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BACKGROUND The Montreal Cognitive Assessment (MoCA) is often used for cognitive screening across health care settings, especially in rehabilitation centers, where assessment and treatment of cognitive function is considered key for successful multidisciplinary treatment. Although the original MoCA validation study suggested a cut score of

Convergent validation of a verbal incidental learning (IL) task from the WAIS-IV using neuroimaging biomarkers is warranted to understand its sensitivity to Alzheimer's disease (AD) pathology. Fifty-five memory clinic patients aged 59 to 87 years received neuropsychological assessment, and measures of IL and quantitative brain imaging. Worse IL-Total Score and IL-Similarities performances were significantly associated with smaller hemispheric hippocampal volumes. IL measures were not significantly correlated with cerebral β-amyloid burden, though a trend was present and effect sizes were mild. These hippocampal volume results suggest that this IL task may be sensitive to AD pathology along the AD continuum.

BACKGROUND The prevalence and incidence of attention-deficit/hyperactivity disorder (ADHD) have increased substantially among children and adolescents over the past decade; however, little is known regarding trends in adult populations. OBJECTIVE The objective of this study was to explore trends in the prevalence, incidence, and correlates of adult ADHD in a national sample of veterans receiving care at Veteran Affairs (VA) hospitals and clinics. RESEARCH DESIGN A retrospective design was used to examine ADHD diagnosed in all VA primary care (PC) and mental health clinics (MHCs) from fiscal years (FYs) 2009 to 2016. Age-adjusted prevalence and incidence were calculated using direct standardization, and Poisson regressions modeled differences in trends between demographic groups. SUBJECTS All veterans with VA PC or MHC visits during the observation period. MEASURES ADHD incidence and prevalence, psychiatric comorbidity, neuropsychological evaluation. RESULTS An annual average of 5.09 million (range: 4.63-5.42 million) VA patients attended a PC or MHC appointment between FY09 and FY16. During this period, age-adjusted annual prevalence increased 258% from 0.23% to 0.84% and incidence increased 240% from 0.14% to 0.48%. Black veterans and older veterans had the lowest prevalence and incidence across all years. Increases in prevalence and incidence occurred across all demographic subgroups. The proportion of patients who had a neuropsychological evaluation within 6 months before or after a new ADHD diagnosis decreased from 12.6% to 10.8% [χ(1)=16.59, P

Although incidental learning (IL) routinely occurs in everyday life, it is infrequently assessed during neuropsychological evaluations. This study aimed to further examine the concurrent validity of IL measures based on the Vocabulary and Similarities subtests from the Wechsler Adult Intelligence Test-Fourth Edition (WAIS-IV). Participants included 43 Veterans referred for outpatient neuropsychological testing. Performances on the IL procedures correlated strongly with performances on the Repeatable Battery for the Assessment of Neuropsychological Status Immediate and Delayed Recall Indices (

The Stroop Color and Word Test is a test of processing speed, response inhibition, and executive functioning (EF). This project examined whether extending the Stroop Color-Word trial beyond the standard time limit could more accurately assess performance on EF measures. Cognitively healthy older individuals (n=198) enrolled in a study of cardiovascular health completed the Stroop as part of a neuropsychological battery. Two scores were computed for the Color-Word trial: the number of items completed within the first 45 seconds (traditional Color-Word score) and the speed of page completion beyond the first 45 seconds (Stroop-Extended score). Criterion measures included the Trail-Making Test Part B (TMT-B), Digit Span Backward, Symbol Digit Modalities Test, Short Category Test, and measures of verbal fluency. Results from hierarchical linear regression analyses indicated that the extended Stroop score accounted for small but statistically significant variance in TMT-B (additional 2.6%) and Digit Span Backwards (additional 2.6%) beyond the standard Color-Word score. These findings suggest that extending the Stroop Color-Word trial beyond the first 45 seconds provides a limited increase in predictive power within a healthy sample with restricted range of performance. The extended Stroop requires additional examination in heterogeneous samples, including clinical populations, to determine its predictive utility.

