[Clinical features of familial multiple sclerosis in Spain]

INTRODUCTION

Multiple sclerosis (MS) is a demyelinating and inflammatory disease of the central nervous system (CNS) with a clear proved genetic susceptibility. The real frequency and clinical features of familial MS is although not well established in Spain.

OBJECTIVE

We studied the clinical and CSF features of familial MS (FMS) patients in comparison with the rest of our patients.

PATIENTS AND METHODS

We reviewed 308 definite MS patients looking for patients with other familial members with MS. We analyzed clinical characteristics (age, age at onset, sex, evolution time, evolution course, symptoms at onset, disability measured by EDSS scale) and IgG synthesis measured by Tibbling-Link index.

RESULTS

We found 23 patients (10 men and 13 women) in 18 independent families with at least other family member diagnosed of definite MS (7.47% of our total MS population). Age and age at onset were no different from non FMS cases. The clinical course was relapsing-remitting in 21 out of 23 FMS cases and secondary progressive in two. No primary progressive cases were found among FMS. At onset the symptom most frequently found in FMS was optic neuritis. Mean EDSS score was lower in FMS cases in comparison with the rest of cases. Link index was increase in 93.7% of patients with FMS.

CONCLUSION

In comparison with non familiar forms FMS patients in Spain, present more often remitting courses, are less disabled, optical neuritis is more frequently seen as onset symptom and IgG synthesis is more often increased.

Aminoglycosides activate oxygen metabolites production in the cochlea of mature and developing rats

The ototoxicity of antibiotics, particularly of aminoglycosides, is a well-known undesirable side effect which may be based on a free radical mechanism. We studied the effect of different antibiotics in the production of reactive oxygen species in freshly isolated cochleas of mature and 2-10 weeks old developing rats. Phorbol myristate acetate induced the release of reactive oxygen species after a lag time close to 30 s and declined back to basal values in 10-20 min. The rate of reactive oxygen species production correlated inversely to the age in 2-10 weeks old rats. The study of a set of antibiotics showed that a very low concentration of gentamicin and streptomycin (10-100 ng/ml) enhanced the effect of phorbol myristate acetate. At the above-indicated concentrations, ciprofloxacin did not modify phorbol myristate acetate-induced activation. These results show the enhancement by aminoglycosides of reactive oxygen species production in cochlear tissues, particularly in developing rats.

Utilisation of predictive, prenatal and diagnostic testing for Huntington's disease in Johannesburg

CONTEXT

Huntington's disease (HD) is a dominantly inherited condition in which the gene defect is known. As such individuals in at-risk families can be tested before symptoms occur, prenatally, or after symptoms appear to confirm the diagnosis.

OBJECTIVES

To investigate the utilisation and sequelae of the predictive, prenatal and diagnostic services offered to families with suspected Huntington's disease.

DESIGN

A retrospective design was used. The 1975-1997 records of the Department of Human Genetics for all families with a history of HD presenting for genetic counselling and DNA analysis were studied.

SETTING

Department of Human Genetics, South African Institute for Medical Research and University of the Witwatersrand, Johannesburg.

SUBJECTS

There were 30 at-risk (50% risk) subjects for predictive testing, 7 women (10 pregnancies) for prenatal testing, and 52 subjects for diagnostic testing.

OUTCOME MEASURES

These were provided by the results from molecular studies and by the action taken by subjects after a predictive or prenatal result was given.

RESULTS

Altogether 15 (50%) subjects for predictive testing had a positive result, but none had serious psychiatric sequelae. Two women were found to be carrying an affected fetus and both requested pregnancy termination. Of 52 diagnostic tests, 33 (63%) were positive.

CONCLUSION

The service was used appropriately, and there were no traumatic incidents following positive results. There was no genotypic or sex bias in subjects presenting for testing. Black and white patients were equally likely to be positive for HD on diagnostic testing. The families appreciated the service and found it useful in the detection and prevention of HD.

