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Biomedical subjects

Robert Howard

Publications and source records attributed to Robert Howard.

At least 19 recordsLinked to original sources
PubMed2007

A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression.

OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) has been reported to be as effective as electroconvulsive therapy (ECT) for major depression. The authors conducted a multicenter randomized, controlled trial to test the equivalence of rTMS with ECT. METHOD: Forty-six patients with major depression referred for ECT were randomly assigned to either a 15-day course of rTMS of the left dorsolateral prefrontal cortex (N=24) or a standard course of ECT (N=22). The primary outcome measures were the score on the 17-item Hamilton Depression Rating Scale (HAM-D) and the proportion of patients with remissions (Hamilton score, <or=8) at the end of treatment. Secondary outcomes included mood self-ratings on the Beck Depression Inventory-II and visual analogue mood scales, Brief Psychiatric Rating Scale (BPRS) score, and both self-reported and observer-rated cognitive changes. The patients were followed up after 6 months. RESULTS: HAM-D scores at the end of treatment were significantly lower for ECT, with 13 patients (59.1%) achieving remission in the ECT group and four (16.7%) in the rTMS group. However, at 6 months the HAM-D scores did not differ between groups. Beck scale, visual analogue mood scale, and BPRS scores were lower for ECT at the end of treatment and remained lower after 6 months. Self- and observer-rated cognitive measures were similar in the two groups. CONCLUSIONS: rTMS was not as effective as ECT, and ECT was substantially more effective for the short-term treatment of depression.

Aged↗
PubMed2006

Reasoning under uncertainty: heuristic judgments in patients with persecutory delusions or depression.

OBJECTIVE: The substantial literature examining social reasoning in people with delusions has, to date, neglected the commonest form of decision making in daily life. We address this imbalance by reporting here the findings of the first study to explore heuristic reasoning in people with persecutory delusions. METHOD: People with active or remitted paranoid delusions, depressed and healthy adults performed two novel heuristic reasoning tasks that varied in emotional valence. RESULTS: The findings indicated that people with persecutory delusions displayed biases during heuristic reasoning that were most obvious when reasoning about threatening and positive material. Clear similarities existed between the currently paranoid group and the depressed group in terms of their reasoning about the likelihood of events happening to them, with both groups tending to believe that pleasant things would not happen to them. However, only the currently paranoid group showed an increased tendency to view other people as threatening. CONCLUSION: This study has initiated the exploration of heuristic reasoning in paranoia and depression. The findings have therapeutic utility and future work could focus on the differentiation of paranoia and depression at a cognitive level.

Adult↗
PubMed2006

Differences between Alzheimer's disease and dementia with Lewy bodies: an fMRI study of task-related brain activity.

We investigated whether previously reported differences between Alzheimer's disease and dementia with Lewy bodies (DLB) in resting occipital activity lead to activation differences within functionally specialized visual cortical areas and deactivation differences in the default network. Patients with Alzheimer's disease (n = 10; 5 male), DLB (n = 9; 4 male) and controls (n = 13; 5 male) performed three functional MRI (fMRI) scanning experiments involving visual colour, face or motion stimuli. Reaction time or accuracy in DLB and Alzheimer's disease differed significantly from controls but not between patient groups, with the exception of accuracy in the face task (DLB < Alzheimer's disease; P = 0.038). The most significant fMRI activations in the pooled data set were in left V4alpha for the colour task (Talairach coordinate: -30, -52, -24; P = 0.002 corrected), the right fusiform face area (FFA) for the face task (34, -48, -22; P = 0.005 corrected) and right intra-parietal sulcus (30, -66, 42; P = 0.003 corrected) for the motion task, with additional activity in right V5 (48, -64, 0; P = 0.015 corrected). Each task was associated with decreases in activity within the default network with prominent deactivation foci bilaterally in the posterior cingulate gyrus (+/-8, -48, 26; left P < 0.001; right P < 0.001 corrected) and medial frontal cortex (+/-18, 42, 32; left P < 0.001; right P < 0.001 corrected). Comparing patterns of task-related activity across groups, DLB patients showed more activation than Alzheimer patients within the superior temporal sulcus (STS) for the motion task (right STS: 44, 0, -20; P = 0.004 corrected; left STS: -40, -4, -26; P = 0.07 corrected). This difference could not be attributed to task performance, cognitive score or age [analysis of covariance (ANCOVA)F (2, 18) = 8.44, P = 0.003]. Within regions of interest, group activation differences were found for the face task (Alzheimer's disease > DLB P = 0.05; Alzheimer's disease > controls P = 0.14) and the motion task (DLB < Alzheimer's disease P = 0.031 and DLB < control P = 0.048). However, these differences could be explained by behavioural performance, failing to reach significance in the ANCOVA analysis. In the default network, group deactivation differences between controls and both patient groups were found for the colour and motion task (colour: control < Alzheimer's disease P = 0.02; control < DLB P = 0.019; motion: control < Alzheimer's disease P = 0.118; control < DLB P = 0.118) but could be accounted for by behavioural performance. The results suggest that cognitive fMRI can be used to detect both performance-dependent and performance-independent differences between Alzheimer's disease and DLB, reflecting the distribution of functional pathology in the two conditions.