Objectives Recent efforts have been made to develop 10 personality disorder spectra scales using items from the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF). These scales, developed by Sellbom et al. (2018, J. Pers. Assess., 1-15), demonstrated good validity and warranted cross-validation. Method In all, 97 veterans undergoing neuropsychological evaluation in a VA outpatient clinic completed the MMPI-2-RF and the MCMI-III. We examined the psychometric properties of the scales and proposed additional scales based on personality constructs found in other established tests and prior versions of the Diagnostic and Statistical Manual for Mental Disorders (DSM; APA, 2013). Results The 10 original and three additional scales demonstrated acceptable psychometric properties. Most of the 13 scales correlated strongly with the corresponding MCMI-III scale, however, DSM criteria coverage was variable between scales. Conclusion These data provide additional support for 10 personality disorder spectra scales based on MMPI-2-RF items and establish preliminary evidence for three additional scales. Further validation is needed in larger and diverse samples.

Purpose/Aim of the Study: The Neurobehavioral Symptom Inventory (NSI) is a 22-item self-report measure created to quantify the somatosensory, cognitive, and affective symptoms of Post-concussive Sy...

Objectives This study examined how depression, anxiety, and sleep items from the Neurobehavioral Symptom Inventory (NSI) predict results from longer inventories. Method This was a retrospective review from 484, predominantly male (96.1%) Veterans, mean age 29.7 years, who underwent brief neuropsychological screening during a comprehensive, multidisciplinary evaluation for mild traumatic brain injury (TBI). Participants completed the NSI, insomnia severity index (ISI), and hospital anxiety and depression scale (HADS). Results OVERALL,: 97.1% who endorsed "severe"/"very severe" anxiety on the NSI had significant anxiety on the HADS; 85% reporting "severe"/"very severe" depression on the NSI, had significant depression on the HADS; and 97.7% reporting "severe"/"very severe" sleep problems on the NSI, had significant sleep difficulties on the ISI. Conclusion Close correspondence between "severe"/"very severe" symptoms on the NSI and lengthier checklists suggests additional checklists may be eliminated and individuals can be referred for mental health treatment. NSI reports of "mild"/"moderate" require further screening.

Incidental memory may reflect a form of learning in everyday life, although it is not consistently evaluated during standard neuropsychological evaluations. Further validation of a recently created measure of verbal Incidental Learning (IL) from the Wechsler Adult Intelligence Scale-IV is necessary to understand the utility of such a measure in clinical settings. Sixty-eight adults aged 50 to 89 were recruited from a Cognitive Disorders Clinic while receiving a standard neuropsychological assessment, along with two additional measures of IL. IL-Total Score was significantly correlated with immediate and delayed memory trials from standard neuropsychological tests (rs = .43 to .73, ps .001, ds = 0.94-2.14), with worse IL performance being associated with lower memory abilities. Participants with probable Alzheimer's disease performed worse on the IL-Total Score than participants with Mild Cognitive Impairment, t(39.997) = 5.46, p .001, d = 1.13. Given the strong relationships between this IL task and traditional memory measures in our sample, and the discrimination of IL-Total Score performance among diagnostic groups despite its short administration time, this IL task may play a role as a measure of memory in brief cognitive evaluations.

The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is a cognitive battery that contains scales of several cognitive abilities, but no scale in the instrument is exclusively dedicated to executive functioning. Although the subtests allow for observation of executive-type errors, each error is of fairly low base rate, and healthy and clinical normative data are lacking on the frequency of these types of errors, making their significance difficult to interpret in isolation. The aim of this project was to create an RBANS executive errors scale (RBANS EE) with items comprised of qualitatively dysexecutive errors committed throughout the test. Participants included Veterans referred for outpatient neuropsychological testing. Items were initially selected based on theoretical literature and were retained based on item-total correlations. The RBANS EE (a percentage calculated by dividing the number of dysexecutive errors by the total number of responses) was moderately related to each of seven established measures of executive functioning and was strongly predictive of dichotomous classification of executive impairment. Thus, the scale had solid concurrent validity, justifying its use as a supplementary scale. The RBANS EE requires no additional administration time and can provide a quantified measure of otherwise unmeasured aspects of executive functioning.

The Grooved Pegboard Test (GPT) is used primarily as a measure of motor functioning, but some research indicates that performance on this test my also reflect cognitive factors, particularly attention and executive functioning. The aim of this study was to examine rule violations as a possible quantifiable measure of executive functioning, particularly inhibitory control. In a sample of 82 veterans undergoing neuropsychological evaluation at a Virginia (VA) outpatient clinic, we recorded instances of two types of rule violations: using the incorrect hand during insertion and placing pegs out of sequence. Criterion measures included the Trail Making Test, the Tower of London, and the Stroop Color and Word Test. As hypothesized, total number of rule violations correlated moderately to strongly with the criterion measures. Notably, 60% of individuals committing two or more rule violations were impaired on at least two of the criterion measures, whereas only 17% of individuals without any rule violations were impaired on two criterion measures. Rule violations during the GPT provide valuable supplementary data for assessing executive dysfunction with no additional task demand or time cost. These data suggest that making two or more errors should raise suspicion of executive dysfunction.