Denervation of rabbit gastrocnemius and soleus muscles: effect on muscle-specific enolase

We report here, for the first time, the expression of the muscle-specific isoform of the glycolytic enzyme, enolase (EC 4.2.1. 11) (beta enolase), in rabbit skeletal muscles. We have analysed the fast-twitch gastrocnemius and the slow-twitch soleus muscles during normal postnatal development and following denervation. We show that, in rabbit, as already described in rodents, beta enolase gene expression behaves as a good marker of the fast-twitch fibers. In soleus muscle, the beta enolase transcript level is 10-20% of that found in gastrocnemius. Denervation, performed at 8 postnatal days, induces an important drop of beta enolase transcript levels in both developing soleus and gastrocnemius muscles, with a 80% decrease observed 1 week after denervation in the operated muscles, as compared to the corresponding contralateral muscles. Thereafter, the beta enolase transcript level continues to decrease in the fast-twitch muscle, with the beta enolase subunit being detectable only in the atrophic fast-twitch fibers. In contrast, the beta transcript level tends to increase in the denervated slow-twitch muscle, reaching about 50% of that in contralateral soleus, at 7 weeks after surgery. The level of beta enolase transcripts still expressed after denervation seems to stabilize at the same low level in both types of inactive muscles. This suggests that the small fraction of beta enolase expression which is not controlled by the nerve, or by the contractile activity imposed by it, is independent of the muscle phenotype.

Lack of lymphoid cell apoptosis in the pathogenesis of tonsillar hypertrophy as compared to recurrent tonsillitis

The pathogenic mechanism of tonsillar hypertrophy is unknown and lacks a proper infectious or immunological explanation. Epidemiological studies point to polluted environments as the main cause of tonsillar hypertrophy in the adaptation of the juvenile organism. Tonsils and adenoids of 67 children aged 2-16 years (mean 5.9 years) were divided into three groups: recurrent tonsillitis (n = 21), recurrent tonsillitis with tonsillar hypertrophy (n = 21) and tonsillar hypertrophy without history of tonsillitis (n = 25). The following biological markers were studied: anti-streptolysin O antibody and anti-deoxy ribonuclease B antibody serology, microbiology and cell count of granulocytes in tonsils and adenoids as well as lymphocyte subsets and "ex vivo" endonuclease activity in tonsils. Anti-streptolysin O antibody and anti-deoxyribonuclease B antibody titres were significantly raised in recurrent tonsillitis. Positive bacterial cultures for Streptococcus pyogenes were rare in cases of tonsillar hypertrophy. T-lymphocytes counts were lower and the proportion of basophils was higher in hypertrophic tonsils than in recurrent tonsillitis. Two parameters of apoptosis were studied; the activation of endonuclease, inducing breakdown of DNA resulting in cell death, and the sensitivity to thapsigargin, known to trigger the cleavage of DNA by apoptotic endonuclease. In children with tonsillar hypertrophy both parameters were decreased contrasting with those with recurrent tonsillitis where apoptosis is increased. It may be speculated that the increase of basophils in children with tonsillar hypertrophy results in increased release of interleukin-4, which could prevent lymphoid apoptosis and lead to cell proliferation in tonsillar tissue.

CONCLUSION

Whereas recurrent tonsillitis is characterised by apoptotic death of lymphoid tissue, tonsillar hypertrophy is caused by environmental pollution agents that trigger the chronic inflammatory process without apoptotic cell death.

Context effects in lexical access: a meta-analysis

The modularity hypothesis was evaluated in this review of 25 studies that investigated context effects in early lexical processing. Selection criteria restricted the review to priming studies and to studies that presented the target word before or at the end of the prime word. Meta-analysis was used to provide summary information about the 17 studies in the review for which effect sizes could be calculated. Overall, the analysis revealed a small effect of context on lexical access. Results provide a disconfirmation of the modularity hypothesis; although multiple interpretations of a word were sometimes accessed, the contextually appropriate interpretation was consistently more strongly activated. The lack of significant heterogeneity of variance suggests that the variability observed across studies was due to sampling error; however, task, timing of target presentation, meaning frequency, type of target, and type of context were identified as potential moderator variables.

