102
BIOL PSYCHIATRY 1992;31:99-105
mox) on atypical psychosis. Folia Psychiat Neurol Japonica 38:425-436.
Miemyk JA, Fang TK, Randall DD (1987): Calmodulin antagonists inhibit the mitochondriai pyruvate dehydrogenase complex. J Biol Chem 262:338-340. Sacks W (1983): Cerebral metabolism in vivo. In Lajtha A (ed), Handbook ofNeurochemistry, vol 3, 2nd ed. New York: Plenum, pp 321-35 !. Sacks W (1983): Cerebral metabolism in vivo. In Lajtha A
Interrater Reliability of Seizure Duration in ECT To the Editor: Because the literature on the interrater reliability of seizure duration measurement using the MECTA SR-I (MECTA Corporation, Portland, OR) is quite disparate, I would like to submit another study of this problem. The MECTA SR-I electroconvuisive therapy (ECT) device records a single-lead electroencephalogram (EEG) of the treatment seizure. EEG monitoring of the treatment ictus in ECT offers the hope of improved sensitivity in detecting adequate and prolonged seizures compared to other monitoring techniques, such as the cuff method, but has been criticised l'or poor interrater reliability. Ries (1985) and Guze et al (1989) found poor interrater reliability with five raters reviewed series of MECTA EEG strips. Guze's study used only unilateral nondominant electrode placement for the treatments from which the EEG strips were obtained. The Ries study used an older (1980) model MECTA machine. Primarily based on their concern about interrater reliability Guze et al (1990) declared the cuff-motor method of seizure duration monitoring superior in clinical applications to the single-lead EEG. On the other hand, Warmflash et al (1987) and Kramer et al (1989) found good MECTA SR-I interrater reliability. Warmflash was using a nonstandard monitoring electrode setup rather than the equipment supplied with the machine. Kramer used EEG strips derived exclusively from bilateral treatments. So this literature leaves unclear whether the interrater reliability is using standard practice with a more upto-date MECTA machine. It also begs the question
Correspondence
(ed), Handbook ofNeurochemistry, vol 3, 2nd ed. New York: Plenum, pp 321-351. Sacks W, Esser AH, Feitei B, Abbott K (1989): Acetazolamide and thiamine: An ancillary therapy for chronic mental illness. Psychiatry Res 28:279-288. Sacks W, Esser AH, Sacks S (1991): Inhibition of pyruvate dehydrogenase complex (PDHC) by antipsychoticdrugs. Biol Psychiatry 29: !76- ! 82.
if interrater reliability is poorer for unilateral electrode placement as compared to bilateral. ! had five psychiatrists, all of whom were experienced ECT clinicians, independently assess 30 readout strips from treatments given with a 1986 MECTA SR-1 machine. The printout also records an electrocardiogram. The strips were randomly chosen from an inventory of strips that had been saved for teaching and research purposes which included all the treatments that had been given with the machine in the previous year. There was no indication given to the examiners if the treatment had been unilateral or bilateral, and they were unaware of the motor duration of the seizure. The raters received no special instructions or training. Other aspects of the treatments and anesthesiology were typical clinical practice as described by Fink (1979). By chance the strips included 8 unilateral treatments and 22 bilateral treatments; see Table I for raw data from the raters• Using a general linear models analysis of variance (ANOVA) no effect of the rater was found on duration monitoring (F(4,149) = 0.07, p less than 0.99). The discrepancy between the shortest and longest estimate of seizure duration of each strip was taken as an indication of interrater reliability. For the entire sample the average maximal discrepancy was 3.4 sec. Of the 8 unilateral treatments the average was 5.0 sec, and for the 22 bilateral treatments the average was 2.8 sec. It is doubtful that the differences between examiners would have significantly changed clinical decisions. For 23 of the 30 strips the maximal discrepancy between examiners wa~ 5 sec or less, and in the remaining 7 strips the average maximal discrepancy was 11 sec. In only one strip, #29, might the high