This study explored the utility of combining data from measures of performance validity and symptom validity among Veterans undergoing neuropsychological evaluation for mild traumatic brain injury (mTBI).Persistent cognitive impairments following mTBI are often reported by returning combat veterans. However, objectively-measured cognitive deficits are not common among individuals with mTBI, raising the question of whether negative impression management influences self-ratings.Self-report ratings were obtained for memory, concentration, decision-making, and processing speed/organization using a 5-point scale ranging from 'none' to 'very severe'. Veterans also completed brief neuropsychological testing which included measures of performance validity.Study 1 examined data from 122 participants and demonstrated that veterans reporting a 'very severe' cognitive deficit were over three times as likely to demonstrate poor effort on a validity test than those without a very severe rating. Study 2 replicated these findings in an independent sample of 127 veterans and also demonstrated that both severity of self-report ratings and performance on an embedded measure of effort were predictive of poor effort on a stand-alone performance validity test.Veterans with suspected mTBI who report 'very severe' cognitive impairment have a greater likelihood of putting forth sub-optimal effort on objective testing.

This study evaluated whether using the Peabody Picture Vocabulary Test-First Edition (PPVT-I) basal and ceiling criteria would result in similar estimates of receptive vocabulary while permitting administration of fewer test items when using the third and fourth editions of the PPVT. Data were retrospectively collected from 119 adult inpatients who completed a neuropsychological screen that included the PPVT-III or PPVT-IV, which were re-scored using PPVT-I criteria. PPVT-III/IV raw scores were not significantly different from PPVT-I raw scores. Although the difference between the PPVT-III/IV and PPVT-I standard scores was statistically significant, the difference was less than 8 points in 95% of cases. On average, 15 fewer items would be administered using the PPVT-I rules, leading to shorter administration time.

Alphabet Printing (in the forward and backward order) is a brief and highly portable test with promise as a screening measure of processing speed and simple working memory, constructs which are only minimally assessed in many of the most commonly-used cognitive screening instruments. The aim of this project was to examine the construct validity of timed Alphabet Printing in a sample of 254 Veterans with cognitive complaints and a history of possible head injury. Criterion measures included more established tests of processing speed and simple working memory, including the Trail Making Test and the Digit Span subtest from the fourth edition of the Wechsler Adult Intelligence Scales. Alphabet Printing scores moderately correlated with the criterion measures of attention, working memory, and processing speed, and demonstrated acceptable classification accuracy in discriminating between individuals with and without evidence of cognitive impairment on Trails B. These findings provide additional support for the possible utility of including Alphabet Printing during cognitive screenings or as part of a larger neuropsychological test battery.

Many Veterans involved in recent OEF/OIF conflicts return with reports of having experienced an mTBI. The Veteran's Affairs (VA) and Department of Defense (DoD) have gone to great lengths to provide information to Veterans regarding possible effects of TBI. Although well intended, this information may possibly have an iatrogenic effect. Conversely, setting positive expectations for recovery from mTBI has been shown to result in decreased symptomatology.One-way ANOVA and Tukey post-hoc analyses were used to determine whether there were significant differences on reported severity and number of PCS symptoms (NSI) among the three experimental groups (recovery focused information; expectation for persistent symptoms; and no information given).Undergraduate students, who were told to imagine they had experienced a military-related TBI, reported varying levels of expected symptoms when given either positive or negative information about symptom expectation.The results indicate that presenting recovery-oriented literature resulted in the lowest report of expected symptoms, whereas presenting no information resulted in the highest report of expected symptoms.Providing Veterans with information regarding a likely positive trajectory of recovery may result in less symptom persistence during rehabilitation.