The oxidation-reduction state of serum proteins in multiple sclerosis patients: effect of interferon beta-1b

The concentration of reduction equivalents in serum was studied in a cohort of healthy individuals, in a group of multiple sclerosis (MS) patients undergoing treatment with interferon beta-1b and another group of MS patients who refused treatment with interferon beta-1b. Two classes of sulfhydryl groups were detectable in serum: (1) the uncovered sulfhydryls, accessible to the oxidation-reduction substrate 5,5-dithiobis-(-2-nitrobenzoic acid) (DTNB); and (2) the hidden sulfhydryls that required previous heat denaturation of serum proteins to become accessible to DTNB. The concentration of the reduced form of both the uncovered- and hidden-type of sulfhydryls was higher in the serum of MS patients than in healthy individuals. Interferon beta-1b lowered the plasma concentration of the uncovered reduced sulfhydryls after 3 months of treatment. This was in contrast to a minor effect of interferon beta-1b in the hidden-form of sulfhydryl groups. The results suggest that the concentration of reduced sulfhydryls is a biochemical marker of the in vivo oxidation/reduction reactions in MS.

[Myotonic dystrophy: DNA instability in monozygotic twins]

INTRODUCTION

Myotonic dystrophy is an autosomal dominant hereditary disorder with variable expression, associated with expansion of the CTG triplet on the gene which codifies myotonia situated on chromosome 19q. We present an unusual case of myotonic dystrophy in a pair of monozygotic twin sisters, determination of CTG expansion in lymphocytes of members of their family and in their father's spermatozoids.

CLINICAL CASE

The patients presented the phenomenon of anticipation of paternal transmission with an expansion of triplet CTG of lymphocyte DNA in a range of 300-1,400 identical repetitions in both. DNA of the paternal lymphocytes and spermatozoids showed a similar expansion of 75 repetitions.

CONCLUSIONS

CTG expansion is not due to previous expansion of DNA in the paternal gametes but to instability of DNA in the cellular mitoses following formation of the zygote.

Visceral protein status and caloric intake in exercising versus nonexercising individuals with end-stage renal disease

OBJECTIVE

To determine if differences exist in kilocalorie and protein intake and visceral protein levels for patients with End-Stage Renal Disease (ESRD) exercising during dialysis versus not exercising.

DESIGN

Prospective study of 11 patients with ESRD over a study period of 12 weeks.

SETTING

Outpatient renal dialysis clinic.

PATIENTS

Patients with ESRD undergoing hemodialysis (HD) three times weekly who met the following criteria were selected: aged 25 to 65 years, nondiabetic, no current physical activity, blood pressure of 160/95 mm Hg or less at the second hour of HD, no unstable angina pectoris. Eleven patients who met the criteria were randomized into two groups; five patients with exercise (E) and six patients without exercise (NE).

INTERVENTIONS

From weeks 5 to 8, E patients began exercise during HD three times a week. Exercise gradually increased by 3 minutes each dialysis day, maintaining 60% to 80% maximal heart rate (HR). By the end of week 8, all E patients reached 45 minutes of exercise, including 5 minutes each of warm-up and cooldown. Patients continued 45 minutes of exercise each dialysis day during HD at 60% to 80% maximal HR during weeks 9 through 12. NE patients remained sedentary throughout the study.

MAIN OUTCOME MEASURE

Twenty-four-hour dietary recalls were obtained weekly for the 12 weeks from all patients for kilocalorie and protein intake. Serum levels of prealbumin, transferrin, and predialysis and postdialysis albumin were obtained immediately before the study onset and at weeks 4, 8, and 12. Comments related to patients' feelings and exercise were recorded but not analyzed statistically.

RESULTS

Analysis of covariance for repeated measures for kilocalories yielded no significance by group or over time. Mean intakes for E patients for weeks 9 through 12 were clinically greater than weeks 1 through 8 by approximately 200 kilocalories. The mean protein intake for E patients at weeks 9 through 12 (79 +/- 41 g) appeared clinically greater than NE patients at weeks 9 through 12 (58 +/- 11 g), although not statistically different. Adequacy of dialysis (Kt/V) and initial levels of each serum protein were covariates for analysis of variance. No statistical differences were found for prealbumin levels. Transferrin levels were within normal ranges but differed (P <.05) by group (E or NE) and time periods. Prealbumin and postalbumin concentrations ranged from slightly low to adequate levels and were different over time (P <. 05).

CONCLUSION

Kilocalorie and protein intakes appeared to increase for E patients during the exercise program. No consistent increases of visceral proteins were found for E patients. A majority of E patients expressed feelings of improved health, better exercise tolerance, and improved appetite and viewed exercise as enjoyable.