Correspondence
BIOL PSYCHIATRY 1992;31:99-105
and low examiner have differed in their clinical response. That is because their estimates of seizure duration fell across a loosely established threshold, 25 sec, that some clinicians use in deciding whether to restimulate the patient or not. In summary, for this group of independent examiners interrater reliability was good. Differences of seizure duration estimate were small and unlikely to be clinically important. This was true for both unilateral and bilateral electrode placements. Michael Lambert
Department of Psychiatry 116A Veterans Affairs Medical Center 4500 S. Lancaster Rd. Dallas, TX 75216
Nutrition and SDAT To the Editor: Several observations suggest that malnutrition could have a role in the pathogenesis of Senile Dementia of ~he Aizheimer Type (SDAT) or could aggravate the mental deterioration that characterizes SDAT (Abalan 1984). We report here the results of a pilot study examining the effects of total oral nutritional supplementation on cognitive function in SDAT. Geriatric inpatients were considered for enrollment. Inclusion criteria were probable SDAT according to the criteria of the NINCDS-ADRDA (McKhann et al 1984), onset of disease after 65 years, age over 66 years, Mini-Mental State (MMS) score (Folstein et al 1975) between 2 and 23. Exclusion criteria were diabetes mellitus, hepatic, renal, or cardiac failure, or major illness; sensory impairment or other conditions impeding assessment; prior nutritional treatment; uncooperativeness, poor oral intake, tube-feeding or being bedridden. Informed consent was obtained from a close relative of each patient. The patients were randomized into treatment and control groups. In addition to nornml hospital food, the treatment group received oral nutrients during the 105 trial days (Table l). Care was taken to administer
103
References Fink M (1979): Com,ulsive Therapy: Theory and Practice,
New York: Raven Press. Guze BH, Liston EH, Baxter LR (1990): Monitoring Seizure Duration During ECT (letter). J Clin Psychiatry 51:3839. Guze BH, Liston EH, Baxter LR, et al (1989): Poor Interrater Reliability of MECTA EEG Recordings of ECT Seizure Duration. J Clin Psychiatry 50:140-142. Kramer AK, Pollack VE, Schneider IS, et al (1989): Interrater Reliability of MECTA SR- 1 Seizure Duration. Biol Psychiatry 25:642-644. Ries RK (1985): Poor Interrater Reliability of MECTA EEG Seizure Duration Measurement During ECT. Biol Psychiatry 20:94-97. Warmflash VL, Stricks L, Sackeim HA, et al (1987): Reliability and Validity Measures of Seizure Duration. Cony Ther 3:18-25.
calcium, magnesium, phosphorus, and trace-element supplemenf~s at intervals greater than three hr. The nurses were asked to ensure food ingestion in the treatment group. Dietary intake was measured in five subjects from this group once a week throughout the trial by a food weighing method. Excluding the liquid nutritional supplements (Table l), the amounts (mean - SD) of calories, proteins, fat, and carbohydrates ingested daily were respectively from day l through day 35, 1254 -+ 259 kCal, 62 -4- 15 g, 49 +- 13 g, 140 +- 34 ~, and from day 36 through day 105,936 _ 235 kCal, 47 _ 14 g, 35 +- 13 g, and 108 +30 g. The control group received normal hospital food with no nutritional supplements. In four control subjects the same food weighing method was used to calculate the amounts (mean _ SD) of calories, proteins, fat, and carbohydrates ingested daily; values were respectively 1386 _+ 440 kCal, 64 +_ 23 g, 53 _+ 24 g, and 162 +_ 45 g. For ethical reasons, all other treatments required by the patients were allowed. Cognitive function of the patients was evaluated at days 0 and 105 using the MMS (score range: 0 30; best score = 30) (Folstein et al 1975). Toxicity was evaluated by clinical observation throughout the
BIOL PSYCHIATRY 1992;31:99-105
mox) on atypical psychosis. Folia Psychiat Neurol Japonica 38:425-436.