Many studies have evaluated the influence of mild traumatic brain injury (mTBI) on neuropsychological test performance and on report of postconcussive symptoms. However, most studies that examine postconcussion syndrome (PCS) do not address the issue of "polytrauma," which is common in military mTBI. This study investigated simultaneously demographic, injury-related, and psychiatric symptom predictors of PCS report in a veteran, polytrauma sample. In prediction of overall report of PCS symptoms with demographic, traumatic brain injury, psychiatric and sleep variables, 60% of the variance was explained. Semipartial correlations revealed that post-traumatic stress disorder uniquely explained 7% of the variance, depression 2%, and sleep dissatisfaction 3%; injury and demographic characteristics accounted for no unique variance. In all 5 hierarchical multiple regressions (prediction of total Neurobehavioral Symptom Inventory score and 4 individual factor scores), the total models were significant (p0.001). Accurate diagnosis and treatment necessitates an integrative analysis of PCS, psychiatric, behavioral, and health symptom report in addition to neuropsychological functioning in the polytrauma population. This study demonstrated that emotional distress was uniquely predictive of total report of PCS and that no injury-related characteristics were predictive. This is of particular relevance in a Veteran population given the high rates of both mTBI and psychiatric disturbance.

OBJECTIVE We assessed the validity of a brief incidental learning measure based on the Similarities and Vocabulary subtests of the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV). BACKGROUND Most neuropsychological assessments for memory require intentional learning, but incidental learning occurs without explicit instruction. Incidental memory tests such as the WAIS-III Symbol Digit Coding subtest have existed for many years, but few memory studies have used a semantically processed incidental learning model. METHODS We conducted a retrospective analysis of 37 veterans with traumatic brain injury, referred for outpatient neuropsychological testing at a Veterans Affairs hospital. As part of their evaluation, the participants completed the incidental learning tasks. We compared their incidental learning performance to their performance on traditional memory measures. RESULTS Incidental learning scores correlated strongly with scores on the California Verbal Learning Test-Second Edition (CVLT-II) and Brief Visuospatial Memory Test-Revised (BVMT-R). After we conducted a partial correlation that controlled for the effects of age, incidental learning correlated significantly with the CVLT-II Immediate Free Recall, CVLT-II Short-Delay Recall, CVLT-II Long-Delay Recall, and CVLT-II Yes/No Recognition Hits, and with the BVMT-R Delayed Recall and BVMT-R Recognition Discrimination Index. CONCLUSIONS Our incidental learning procedures derived from subtests of the WAIS-IV Edition are an efficient and valid way of measuring memory. These tasks add minimally to testing time and capitalize on the semantic encoding that is inherent in completing the Similarities and Vocabulary subtests.

BACKGROUND/STUDY CONTEXT: Although many of the Mini-Mental State Examination's (MMSE) limitations are well accepted among geriatricians, neuropsychologists, and other interested clinicians and researchers, its continued use in psychometrically unsound ways suggests that additional investigation and dissemination of information are sorely needed. The authors aimed to describe the reliability and validity of the MMSE as a measure of cognitive function among healthy older adults.The authors examined MMSE performance in 124 stroke- and dementia-free, community-dwelling older adults (65% male; mean age = 66.5 years). All participants were administered an extensive neuropsychological battery composed of measures of attention, executive function, memory, and visuospatial function. A subset of 99 participants also underwent magnetic resonance imaging (MRI). MMSE test-retest reliability was examined among 65 participants who underwent repeat MMSE testing over an average interval of 83.2 days.Spearman test-retest correlation for total MMSE scores was r S = .35 (p = .004), for Serial Sevens was r S = .40 (p = .001), and for Word Recall was r S = -.01 (p = .96). Total MMSE performance correlated significantly with a minority of neuropsychological tests and MRI-derived indices of white matter disease and brain atrophy. A subset of 17% of participants demonstrated inappropriate intrusion of MMSE Pentagon Copy during another test of visuospatial recall.Overall, MMSE scores exhibited ceiling effects, poor test-retest reliability, limited sensitivity to subtle brain abnormalities, and a high rate of intrusion elsewhere in the neuropsychological battery. Individual MMSE items demonstrated poor construct validity. These qualities illustrate the serious limitations of the MMSE in detecting individual differences in cognitive function among healthy older adults.