SF-36 scores vary by method of administration: implications for study design

BACKGROUND

Previous research suggests that people respond differently to health status measures when data are collected by interview or self completion of a questionnaire. The objective of this study was to determine whether SF-36 health status scores differ systematically by method of administration.

METHOD

A randomized cross-over study was carried out on 210 new attenders at general medicine, endocrinology, gastroenterology and urological out-patient departments. The outcome was the difference in SF-36 profiles comparing clinic based interviews with self completion at home by the same subjects.

RESULTS

For seven of the eight variables of the SF-36 scores were lower in the self assessment, the differences being statistically significant in four of the eight comparisons. The largest differences were in role limitations due to emotional problems (difference 14.74, 95 per cent confidence interval (CI) 7.76-21.7) and social function (difference 7.21, 95 per cent CI 3.19-11.23).

CONCLUSIONS

Clinic based interviews systematically exaggerate health status compared with self assessment. The difference is sufficiently large to underestimate the effectiveness of health service interventions when a clinic based pre-intervention and postal self completed follow-up design is used, unless adjustment is made for this systematic bias.

Safety profile of ultrasmall superparamagnetic iron oxide ferumoxtran-10: phase II clinical trial data

The safety data from the phase II clinical trial of ferumoxtran-10, an ultrasmall superparamagnetic iron oxide contrast agent, are presented. One hundred and four patients with focal liver or spleen pathologies underwent ferumoxtran-10-enhanced magnetic resonance (MR) imaging at doses of 0.8, 1.1, and 1.7 mg Fe/kg. Overall, 15% patients reported a total of 33 adverse events, regardless of causality. The adverse events most frequently seen were dyspnea (3.8%), chest pain (2.9%), and rash (2.9%). No serious adverse events were reported during the 48 hour observation period. There were no clinically significant effects on vital signs, physical examination, and laboratory results. Ferumoxtran-10 is a safe and well tolerated MR contrast agent.

The beta enolase subunit displays three different patterns of microheterogeneity in human striated muscle

In higher vertebrates, the glycolytic enzyme enolase (2-phospho-D-glycerate hydrolyase; EC 4.2.1.11) is active as a dimeric protein formed from three subunits--alpha: ubiquitous, beta: muscle specific, and gamma: neuron specific--encoded by different genes. In the present study, we have shown that an antiserum previously produced against the mouse beta beta enolase is also a specific reagent for the muscle specific human enolase. Using this antiserum to study human muscles, we demonstrated novel patterns of the beta subunit microheterogeneity which are distinctive from those observed previously in rodents and which appear to be independent of age, gender and muscular activity. Two variants of the beta subunit differing by their size have been detected: one heavy form of 46 kDa (beta H) and one light form of 45 kDa (beta L). Muscle biopsies expressed either beta H or beta L or beta H + beta L, and all muscles of an individual expressed the same variants. The products of in vitro translation of RNA prepared from human muscle displayed beta subunit variants identical to those of the protein present in the biopsy. Therefore the differences observed between individuals reveal a difference already present at the level of the RNA transcripts. These observations suggest the existence of an yet undescribed polymorphism of the human beta enolase gene which could affect the coding sequence. Comparative immunocytochemical and histochemical analyses of biopsies demonstrated that the beta subunit was expressed in all fast fibres (type II), but not in slow fibres (type I). No difference was observed in the intensity of beta enolase immunolabelling between the various types (IIA, IIAB, IIB) of fast fibres. No significant difference in fibre type composition and histological appearance was visible between muscles presenting either one of the three patterns of microheterogeneity.

[Pre- and postoperative quality of life of patients with ulcerative colitis and familial adenomatous polyposis with ileoanal pouch operation]

After ileal pouch-anal anastomosis in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP), in addition to postoperative morbidity and functional outcome quality of life is a relevant factor for assessment of the operation's success. Between 1982 and 1997 restorative proctocolectomy was performed in 602 patients (UC: n = 424; FAP: n = 178) at the Department of Surgery, University of Heidelberg. The assessment of pre- and postoperative quality of life was done through a prospective study (before restorative proctocolectomy, before and 1 year after closure of ileostomy). This study (UC: n = 27; FAP: n = 7) revealed a poor preoperative quality of life in patients with ulcerative colitis. Proctocolectomy is the decisive factor for the improvement of quality of life in the surgical treatment in UC. Quality of life could not be further significantly improved by ileostomy closure. Before proctocolectomy, FAP patients showed a quality of life, activity and function similar to that of healthy controls. In FAP patients proctocolectomy led to a significant loss of quality of life. This loss could only partly be regained by ileostomy closure. Quality of life and activity comparable to that of healthy controls can be achieved in UC patients by restorative proctocolectomy.

