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Background CT scan measures of emphysema and airway disease have been correlated with lung function in cohorts of subjects with a range of COPD severity. The contribution of CT scan-assessed airway disease to objective measures of lung function and respiratory symptoms such as dyspnea in severe emphysema is less clear. Methods Using data from 338 subjects in the National Emphysema Treatment Trial (NETT) Genetics Ancillary Study, densitometric measures of emphysema using a threshold of −950 Hounsfield units (%LAA-950) and airway wall phenotypes of the wall thickness (WT) and the square root of wall area (SRWA) of a 10-mm luminal perimeter airway were calculated for each subject. Linear regression analysis was performed for outcome variables FEV 1 and percent predicted value of FEV 1 with CT scan measures of emphysema and airway disease. Results In univariate analysis, there were significant negative correlations between %LAA-950 and both the WT ( r = −0.28, p = 0.0001) and SRWA ( r = −0.19, p = 0.0008). Airway wall thickness was weakly but significantly correlated with postbronchodilator FEV 1 % predicted (R = −0.12, p = 0.02). Multivariate analysis showed significant associations between either WT or SRWA (β = −5.2, p = 0.009; β = −2.6, p = 0.008, respectively) and %LAA-950 (β = −10.6, p = 0.03) with the postbronchodilator FEV 1 % predicted. Male subjects exhibited significantly thicker airway wall phenotypes (p = 0.007 for WT and p = 0.0006 for SRWA). Conclusions Airway disease and emphysema detected by CT scanning are inversely related in patients with severe COPD. Airway wall phenotypes were influenced by gender and associated with lung function in subjects with severe emphysema.

Board certification is intended to protect the public by identifying practitioners that have met minimum standards for education and training in their specialty or discipline. For varied reasons, clinical neuropsychology, like professional psychology as a whole, has struggled to achieve levels of board certification comparable to the medical profession. Rohling, Lees-Haley, Langhinrichsen-Rohling,Williamson (2003) have recently published a critique of the board certification process in clinical neuropsychology as it is conducted by American Board of Clinical Neuropsychology (ABCN), arguing that one reason for this failure is the overly restrictive nature of the process. In their paper, Rohling et al. provide a signal detection analysis that makes several assumptions about the process and conclude with recommendations for improving the process to better identify "competent" neuropsychologists in practice. While we agree in principle with many of their recommendations, and ABCN had, in fact, implemented several prior to publication of their article, the article contains many faulty assumptions and logical inconsistencies that we believe are harmful to constructive review of the certification process. In this article, we provide a critical review of their analysis and present new and additional data that demonstrate the procedure is not overly restrictive. A primary consideration is the low incidence of seeking board certification among professionals who identify themselves as neuropsychologists (i.e., a low application rate), rather than an overly restrictive process. We describe steps taken to improve the process and conclude that there are numerous areas of agreement with Rohling et al., including the need for ongoing review and continued improvement in the board certification process in all psychological specialties.

To investigate whether affective experience is linked to the neurodynamics of basic emotional systems, a novel mood-induction procedure was utilized to induce affective changes and observe the neural consequences. The internal motor imagery of laughter and crying (to evoke joy and sadness), along with the affectively neutral task of walk imagery, allowed evocation of affective states without the confounding effects of motor artifacts. Affective response scores (nine-point Likert scale) indicated that internal laughter significantly increased happiness and decreased sadness. Conversely, crying imagery significantly increased sadness and decreased happiness. Seven brain regions exhibited BOLD signal changes in the emotion tasks, which were not observed during the neutral walking task. These regions are the left basal ganglia, right putamen, insula, thalamus, and inferior occipital gyrus, and left and right caudate. These data suggest that there may be a shared neural system for activating affective responses.

This article reviews research documenting the role of psychosocial factors in various areas. Its goal is to highlight the importance of identifying and addressing psychosocial dysfunction in patients with chronic obstructive pulmonary disease and the benefits gained by including psychosocial interventions for patients with chronic obstructive pulmonary disease within pulmonary rehabilitation programs.