To examine interactive relations of blood pressure (BP) and age to MRI indices of subclinical cerebrovascular disease in middle-aged to older adults.One hundred and thirteen stroke-free and dementia-free, community-dwelling adults (ages 54-81 years; 65% men; 91% white) engaged in (1) clinical assessment of resting SBP and DBP; (2) MRI rated for periventricular white matter hyperintensities (WMH) and deep WMH silent brain infarction (SBI) and brain atrophy (i.e. ventricular enlargement and sulcal widening ). Principal components analysis of the MRI ratings yielded a two-component solution--(1) periventricular and deep WMH SBI; and (2) ventricular enlargement, sulcal widening.Relations of SBP, DBP and pulse pressure (PP) (and their interactions with age) to each MRI component were examined in multiple regression analyses adjusted for age, sex, fasting plasma glucose and cholesterol, and antihypertensives. For component 1, results indicated significant interactions of SBP and PP with age (P0.05); higher levels of SBP and PP were associated with greater white matter disease and brain infarction at younger ages (≤ 68 years). Significant interactions of SBP and DBP with age were also noted for component 2 (P0.05); higher levels of BP were associated with greater brain atrophy at younger ages (≤ 63 years).: Higher BP and PP are associated with greater subclinical cerebrovascular disease most prominently in the 'young old'. Appropriate management of hypertension and arterial stiffening may be critical to the preservation of brain structure with ageing.

Incidental learning (IL) measures provide complementary assessment data reflecting subconscious encoding of information using methods that differ from the procedures of many traditional memory tests. We examined the concurrent validity of an IL measure based on the coding subtest of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Participants included veterans referred for outpatient neuropsychological testing. Performance on the IL procedures correlated more strongly with memory indices than other indices on the RBANS. Patients with at least four correct responses very rarely had significant memory impairments. Thus, IL appears to contribute to the overall assessment of memory and requires little administration time.

To examine relations of blood pressure (BP) with single photon emission computed tomography (SPECT)-derived estimates of cerebral blood flow in older men and women.Seventy-four stroke and dementia-free, community-dwelling older adults (ages 54-83 years; 68% men; 91% white) free of major medical, neurological, or psychiatric disease, engaged in clinical assessment of resting SBP and DBP, MRI rated for brain atrophy, and brain single photon emission computed tomography (SPECT) studies with computerized coding of cortical and select subcortical regions of interest.Given significant interactions of BP and sex with respect to multiple SPECT outcomes, sex-stratified multiple regression models were computed. Models were adjusted for age, fasting glucose levels, antihypertensive medication, BMI, and MRI ratings of brain atrophy. In men (n = 50), higher levels of SBP and/or DBP were associated significantly with lower estimates of cerebral perfusion in the right and left frontal, temporal, parietal, and occipital cortex, thalamus, head of caudate, and cingulate cortex accounting for up to 28% of the variance in these measures (P0.05). In women (n = 24), higher DBP was related marginally to higher levels of perfusion in the right temporal cortex (P = 0.05).Higher resting SBP or DBP was associated with lower levels of cerebral perfusion in otherwise healthy older men, but not women, in the present sample. Reduced cerebral blood flow may play a pathogenic role in increasing risk for stroke, dementia, and/or cognitive decline, particularly among older men with high BP.

Reliable Digit Span (RDS) is a measure of effort derived from the Digit Span subtest of the Wechsler intelligence scales. Some authors have suggested that the age-corrected scaled score provides a more accurate measure of effort than RDS. This study examined the relative diagnostic accuracy of the traditional RDS, an extended RDS including the new Sequencing task from the Wechsler Adult Intelligence Scale-IV, and the age-corrected scaled score, relative to performance validity as determined by the Test of Memory Malingering. Data were collected from 138 Veterans seen in a traumatic brain injury clinic. The traditional RDS (≤ 7), revised RDS (≤ 11), and Digit Span age-corrected scaled score ( ≤ 6) had respective sensitivities of 39%, 39%, and 33%, and respective specificities of 82%, 89%, and 91%. Of these indices, revised RDS and the Digit Span age-corrected scaled score provide the most accurate measure of performance validity among the three measures.

Veterans undergoing evaluation for mild traumatic brain injury commonly report insomnia, psychiatric symptoms, and cognitive dysfunction. This study examines the effects of self-reported amount of sleep and subjective sleep quality on neuropsychological test performance.262 veterans were seen for neuropsychological assessment in a Veterans Affairs traumatic brain injury clinic. All participants completed measures of depression, anxiety, and sleep satisfaction, and also estimated the number of hours they slept the night before the assessment. Factor scores of attention/concentration and memory were created using factor analyses. Data were analyzed with linear regression.Depression and anxiety were significantly correlated with sleep satisfaction and predictive of cognitive ability. Both sleep satisfaction and hours slept were significantly correlated with memory, but not attention. After controlling for the effects of depression and anxiety, hours slept but not sleep satisfaction was predictive of memory test performance.Perceived sleep quality is heavily influenced by psychiatric symptoms; therefore, veterans' report of sleep satisfaction may merely reflect their overall level of distress. Sleep quantity, however, appears to uniquely contribute to memory performance. Thus, assessment of sleep is important and provides clinicians with useful information, especially among individuals with psychiatric comorbidities.