Adenoidal and tonsillar lymphocyte subsets in AIDS children

Tonsils and adenoids are secondary lymphoid organs exposed to the environment. The most important classifications of AIDS include the lymphocyte subsets of peripheral blood. We have studied the lymphocyte subsets in peripheral blood and secondary lymphoid organs in a control group of children suffering adenotonsillar pathology and in five children with AIDS and the same adenotonsillar pathology. The antigen surface markers were determined by flow cytometry in lymphocytes isolated from peripheral blood, and from tonsils and adenoids after tonsillectomy and adenoidectomy, in the control group and in children diagnosed with AIDS. The most important findings in tonsils and adenoids were a decrease of the total T lymphocytes, helper T lymphocytes and CD4/CD8 ratio; an increase of cytotoxic T lymphocytes and B lymphocytes, as well as a 200% increase in monocytes of AIDS-affected children. These observations show the value of analyzing the lymphocyte subsets of the tonsils and adenoids of AIDS-affected children, and establishing an earlier relation to clinical symptoms.

[Familial cerebral cavernomatosis associated with cutaneous angiomas]

OBJECTIVE, PATIENTS AND METHOD: We present a genealogical study of a person with familial cerebral cavernomatosis (CCF) discovered following study of a man who presented with status epilepticus at the age of 35 years. This had also affected another three members of the family consisting of a total of 43 persons, studied over six generations.

RESULTS

In the family members studied we did not find cavernomas at other sites but there were dermatological lesions whose relation to cerebral cavernomas (CC) is discussed. CCs are the second commonest type of cerebral vascular malformations. Their major clinical features are epilepsy and cerebral haemorrhage. There are two forms of CC: a sporadic form with single lesions and a familial form with multiple lesions. Although the condition has been recognized since 1854, very little is known about it. Recently a gene causing the familial form has been found on chromasome 7.

CONCLUSIONS

We discuss the clinical findings in this family with relation to descriptions in the literature. We emphasize the importance of MR in diagnosis of the condition and for detection of asumptomatic carriers. We consider a possible relationship between these findings and genes which have been mapped, and in view of recent genetic data, the hypothesis of a possible Spanish ancestor with the condition.

Management of postmenopausal osteoporosis for primary care

OBJECTIVE

The shift in health care delivery from a subspecialty to primary care system has transferred the responsibility of preventing osteoporotic fractures from specialists in metabolic bone disease to the web of physicians--family practitioners, general internists, pediatricians, and gynecologists--who provide the bulk of primary care. The challenge for this group of physicians is to decrease the rising prevalence of osteoporotic hip and vertebral fractures while operating within the cost parameters. It is the goal of this brief summary to provide primary practitioners with focused guidelines for the management of postmenopausal osteoporosis based on new and exciting developments. Prevention and treatment will change rapidly over the next decade and these advances will require changes in these recommendations.

DESIGN

We identified patients at risk for osteoporosis and provided indications for bone mass measurement, criteria for diagnosis of osteoporosis, therapeutic interventions, and biochemical markers of the disease.

RESULTS

Prevention and treatment are discussed, including hormone replacement therapy and use of calcitonin, sodium fluoride, bisphosphonates, and serum estrogen receptor modulators.

CONCLUSIONS

Postmenopausal osteoporosis should no longer be an accepted process of aging. It is both preventable and treatable. Primary care physicians must proactively prevent and treat osteoporosis in their daily practice, and combination therapies are suggested.

Interferon beta-1b inhibits reactive oxygen species production in peripheral blood monocytes of patients with relapsing-remitting multiple sclerosis

We studied the rate of reactive oxygen species (ROS) production by monocytes 'ex vivo' in a cohort of healthy individuals, in a group of MS patients undergoing treatment with interferon beta-1b and another group of MS patients who refused treatment with interferon beta-1b. The rate of ROS production in healthy individuals was slightly lower than in non-treated MS patients. The lower rate of ROS production was obtained in monocytes of MS patients treated with interferon beta-1b. These results indicate that the treatment of relapsing-remitting MS patients with interferon beta-1b rendered the NADPH oxidase of the monocytes less sensitive to trigger reactive oxygen species (ROS).