Miemyk JA, Fang TK, Randall DD (1987): Calmodulin antagonists inhibit the mitochondriai pyruvate dehydrogenase complex. J Biol Chem 262:338-340. Sacks W (1983): Cerebral metabolism in vivo. In Lajtha A (ed), Handbook ofNeurochemistry, vol 3, 2nd ed. New York: Plenum, pp 321-35 !. Sacks W (1983): Cerebral metabolism in vivo. In Lajtha A
Interrater Reliability of Seizure Duration in ECT To the Editor: Because the literature on the interrater reliability of seizure duration measurement using the MECTA SR-I (MECTA Corporation, Portland, OR) is quite disparate, I would like to submit another study of this problem. The MECTA SR-I electroconvuisive therapy (ECT) device records a single-lead electroencephalogram (EEG) of the treatment seizure. EEG monitoring of the treatment ictus in ECT offers the hope of improved sensitivity in detecting adequate and prolonged seizures compared to other monitoring techniques, such as the cuff method, but has been criticised l'or poor interrater reliability. Ries (1985) and Guze et al (1989) found poor interrater reliability with five raters reviewed series of MECTA EEG strips. Guze's study used only unilateral nondominant electrode placement for the treatments from which the EEG strips were obtained. The Ries study used an older (1980) model MECTA machine. Primarily based on their concern about interrater reliability Guze et al (1990) declared the cuff-motor method of seizure duration monitoring superior in clinical applications to the single-lead EEG. On the other hand, Warmflash et al (1987) and Kramer et al (1989) found good MECTA SR-I interrater reliability. Warmflash was using a nonstandard monitoring electrode setup rather than the equipment supplied with the machine. Kramer used EEG strips derived exclusively from bilateral treatments. So this literature leaves unclear whether the interrater reliability is using standard practice with a more upto-date MECTA machine. It also begs the question
Correspondence
(ed), Handbook ofNeurochemistry, vol 3, 2nd ed. New York: Plenum, pp 321-351. Sacks W, Esser AH, Feitei B, Abbott K (1989): Acetazolamide and thiamine: An ancillary therapy for chronic mental illness. Psychiatry Res 28:279-288. Sacks W, Esser AH, Sacks S (1991): Inhibition of pyruvate dehydrogenase complex (PDHC) by antipsychoticdrugs. Biol Psychiatry 29: !76- ! 82.
if interrater reliability is poorer for unilateral electrode placement as compared to bilateral. ! had five psychiatrists, all of whom were experienced ECT clinicians, independently assess 30 readout strips from treatments given with a 1986 MECTA SR-1 machine. The printout also records an electrocardiogram. The strips were randomly chosen from an inventory of strips that had been saved for teaching and research purposes which included all the treatments that had been given with the machine in the previous year. There was no indication given to the examiners if the treatment had been unilateral or bilateral, and they were unaware of the motor duration of the seizure. The raters received no special instructions or training. Other aspects of the treatments and anesthesiology were typical clinical practice as described by Fink (1979). By chance the strips included 8 unilateral treatments and 22 bilateral treatments; see Table I for raw data from the raters• Using a general linear models analysis of variance (ANOVA) no effect of the rater was found on duration monitoring (F(4,149) = 0.07, p less than 0.99). The discrepancy between the shortest and longest estimate of seizure duration of each strip was taken as an indication of interrater reliability. For the entire sample the average maximal discrepancy was 3.4 sec. Of the 8 unilateral treatments the average was 5.0 sec, and for the 22 bilateral treatments the average was 2.8 sec. It is doubtful that the differences between examiners would have significantly changed clinical decisions. For 23 of the 30 strips the maximal discrepancy between examiners wa~ 5 sec or less, and in the remaining 7 strips the average maximal discrepancy was 11 sec. In only one strip, #29, might the high