Mild traumatic brain injury (mTBI) is not uncommon among Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans, and many individuals within this group report lingering cognitive difficulties following their injury. For Department of Veterans Affairs clinicians, an accurate assessment of cognitive symptoms is important in providing appropriate clinical care. Although self-assessment is commonly employed to screen for difficulties in cognitive functioning, little is known about the accuracy of self-report in this population. This study collected cognitive, psychiatric, and self-report data from 105 OIF/OEF veterans with mTBI to examine the relationship between self-reported cognitive functioning and objective neuropsychological test performance. Additionally, clinicians who frequently work with OIF/OEF veterans were asked to predict the magnitude of these associations. Self-reported cognitive functioning was not significantly correlated with objective cognitive abilities, suggesting that objective neuropsychological testing should be used when cognitive weakness is suspected. Perceived cognitive deficits were associated with depression, anxiety, and posttraumatic stress disorder, illustrating the additional importance of adequate assessment and treatment of psychiatric symptoms. Clinicians tended to overestimate the association between self-report and test performance.

The Cognitive Estimation Test (CET), which purportedly assesses aspects of executive functioning, consists of answering questions that require deductive reasoning. This paper explored the CET's psychometric properties in neurorehabilitation samples, including its reliability and strength of association with tests involving varying levels of executive skill. Among 112 patients (age = 65.3 years, SD = 12.5) with various neurological impairments, CET performance had limited reliability and was moderately correlated with nearly all cognitive tests examined, regardless of their executive demands. These findings highlight the poor divergent validity of the CET and raise questions of its utility in cognitive assessment.

Recent reports of increasing incidence, especially in men, led us to update through 1989 an earlier study of colorectal cancer incidence in Rochester that covered the period 1940 through 1979. The combined data reflected cancer trends in the community over half a century. Data resources of the Rochester Epidemiology Project were used to identify new cases of colon and rectal cancer among Rochester residents. Incidence rates were estimated using decennial census data, and 95% confidence intervals were based on the Poisson distribution. The GLIM statistical package was used to evaluate trends over time. Age-adjusted (US white 1970) incidence rates of colorectal cancer for men were 53.7, 61.3, 53.7, 54.2, and 52.5 per 100,000 person-years, respectively, for the decades 1940 to 1949, 1950 to 1959, 1960 to 1969, 1970 to 1979, and 1980 to 1989. Comparable rates for women were 42.7, 49.3, 42.9, 40.7, and 40.9 per 100,000 person-years. No statistically significant changes were seen in the incidence of colon and rectum cancer for men or women. There was no consistent trend in tumor stage at diagnosis and the mean size of the initial lesion did not change with time. The incidence of colorectal cancer has not changed over the past 50 years in this community where case ascertainment has been consistent and complete.

PURPOSE: The aim of our study was to evaluate the risks of multiple hemorrhoidal bandings in a single session. METHODS: We retrospectively examined all of the patients who had hemorrhoidal bandings from July 1989 to August 1992. RESULTS: Patients with multiple hemorrhoidal banding in a single session when compared with patients with single banding had greater discomfort and pain (29 percentvs.4.5 percent), but this discomfort was usually manageable with oral analgesia of limited duration. There were also more vasovagal symptoms (5.2 percentvs.0 percent), local swelling and edema (2.6 percentvs.0 percent), and urinary hesitancy and frequency (12.3 percentvs.0 percent) in the multiple-banded patients. No major complication such as massive delayed bleeding and perineal or pelvic sepsis was noted. CONCLUSION: Most patients tolerated multiple hemorrhoidal banding in a single session with acceptably low complications. Multiple banding in a single session is a safe and cost-effective alternative.