The production of free oxygen radicals and nitric oxide in the rat cochlea

Rat cochleas were analysed for free oxygen radicals (FOR) and nitric oxide (NO) production by the chemiluminescent oxidation of luminol. 4Beta-phorbol-12beta-myristate-13alpha-acetate (PMA), a well-known agonist of protein kinase C, induced the release of FOR after a time lag close to 30 s and reverted to basal values in approximately 10 min. Sphingosine inhibited by nearly 50% the response to PMA, whereas staurosporine caused an inhibition of 100%. The incubation of rat cochleas with 0.5 mM arginine potentiated the chemiluminescent reaction induced by PMA causing an additional oxidation of luminol that was inhibited by the NO synthase inhibitor N-methyl-arginine (NMA). Our results show for the first time the presence in the cochlea of cell populations producing FOR and NO and the real time production following cell activation. This procedure may help to explain the mechanisms involved in ototoxicity, as in the case of streptomycin and gentamicin that enhanced PMA-dependent production of FOR and NO.

Attempted vaginal birth after cesarean section: a multicenter comparison of outpatient prostaglandin E(2) gel with expectant management

Objective: To compare the clinical effectiveness and safety of outpatient administration of an intracervical prostaglandin (PG) E(2) gel with expectant management for women with an unfavorable cervix who wish to attempt a vaginal birth after cesarean section.Study Design: This outpatient study was a randomized, multicenter investigation involving pregnant women at term with one previous low transverse cesarean section. Each had an unfavorable cervix (Bishop score </=4) and was a candidate for vaginal delivery. Those randomly assigned to receive the gel, rather than expectant management, were given a 0.5 mg dose of PGE(2) (Prepidil) intracervically at 39 weeks gestation. This cervical ripening treatment was repeated at weekly office visits for up to 3 doses.Results: Of the 294 cases, 143 received the gel while 151 underwent expectant management. No differences between the two groups were found for maternal demographics, race, parity, or predose Bishop score. The rates of repeat cesarean section did not differ (P =.68) with use of the gel (61, 42%) or with expectant therapy (48, 45%). The onset of active labor, the duration of labor among those delivering vaginally, and the 1-minute and 5-minute Apgar scores were not different between the two groups. No uterine rupture was apparent, and adverse effects during labor were as likely to occur in the two groups.Conclusions: Although its safety was confirmed for outpatient use and for persons with a prior cesarean delivery, intracervical prostaglandin E(2) gel did not improve the chance of a vaginal birth after a cesarean delivery.

Endogenous apoE expression modulates HDL3 binding to macrophages

We have previously shown that expression of a human apoE cDNA in J774 macrophages enhances cholesterol efflux to HDL3. We have also shown that endogenous apoE expression produces a cell surface pool of apoE associated with proteoglycans. In this series of experiments, we first demonstrate the presence of a cell surface proteoglycan-associated apoE pool in human monocyte-derived macrophages. We then examine the hypothesis that endogenous expression of apoE modulates HDL3 binding to macrophages, thereby, accounting for enhanced cholesterol efflux to HDL3, specifically examining a role for the cell surface pool. Enhanced binding of apoE-free human HDL3 to apoE-expressing macrophages, compared to non-expressing macrophages, was observed at 37 degrees C and 4 degrees C. The enhanced binding was not due to apoE secreted into the medium, as determined by experiments utilizing conditioned medium from apoE-secreting cells. Removal of the cell surface pool of apoE, however, substantially reduced the incremental HDL3 binding produced by apoE expression. Cellular cholesterol mass measurements demonstrated that experimental conditions that reduced HDL3 binding to apoE-expressing macrophages, did not substantially reduce cholesterol efflux to HDL3. In summary, our results document a clear role for cell surface pool of apoE in modulating HDL3 interaction with macrophages. The enhanced binding, however, does not appear to be a major mechanism contributing to the increased cholesterol efflux to HDL3, which results from endogenous macrophage expression of apoE.