The concept of assessing health-related quality of life has a brief and vibrant history. In this monograph, theoretical issues related to the term and the reasons assessment of quality of life is important are discussed. There is a great deal of ambiguity surrounding definitions of the concept. This equivocation is caused in part by the fact that thinking on both the concept of health-related quality-of-life assessment and the way in which it should be measured are still evolving. Methodologic concerns regarding the assessment of health-related quality of life are discussed, including ways in which the validity and reliability of measurement approaches are established. These characteristics are important because they are necessary to ensure that accurate information is obtained with whatever instrument or procedure is used. Many significant issues relate to the use of quality-of-life assessment, and these are delineated. Consideration and resolution of these issues are prerequisites to the introduction of a given assessment instrument or procedure into a study. A large section of this article is devoted to a review of selected measures of health-related quality of life. Three types of measures are discussed. The first type is referred to as general. These measures are designed to be used across different diseases, different treatments or interventions, and different groups of patients. The reliability and validity of general instruments or procedures, plus their history of empirical use, make them invaluable methods of measurement. The second type of measures is referred to as disease specific. These measures are designed to assess specific diagnostic or patient populations with the goal of detecting responsiveness or clinically significant changes. The ability to assess such changes in a particular patient population has led to major growth in the development and introduction of these instruments in the past few years. The final type of measure consists of batteries of separate instruments that are scored independently. The advantage of using this approach is that the battery can be put together to assess whatever aspects of health-related quality of life need to be measured. Examples of quality-of-life assessment in medical research include a discussion of how various procedures are used to measure the construct with asthma, chronic respiratory disorders, and human immunodeficiency virus (HIV) disease. All three types of assessment--general, disease specific, and batteries of measures--have been used in this respect. Newer methods of assessment, particularly disease-specific instruments and procedures, are also described.(ABSTRACT TRUNCATED AT 250 WORDS)

The interpretation of change scores in neuropsychological assessment is of increasing importance. In order to illustrate a regression approach to depicting change, 50 patients with chronic seizure disorders were assessed twice with the WAIS-R and the Wechsler Memory Scale-Revised over an average interval of 7.8 months. Regression analysis was employed to develop norms for change that were converted into standardized scores. These T Scores for Change were analyzed with a MANOVA to compare the effects of epilepsy surgery on cognition and memory in 50 right-temporal lobectomy and 47 left-temporal lobectomy patients. Significant group, test, and interaction effects were found. A profile of the T Scores for Change permitted quick and accurate appreciation of the major findings. The characteristics of the regression-derived T Score approach are compared with a recently suggested reliability approach.

Publisher Summary This chapter deals with often differing data and prognosis provided by the neuropsychiatrist and the neuropsychologist. It reflects the general psychology literature that raises the question as to whether laboratory testing of memory function truly reflects memory function in everyday life. Present practice in surgical epilepsy centers is a preoperative neuropsychological evaluation, particularly of memory function. The longitudinal study of epilepsy patients who have undergone temporal lobectomy at the Medical College of Ohio has emphasized utilization of neuropsychiatric evaluation as well as neuropsychological testing. Data and prognosis reported by the neuropsychologist are frequently in contrast with neuropsychiatric assessment, which provides subjective reports by the patient as well as review of performance-demanding memory ability, in the spheres of education and work. Comparisons of neuropsychological and neuropsychiatric data were expressed in terms of concordant or discordant findings.

Guilmette and Hagan present an issue that is important to neuropsychologists who engage in forensic practice: the applicability of the APA Ethics Code to situations where neuropsychologists consult with attorneys but do not testify or otherwise reveal their identity to opposing attorneys or consultants. The resulting anonymity could encourage the misuse of neuropsychological knowledge, according to Guilmette and Hagan. A review of the APA Ethics Code reveals that deliberate use of neuropsychological knowledge to assist attorneys in misleading juries and others is clearly not consistent with the spirit or the letter of the Code. Neuropsychologists are advised to behave in a manner consistent with the Code, even when seemingly protected by a cloak of anonymity.

