver transplantation should be considered as an early therapeutic option in children with citrullinaemia to prevent ongoing cerebral insult associated with hyperammonaemia.

Reversible dementia in idiopathic normal pressure hydrocephalus: A case report

Objective - To present a woman with idiopathic normal pressure hydrocephalus (NPH) showing marked improvement in mental function after shunt operation. Design - Case report.Setting - Primary health care.Patient - The clinical symptoms of gait disturbance, occasional urine incontinence and severely impaired mental function typical of NPH were all present. Although dementia predominated in the clinical picture, the diagnosis was confirmed by computer tomography (CT) and cerebrospinal fluid infusion test and cisternography.Main outcome measures - A marked improvement of mental functions was observed after shunt operation.Results - Mini Mental State Examination score before shunt operation was 9 compared with 20 one year after operation. Also ventricle size was reduced as evaluated by CT scan.Conclusion - This reported case contrasts previous reports concluding that shunt responsive patients have only slight mental disturbances without significant improvement of mental status after shunt operation.