One hundred twenty patients with primary retrorectal tumors (79 congenital, 14 neurogenic, 13 osseous, and 14 miscellaneous) had their initial treatment at the Mayo Clinic from 1960 to 1979. The mean age was 43 years (100 patients were adults). Female predominance was associated with congenital cysts (15:1) and male predominance with chordomas (5:1). Forty-three percent of the patients had malignant lesions. No dermoid cysts were found in this series. Diagnosis was made by digital examination or sacral radiographs in all patients. Computed tomography scan was the most important diagnostic method; the rate of positive findings was 100 percent in 20 patients. Approach to the tumor was posterior in 79 of 102 patients in whom resection was possible. Ten of 66 patients with benign tumors had recurrence. The five-year survival rate for patients with chordomas was 75 percent and for patients with other malignant lesions was 17 percent. Because preoperative biopsy can cause tumor spread, abscess, fecal fistula, or meningitis, it should not be performed if tumors are potentially resectable. Whenever possible, total resection should be done.

The issue of whether patients who have invasive carcinoma in an otherwise benign polyp should undergo surgical resection of that bowel segment is controversial. We examined the records of 83 patients with such polyps that were removed endoscopically between 1978 and 1981. After exclusion of 18 patients from the study for various reasons, our study group consisted of 65 patients who had undergone complete endoscopic removal of 69 polyps that contained a malignant process. Carcinoma in situ was found in 34 polyps, and 3 patients with such polyps had a recurrent malignant lesion of the same degree. These recurrent tumors were treated successfully by aggressive endoscopic removal. Seventeen polyps that contained invasive carcinoma were treated endoscopically without resection, and two patients in this group subsequently had recurrent carcinoma at the site of the original polyp. These recurrent lesions were resected, and neither patient had evidence of nodal metastasis. Of the 18 patients who underwent immediate resection of invasive carcinoma, 2 had residual carcinoma at the time of the resection, although no lymph node metastasis was found. We conclude that colonic polyps with carcinoma in situ can be treated safely with complete endoscopic removal. Invasive carcinoma in a polyp can be treated safely with complete polypectomy, and immediate resection may not be necessary. This group of patients, however, should undergo thorough follow-up studies and periodic endoscopic reexamination.

A prospective study was done on 34 patients using magnetic resonance imaging (MRI) and computed tomography (CT) preoperatively to stage patients with known rectal carcinoma. The study was done to determine the accuracy and clinical usefulness of CT and MRI. The Thoeni staging method was used. Twenty-four of 30 cases were staged correctly by CT. Sixteen of 27 were staged correctly by MRI. CT detected lymph node metastases in six of 15 cases with one false-positive. MRI detected lymph node metastases in two of 15 patients with one false-positive. CT was the preferred examination, and was useful in some cases. These cases included patients with small tumors who were considered for local excision and patients with extensive disease who were candidates for preoperative or intraoperative radiation treatment. MRI demonstrated extensive disease, as did CT in our later cases.

A technique to measure the pH on the surface of rectal mucosa of humans and dogs is described.

We conducted a retrospective cohort study of 751 residents of Rochester, Minnesota, whose small (1 cm or less) colorectal polyps had been treated without biopsy. Eighteen colorectal carcinomas were found in this group in the course of more than 10,000 person-years of follow-up, whereas 15.27 cases were expected (relative risk, 1.2). The overall rate for the development of cancer and the relative risks for various subgroups of the cohort were not significantly elevated, and survival in this cohort was not impaired. We conclude that fulguration of selected small colorectal polyps without prior biopsy does not subject patients to an unusual risk for development of colorectal carcinoma. Customary periodic medical examination should suffice for patients with these lesions.

A series of 1007 patients was randomly divided into two groups, one a group of 499 patients who underwent rigid sigmoidoscopy and the other a group of 508 patients who had flexible sigmoidoscopy. Contrast barium enema studies were subsequently performed in all patients. Eighteen per cent of the patients had a neoplasm. We concluded that, given the amount of colon surveyed by rigid and flexible sigmoidoscopy in conjunction with contrast barium enema, there was no difference in the rate of detection between the two endoscopic techniques.

Of 323 patients with colorectal polyps that either were larger than 1 cm in diameter or were 1 cm or smaller but had been subjected to biopsy or excision, 20 (6%) had subsequent development of a colorectal carcinoma, an incidence rate of 4.6 per 1,000 person-years of follow-up. These 20 cases of cancer compared with 7.38 cases expected; thus, the risk of colorectal carcinoma in these patients was 2.7 times that in the general population (P less than 0.001). Although risks were greater for certain subgroups of patients, the differences detected were usually modest. We conclude that patients with large colorectal polyps (more than 1 cm in diameter) should be closely followed up after treatment of the initial polyp, regardless of the size, site, or histologic type of the polyp, the age or sex of the patient, or the type of initial treatment (excision or fulguration). Those patients with more than one polyp, especially if more than one segment of the colon is involved, need special attention. Examination of the entire colon is important because the site of development of carcinoma may be distant from the site of the initial polyp.