Aged↗
PubMed2006

Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial.

OBJECTIVE: To evaluate the effectiveness of a training and support intervention for nursing home staff in reducing the proportion of residents with dementia who are prescribed neuroleptics. DESIGN: Cluster randomised controlled trial with blinded assessment of outcome. SETTING: 12 specialist nursing homes for people with dementia in London, Newcastle, and Oxford. PARTICIPANTS: Residents of the 12 nursing homes; numbers varied during the study period. INTERVENTION: Training and support intervention delivered to nursing home staff over 10 months, focusing on alternatives to drugs for the management of agitated behaviour in dementia. MAIN OUTCOME MEASURES: Proportion of residents in each home who were prescribed neuroleptics and mean levels of agitated and disruptive behaviour (Cohen-Mansfield agitation inventory) in each home at 12 months. RESULTS: At 12 months the proportion of residents taking neuroleptics in the intervention homes (23.0%) was significantly lower than that in the control homes (42.1%): average reduction in neuroleptic use 19.1% (95% confidence interval 0.5% to 37.7%). No significant differences were found in the levels of agitated or disruptive behaviour between intervention and control homes. CONCLUSIONS: Promotion of person centred care and good practice in the management of patients with dementia with behavioural symptoms provides an effective alternative to neuroleptics.

Accidental Falls↗
PubMed2006

Abuse of vulnerable people with dementia by their carers: can we identify those most at risk?

OBJECTIVE: We wanted to explore possible associations between characteristics of carers, dementia sufferers and the caring situation and the presence of abuse that was acknowledged by carers. METHODS: Eighty-two carers of dementia sufferers were interviewed in their homes about three types of abuse (verbal abuse, physical abuse and neglect) using a structured questionnaire. RESULTS: Fifty-two percent (n = 43) carers admitted to having carried out some form of abuse. Verbal abuse was the most common form (n = 42, 51%), while 20% (n = 16) of carers admitted to physical abuse and 4% (n = 3) to neglect abuse. Significant associations were found between verbal abuse and psychological ill health in the carer and behavioural problems in the dementia sufferer. Physical abuse was significantly associated with higher levels of self-reported good health by the carer. High expressed emotion measured in carers was highly correlated with all types of abuse. CONCLUSION: It is possible to identify situations where people with dementia may be at high risk of abuse from their carers. Any effective intervention strategy should address psychological health problems in the carer, behavioural problems in the dementia sufferer and a strategy to manage high levels of expressed emotion in these situations.

Adult↗
PubMed2006

Male gender influences response to an educational package for delirium prevention among older people: a stratified analysis.

BACKGROUND: Increasing evidence is pointing towards the efficacy of intervention programmes in decreasing the incidence of delirium among older people admitted to hospital. We have previously shown that an educational package directed at doctors and nurses significantly decreased the point prevalence of delirium among older people on a general medical ward. It is not yet established whether specific and 'fixed' patients' characteristics influence the rate of response to such an intervention. METHODS: A secondary, exploratory stratified analysis was carried out to determine whether age, sex and presence of dementia might influence the effect of the intervention through a delirium educational package. This information is important in order to increase the effectiveness of preventive measures across various patients' subgroups. RESULTS: Male gender (OR 0.17, 0.05-0.65) significantly (p = 0.030) and positively influence the response to the educational package compared to female gender (OR 1.04, 0.38-2.81). Neither age nor the presence of underlying dementia was associated with a significant influence on the rate of response to the delirium prevention package. CONCLUSION: Staff may be more likely to implement an earlier and more effective intervention for males who are perceived as presenting a higher risk to themselves and others. The results reported highlight the need to increase staff's vigilance to female patients whose prodromal symptoms of delirium may be underemphasised. Understanding different sub-group responses to preventive educational packages for delirium is an important consideration if these are to be applied widely.

Age Factors↗
PubMed2006

Neuroleptic drugs in dementia: benefits and harm.

Neuroleptic (antipsychotic) drugs are often used to treat psychiatric symptoms frequently seen in dementia, but their use is controversial. We present a new meta-analysis to assess the efficacy of these drugs for the treatment of psychiatric symptoms in Alzheimer's disease, and discuss the more limited evidence for their potential benefits in other dementias. We recommend that these treatments be limited to the short-term treatment of psychiatric symptoms associated with serious distress or risk.