Freides' (1993) suggestion that all quantitative data from neuropsychological evaluations accompany reports has several professional and practical implications. The authors consider the possible ethical ramifications of doing so and caution that routinely appending raw quantitative data may not be advisable. Electronic methods of data transmission can be used to provide quantitative information quickly when necessary. Commentary from readers is invited.

The term quality of life has enjoyed colloquial use in several human service and health-related fields for some time, although its use as a scientific concept is relatively recent. The biomedical fields have shown a recent upsurge of interest in quality of life and psychosocial factors in general. A major conceptual impetus to the scientific application of psychosocial concepts in health care was provided by George Engel’s (1980) paper on the biopsychosocial model of medicine. Using a systems theory framework, Engel argued that the inclusion of psychosocial information in the formulation of medical concepts, in research, and in patient care serves to make medicine a more scientific enterprise when compared to more narrow biomedical models or with nonscientific “holistic” models. Engel’s viewpoint has been widely embraced by medical schools, and a new generation of physicians and medical investigators are being trained in the biopsychosocial model.

Our initial paper arguing against the practice of routinely appending raw data to reports of neuropsycholog-ical examinations (Naugle & McSweeny, 1995) elicited two responses in favor of doing so (Freides, 1995; Matarazzo, 1995). This paper reviews the major points raised by those two writers and provides our responses to their objections. We continue to recommend that the type and amount of data to be included with a report be tailored to the needs and competency of the referral source who receives that report.

One of the major social programs of the 1960s was the development of community mental health centers. As with most early attempts at evaluation, the results were pessimistic. This article reanalyzes one of the earliest, and best-known, evaluations of a community-based treatment facility. Following the conceptual framework of Campbell and his associates, it was found that the various threats to the validity of the findings indicate a consistent and systematic bias against detecting a positive effect for the new mental health center. In light of recent federal legislation mandating formal evaluations, appropriate procedures are discussed.

Nursing homes play an important role in the community-based care of chronic mental patients, yet there is little research in that setting. The present study gathered and analyzed descriptive data on 20 nursing homes in a large urban area, including data about structure, staffing, policy, treatment, residents, discharge, psychosocial climate, and neighborhood characteristics. Results suggested a clear difference between skilled nursing versus intermediate care facilities, with the latter playing a larger role in caring for mental patients. More important, data suggested such facilities play primarily a custodial rather than treatment role, and that managers expect patients in nursing homes to stay indefinitely. In view of this, our justifications for community care, such as social integration, need to be examined anew.

Three hundred and three patients with chronic obstructive pulmonary disease and concomitant neuropsychological impairment plus 99 healthy control subjects matched on the basis of socio-demographic variables were administered an expanded version of the Halstead-Reitan Battery and a battery of instruments measuring the quality of everyday-life functioning. The results indicated that neuropsychological measures can be used to predict everyday-life functioning in impaired persons, but few significant relationships were observed in the normals. Neuropsychological status was more consistently related to activities of daily living and basic social role performance than to emotional status. Complex, multifunctional neuropsychological tasks were found to be the best overall predictors of life functioning, whereas more specific tasks served as better predictors of specific dimensions of life functioning.

An interrupted time-series analysis of local directory-assistance calls in the Cincinnati area from 1962 to 1976 revealed a significant reduction in the daily frequency of calls after charges were introduced in 1974. No reductions occurred in the daily frequency of long-distance directory-assistance calls, which remained free. The results attest to the efficacy of response-cost procedures with large subject populations in the natural environment. The applicability of response-cost procedures to social and business problems is discussed.