Twenty-two patients with leiomyosarcoma of the rectum (n = 19) or the anus (n = 3) were treated surgically at the Mayo Clinic from 1950 through 1985. The majority of tumors occurred in men (1.4:1.0) during the sixth and seventh decades of life. Fifty-nine percent of the patients had symptoms including, most commonly, change in bowel habit, bleeding, and pain. Wide local excision was performed in 10 patients, whereas a more radical surgical procedure, including abdominoperineal resection (n = 8), pelvic exenteration (n = 2), and low anterior resection (n = 1), were performed in 11 patients. One tumor was unresectable. The overall survival until death from disease was 90% at 1 year, 74% at 5 years, and 51% at 10 years postoperatively. The percentage of patients free of disease at 1, 5, and 10 years postoperatively was 85, 62, and 40, respectively. Wide local resection was not superior to a more radical surgical approach in preventing tumor recurrence or improving survival. Lesions less than 2.5 cm and confined to the bowel wall can be treated by wide local excision, whereas larger or more extensive tumors should be treated by a more radical surgical approach.

Thirty adenomas of the large bowel, removed from 15 females and 15 males, were examined for the presence of estrogen receptor protein. The finding of positive binding capacity in two of the 30 adenomas supports the hypothesis that hormonal dependency does not play a major role in the development and growth of colorectal adenomas.

Manometric studies of internal sphincter responses were carried out on 15 patients--14 with rectal prolapse and one with mucosal prolapse with proctitis cystica profunda. In all 12 patients studied preoperatively, the internal sphincter reflexes (inhibitory reflex) were absent or markedly obtunded. Anterior resection was performed on three of the patients in whom preoperative and postoperative manometric studies could be carried out. In one, the inhibitory reflex returned to normal after successful corrective surgery and in one, absence of the reflex persisted after anterior resection and this patient eventually had recurrent rectal prolapse.

A series of 121 patients with chronic fissure-in-ano who underwent fissurectomy with superficial midline sphincterotomy was studied. The mean follow-up was 8.1 years. Minor problems with anal competence occurred after the operation in 30 patients (25 per cent). Within two months, this problem had resolved in all patients. One patient (0.8 per cent) had a true recurrence. Five patients (4.1 per cent) had recurrent acute anal abrasions as the result of passage of a hard stool. These healed spontaneously. Twelve patients (9.9 per cent) had fragile scars, but this was a significant problem in only five (4.1 per cent). No patient had significant stricture formation, keyhole deformities, or major persistent problems with anal competence. The patients graded their operations with regard to satisfaction: 118 (97.5 per cent) reported satisfactory results and three (2.5 per cent) reported unsatisfactory results. This study shows that fissurectomy with superficial midline sphincterotomy is a viable approach to the surgical management of chronic fissure-in-ano.

Forty patients with fecal incontinence underwent sphincter repair between 1975 and 1984. Divided sphincter musculature resulted from obstetrical injury in 23 and previous anorectal surgery in 17. Eighteen had undergone a previous attempt at repair. Fifteen patients experienced seepage of stool and 25 had gross incontinence. In nine patients, reconstruction of the external sphincter was by overlap of the muscle ends. Twenty-four others underwent accurate approximation of the external sphincter muscle and anterior plication of the levator muscles, and in seven the anal canal was made smaller by narrowing the anal orifice. Follow-up was an average of 67 months after operation (range, 2.4 to 166 months). Continence was objectively improved in 62 percent (P less than .01) when performance criteria were analyzed by Wilcoxon signed-rank test, although 85 percent of the patients reported subjective improvement. Requirements for protective pads were reduced in 57 percent (P less than .01) and fewer social limitations were experienced in 52 percent (P less than .01). There was no significant correlation between outcome and type of operation.

We have confirmed the finding that cell-free filtrates of disrupted, freshly obtained inflammatory bowel disease lymphocytes were cytotoxic in vitro for human colonic epithelial cells. Furthermore, we have shown that the properties of the cytotoxic factor in these filtrates conformed exactly to those described for lymphotoxin released by the incubation in vitro of inflammatory bowel disease lymphocytes with colonic target cells. In addition, the properties conformed very closely to those described by others in their characterization of lymphotoxin released by stimulation of lymphocytes in vitro by phytohemagglutinin except for the action of trypsin.