Alzheimer Disease↗
PubMed2006

Misunderstanding the intentions of others: an exploratory study of the cognitive etiology of persecutory delusions in very late-onset schizophrenia-like psychosis.

OBJECTIVE: The objective of this study was to explore the cognitive etiology of persecutory delusion formation and maintenance in very late-onset schizophrenia-like psychosis (SLP). METHOD: Probabilistic reasoning, causal attributional style, and mentalizing ability were examined in 29 patients with SLP, 30 with onset of depression after the age of 60 years and 30 healthy comparison subjects. RESULTS: Patients with SLP made significantly more errors than the healthy comparison group in deception, but not false belief, mentalizing tasks. There were no significant performance differences between groups on the probabilistic reasoning task or the attributional style task. CONCLUSIONS: Mentalizing errors may contribute to the development and maintenance of persecutory delusions in SLP. These patients do not appear to show the wider range of cognitive biases described in deluded patients with schizophrenia with onset in younger adult life.

Age of Onset↗
PubMed2006

Prevention, diagnosis and treatment of delirium: staff educational approaches.

Delirium is a common disorder especially among older people admitted to medical and surgical units. Research has demonstrated that many cases are underdiagnosed, misdiagnosed or not properly managed. Some of the difficulties encountered in the diagnosis, treatment and prevention may, in part, stem from a historical low emphasis on delirium in medical and nursing education. In recent years, attempts have been made to understand the impact of education on the prevention and management of delirium. In this review, diagnosis, treatment and prevention of delirium are considered in relation to the difficulties encountered in each of these areas. The role of increasing doctors' and nurses' awareness in the understanding of delirium through educational programs is also reviewed. The outcome of many cases of delirium is not changed by current treatment; however, there is increasing evidence that strategies employing appropriate multicomponent and/or educational staff intervention programs may decrease the prevalence of delirium.

Delirium↗
PubMed2005

Tract-specific anisotropy measurements in diffusion tensor imaging.

Diffusion tensor magnetic resonance imaging (DT-MRI) has been used to examine the microstructure of individual white matter tracts, often in neuropsychiatric conditions without identifiable focal pathology. However, the voxel-based group-mapping and region-of-interest (ROI) approaches used to analyse the data have inherent conceptual and practical difficulties. Taking the example of the genu of the corpus callosum in a sample of schizophrenic patients, we discuss the difficulties in attempting to replicate a voxel-based finding of reduced anisotropy using two ROI methods. Firstly we consider conventional ROIs; secondly, we present a novel tractography-based approach. The problems of both methods are explored, particularly of high variance and ROI definition. The potential benefits of the tractographic method for neuropsychiatric conditions with subtle and diffuse pathology are outlined.

Adult↗
PubMed2005

An educational intervention can prevent delirium on acute medical wards.

BACKGROUND: Delirium is a common disorder in hospitalised older people and established cases may have a poor outcome that is not readily improved by intervention. Prevention of cases through education of medical and nursing staff has not been fully studied. OBJECTIVES: To test the hypothesis that an educational package for medical and nursing staff would both reduce the number of incident cases of delirium and increase recognition of cases of delirium within an acute medical admissions ward. DESIGN: Single-blind case-control study. SETTING: Two acute admissions wards in a busy inner-city teaching hospital. SUBJECTS: 250 acute admissions over the age of 70 years. METHODS: An educational package for staff on one ward consisting of a 1 hour formal presentation and group discussion, written management guidelines and follow-up sessions. The follow-up sessions, which were based on one-to-one and group discussions, aimed at providing continuous support of staff through emphasising learning and testing knowledge. Diagnosis and management of some discharged delirium patients were also discussed to allow staff to learn from previous experience. The main outcome measures are point prevalence of delirium established by researchers, and recognition and case-note documentation of delirium by clinical staff. RESULTS: The point prevalence of delirium was significantly reduced on the intervention compared to the control ward (9.8% versus 19.5%, P < 0.05) and clinical staff recognised significantly more delirium cases that had been detected by research staff on the ward where the educational package had been delivered. CONCLUSION: A focused and inexpensive educational programme can decrease the prevalence of delirium among older inpatients.

Acute Disease↗
PubMed2004

Liver volume in thalassaemia major: relationship with body weight, serum ferritin, and liver function.