CHRONIC OBSTRUCTIVE LUNG DISEASE 309 tive functions (reasoning, perceptual-motor integration) are most severely affected, although memory appears to be relatively spared. About half the patients had definite motor difilculties, while verbal skills tended to be preserved. We do not have adequate data to speculate on which physiologic changes attendant to COPD are contributing to CNS disturbance. The negative correlation with arterial oxygenation is impressive considering the narrow range of arterial oxygen levels imposed by the patient selection criteria of PAO, 59 mg Hg. Although treatment effects have not yet been considered in the present study, the relationships between hypoxemia and neuropsychologic functioning in our patients are consistent with earlier reports that oxygen treatment may improve mental abilities’ and EEGs’ in selected COPD patients. As the NOTT patients receive repeat evaluation at the completion of six months of oxygen treatment, we should be in a better position to determine whether cerebral function improves or if there is evidence of persisting organicity despite systematic correction of hypoxemia. Of more immediate significance to the physician, our results underscore that for many patients, hypoxic COPD is associated with disease of the brain as well as of the lungs and heart.

Mental imagery plays an important role in the theory and practice of several behavior therapy techniques including desensitization, flooding and covert sensitization (Gambrill, 1977). Indeed, existing experimental evidence led Singer (1974) to conclude that desensitization “depends essentially on the production of visual imagery” (p. 510).

• As part of a six-center clinical trial of the effectiveness of continuousvnocturnal oxygen in the management of hypoxemic chronic obstructive pulmonary disease (COPD), we performed detailed neuropsychologic assessments of these patients prior to their beginning treatment. The 203 patients (age, 65 years; Pao2, 51 mm Hg; forced expiratory volume in 1 s, 0.74 L) performed significantly worse than controls on virtually all neuropsychologic tests. Moderate to severe test impairment suggestive of cerebral dysfunction was found in 42% of the patients, as compared with 14% of controls. Higher cognitive functions (abstracting ability, complex perceptual-motor integration) were most severely affected, although half the patients also showed decrements in motor speed, strength, and coordination. Low-order significant inverse correlations were found between neuropsychologic impairment and Pao2, resting arterial oxygen saturation and hemoglobin levels and maximum work. It is concluded that cerebral disturbance is common in hypoxemic COPD and may be related in part to decreased availability of oxygen to the brain. (Arch Intern Med1982;142:1470-1476)

• The Nocturnal Oxygen Therapy Trial (NOTT) showed previously that patients with hypoxemic chronic obstructive pulmonary disease (COPD) frequently suffered from neuropsychologic deficit and experienced disturbed mood, personality, and life quality. The present study has followed up 150 NOTT patients six months after they were randomized to continuous oxygen treatment (COT) or nocturnal oxygen treatment (NOT). Tested off oxygen, 42% showed modest neuropsychologic improvement after six months of therapy, and the rates for COT and NOT were comparable. A subsample (n = 37) was examined a third time, after 12 months of treatment. At this point patients receiving COT registered better neuropsychologic performance than those receiving NOT. Concurrently, the COT group began showing improved survival. Despite mild neuropsychologic improvement, patients reported little change in emotional status or life quality. It is concluded that prolonged oxygen treatment is associated with small but definite improvement in brain functioning among patients with hypoxemic COPD, and that COT might have some advantage over NOT in enhancing neuropsychologic functioning as well as survival. (Arch Intern Med1983;143:1941-1947)

• Two hundred three patients with hypoxemic chronic obstructive pulmonary disease (COPD) and 73 healthy control subjects matched for age, sex, race, and neighborhood of residence were administered three self-report inventories concerned with the following four dimensions of life quality: emotional functioning, social-role functioning, activities of daily living, and recreational pastimes. An additional inventory was administered to a spouse or another close relative of each patient. The life quality of patients with COPD was found to be impaired relative to healthy subjects on all dimensions. Depression was the preponderant emotional disturbance reported; difficulties with home management and reduction in social interaction were the primary social-role deficits. Ambulation, mobility, sleep and rest, and a variety of recreational pastimes were also severely affected. Life quality exhibited moderate but significant relationships to neuropsychological, pulmonary, and cardiac functioning and to exercise capability. Age and socioeconomic status were found to be possible moderators of the relationship of COPD to life quality. A model to integrate these findings is proposed. Implications for the management of COPD and for the evaluation of medical treatments of chronic disabling conditions are described. (Arch Intern Med1982;142:473-478)