Correspondence
BIOL PSYCHIATRY 1992;31:99-105
and low examiner have differed in their clinical response. That is because their estimates of seizure duration fell across a loosely established threshold, 25 sec, that some clinicians use in deciding whether to restimulate the patient or not. In summary, for this group of independent examiners interrater reliability was good. Differences of seizure duration estimate were small and unlikely to be clinically important. This was true for both unilateral and bilateral electrode placements. Michael Lambert
Department of Psychiatry 116A Veterans Affairs Medical Center 4500 S. Lancaster Rd. Dallas, TX 75216
Nutrition and SDAT To the Editor: Several observations suggest that malnutrition could have a role in the pathogenesis of Senile Dementia of ~he Aizheimer Type (SDAT) or could aggravate the mental deterioration that characterizes SDAT (Abalan 1984). We report here the results of a pilot study examining the effects of total oral nutritional supplementation on cognitive function in SDAT. Geriatric inpatients were considered for enrollment. Inclusion criteria were probable SDAT according to the criteria of the NINCDS-ADRDA (McKhann et al 1984), onset of disease after 65 years, age over 66 years, Mini-Mental State (MMS) score (Folstein et al 1975) between 2 and 23. Exclusion criteria were diabetes mellitus, hepatic, renal, or cardiac failure, or major illness; sensory impairment or other conditions impeding assessment; prior nutritional treatment; uncooperativeness, poor oral intake, tube-feeding or being bedridden. Informed consent was obtained from a close relative of each patient. The patients were randomized into treatment and control groups. In addition to nornml hospital food, the treatment group received oral nutrients during the 105 trial days (Table l). Care was taken to administer
103
References Fink M (1979): Com,ulsive Therapy: Theory and Practice,
New York: Raven Press. Guze BH, Liston EH, Baxter LR (1990): Monitoring Seizure Duration During ECT (letter). J Clin Psychiatry 51:3839. Guze BH, Liston EH, Baxter LR, et al (1989): Poor Interrater Reliability of MECTA EEG Recordings of ECT Seizure Duration. J Clin Psychiatry 50:140-142. Kramer AK, Pollack VE, Schneider IS, et al (1989): Interrater Reliability of MECTA SR- 1 Seizure Duration. Biol Psychiatry 25:642-644. Ries RK (1985): Poor Interrater Reliability of MECTA EEG Seizure Duration Measurement During ECT. Biol Psychiatry 20:94-97. Warmflash VL, Stricks L, Sackeim HA, et al (1987): Reliability and Validity Measures of Seizure Duration. Cony Ther 3:18-25.
calcium, magnesium, phosphorus, and trace-element supplemenf~s at intervals greater than three hr. The nurses were asked to ensure food ingestion in the treatment group. Dietary intake was measured in five subjects from this group once a week throughout the trial by a food weighing method. Excluding the liquid nutritional supplements (Table l), the amounts (mean - SD) of calories, proteins, fat, and carbohydrates ingested daily were respectively from day l through day 35, 1254 -+ 259 kCal, 62 -4- 15 g, 49 +- 13 g, 140 +- 34 ~, and from day 36 through day 105,936 _ 235 kCal, 47 _ 14 g, 35 +- 13 g, and 108 +30 g. The control group received normal hospital food with no nutritional supplements. In four control subjects the same food weighing method was used to calculate the amounts (mean _ SD) of calories, proteins, fat, and carbohydrates ingested daily; values were respectively 1386 _+ 440 kCal, 64 +_ 23 g, 53 _+ 24 g, and 162 +_ 45 g. For ethical reasons, all other treatments required by the patients were allowed. Cognitive function of the patients was evaluated at days 0 and 105 using the MMS (score range: 0 30; best score = 30) (Folstein et al 1975). Toxicity was evaluated by clinical observation throughout the