BACKGROUND: It is not known whether body weight alone can adjust for the volume of liver in the calculation of the chelating dose in beta-thalassaemia major patients, who frequently have iron overload and hepatitis. OBJECTIVE: The hypothesis is that liver volume in children and adolescents suffering from beta-thalassaemia major is affected by ferritin level and liver function. MATERIALS AND METHODS: Thirty-five beta-thalassaemia major patients aged 7-18 years and 35 age- and sex-matched controls had liver volume measured by MRI. Serum alanine aminotransferase (ALT) and ferritin levels were obtained in the thalassaemia major patients. RESULTS: Body weight explained 65 and 86% of the change in liver volume in beta-thalassaemia major patients and age-matched control subjects, respectively. Liver volume/kilogram body weight was significantly higher (P < 0.001) in thalassaemia major patients than in control subjects. There was a significant correlation between ALT level and liver volume/kilogram body weight (r = 0.55, P = 0.001). Patients with elevated ALT had significantly higher liver volume/kilogram body weight (mean 42.9 +/- 12 cm3/kg) than control subjects (mean 23.4 +/- 3.6 cm3/kg) and patients with normal ALT levels (mean 27.4 +/- 3.6 cm3/kg). CONCLUSIONS: Body weight is the most important single factor for liver-volume changes in thalassaemia major patients, but elevated ALT also has a significant role. Direct liver volume measurement for chelation dose adjustment may be advantageous in patients with elevated ALT.

Adolescent↗
PubMed2004

Investigation of the diffusion processes in a self-processing acrylamide-based photopolymer system.

Results from the investigation of the diffusion processes in a dry acrylamide-based photopolymer system are presented. The investigation is carried out in the context of experimental research on optimization of the high-spatial-frequency response of the photopolymer. Tracing the transmission holographic grating dynamics at short times of exposure is utilized to measure diffusion coefficients. The results reveal that two different diffusion processes contribute with opposite sign to the refractive-index modulation responsible for the diffraction grating buildup. Monomer diffusion from dark to bright fringe areas increases the refractive-index modulation. It is characterized with diffusion constant D0 = 1.6 x 10(-7) cm2/s. A second diffusion process takes place during the recording. It decreases the refractive-index modulation and we ascribe it to diffusion of short-chain polymer molecules or radicals from bright to dark fringe areas. The estimated diffusion coefficient for this process is D0 = 6.35 x 10(-10) cm2/s. The presence of the second process could be responsible for the poor high-spatial-frequency response of the investigated photopolymer system. Comparison with the diffusion in photopolymer systems known for their good response at high spatial frequencies shows that both investigated diffusion processes occur in a much faster time scale.

Journal Article↗
PubMed2004

The cerebellum and decision making under uncertainty.

This study aimed to identify the neural basis of probabilistic reasoning, a type of inductive inference that aids decision making under conditions of uncertainty. Eight normal subjects performed two separate two-alternative-choice tasks (the balls in a bottle and personality survey tasks) while undergoing functional magnetic resonance imaging (fMRI). The experimental conditions within each task were chosen so that they differed only in their requirement to make a decision under conditions of uncertainty (probabilistic reasoning and frequency determination required) or under conditions of certainty (frequency determination required). The same visual stimuli and motor responses were used in the experimental conditions. We provide evidence that the neo-cerebellum, in conjunction with the premotor cortex, inferior parietal lobule and medial occipital cortex, mediates the probabilistic inferences that guide decision making under uncertainty. We hypothesise that the neo-cerebellum constructs internal working models of uncertain events in the external world, and that such probabilistic models subserve the predictive capacity central to induction.

Adolescent↗
PubMed2004

Skeletal injury patterns in older females.

Injury patterns in elderly patients are different from those in younger patients. With recent emphasis on osteoporosis and its effects, we looked at a continuous series of patients from one Level 1 trauma center regarding injury patterns by gender. For all patients older than 65 years, and including all mechanisms, older women were more likely to sustain forearm and wrist fractures than were older men. For the individual mechanism of motor vehicle collision there was a significant increase in the extremity Abbreviated Injury Scores in older women compared with older men. Similarly, older women were more likely to sustain lower leg fractures and distal upper extremity fractures than were older men. This raises the possibility that increased bone loss, as seen in older women, may be reflected in the injury patterns they sustained given the same mechanism. More work is warranted in this region to potentially diminish these effects.

Accidental Falls↗
PubMed2004

Neuropsychological processing associated with recovery from depression after stereotactic subcaudate tractotomy.

OBJECTIVE: The authors compared patients who underwent stereotactic subcaudate tractotomy for depression, who were still depressed or recovered from depression, to identify therapeutic mechanisms. METHOD: Ten depressed and eight recovered psychosurgery patients, along with nine never-depressed subjects and nine who had recovered from depression with medication, completed the Iowa Gambling Task, a measure of decision making in the face of feedback. Psychosurgery patients also completed general neuropsychological testing. RESULTS: Recovered psychosurgery patients exhibited insensitivity to negative feedback on the Iowa Gambling Task compared to the other three groups. This difference between the groups remained when general neuropsychological performance was covaried out. CONCLUSIONS: These findings suggest acquired relative insensitivity to negative information as a specific mechanism mediating the antidepressant effect of stereotactic subcaudate tractotomy. Such insensitivity is not secondary to deficits in general neuropsychological functioning and is not a function of recovery from depression per se.

Adult↗