Neuropsychological symptoms of juvenile-onset batten disease: experiences from 2 studies

Juvenile neuronal ceroid lipofuscinosis (Batten disease) is a progressive and fatal autosomal-recessive inherited lysosomal storage disorder of childhood. Core symptoms include vision loss, seizures, and mental and motor decline. This article presents data from 2 studies of neuropsychological function in juvenile neuronal ceroid lipofuscinosis. In the first cross-sectional pilot study, 15 children with genetic or clinicopathologic confirmation of juvenile neuronal ceroid lipofuscinosis completed a brief test of attention (mean age = 14.3 +/- 2.9 years, range = 8.75-18.74 years; 7 males, 8 females). Average attention performances were significantly below age-expected normative data. A second longitudinal study was then initiated to study neuropsychological function in greater depth, including change in function over time. The authors have enrolled 18 children to date (mean age = 12.88 +/- 3.59 years, range = 6.26-18.65; 11 males, 7 females). Of these, 5 children have completed a second (annual) re-evaluation. Results thus far indicate significant impairment in domains of auditory attention, memory, estimated verbal intellectual function, and verbal fluency. Neuropsychological impairment was significantly correlated with disease duration and with motor function as assessed by a disease-specific clinical neurologic rating scale. There was no significant difference between males and females in neuropsychological test performance. Neuropsychological function was worse among children with a positive seizure history. Juvenile neuronal ceroid lipofuscinosis-affected children exhibited significant and pervasive impairments on tests of auditory attention, verbal memory and repetition, verbal fluency, and an estimate of verbal intellectual ability. Preliminary follow-up data from an annual reassessment showed progressive declines in cognitive function, in particular on a task of working memory. Neuropsychological deficits are pervasive and progressive. Future research will focus on clarifying the relationship among disease duration, motor function, and neuropsychological performances, including the relative sensitivity of neuropsychological testing at different stages of motor impairment or disease duration.

Projected number of people with Parkinson disease in the most populous nations, 2005 through 2030

Based on published prevalence studies, we used two different methodologies to project the number of individuals with Parkinson disease (PD) in Western Europe's 5 most and the world's 10 most populous nations. The number of individuals with PD over age 50 in these countries was between 4.1 and 4.6 million in 2005 and will double to between 8.7 and 9.3 million by 2030.

Standardized assessment of behavior and adaptive living skills in juvenile neuronal ceroid lipofuscinosis

We obtained information about the behavioral, psychiatric, and functional status of 26 children (13 males, 13 females) with juvenile neuronal ceroid lipofuscinosis (JNCL; mean age 12y 3mo [SD 3y 4mo]; range 6y 9mo to 18y 8mo). Twenty-five children had visual impairment and 18 were known to have a positive seizure history before enrollment. Parents completed the Child Behavior Checklist, Scales of Independent Behavior - Revised, and a structured interview to assess obsessive-compulsive symptoms. Participants exhibited a broad range of behavioral and psychiatric problems, rated as occurring frequently and/or as severe in more than half of the sample. Males and females did not differ with regard to the number of behavioral and psychiatric problems. Children were also limited in their ability to perform activities of daily living, including self-care, hygiene, socialization, and other age-appropriate tasks. Results provide a quantitative baseline for behavioral and psychiatric problems and functional level in JNCL, against which further decline can be measured. Longitudinal assessment of behavioral and psychiatric symptoms and functional abilities is continuing and will provide much-needed data on the natural history of JNCL.

A clinical rating scale for Batten disease: Reliable and relevant for clinical trials

BACKGROUND

Batten disease (juvenile neuronal ceroid lipofuscinosis [JNCL]) is an autosomal recessive neurodegenerative disorder characterized by blindness, seizures, and relentless decline in cognitive, motor, and behavioral function. Onset is in the early school years, with progression to death typically by late adolescence. Development of a clinical instrument to quantify severity of illness is a prerequisite to eventual assessment of experimental therapeutic interventions.

OBJECTIVE

To develop a clinical rating instrument to assess motor, behavioral, and functional capability in JNCL.

METHODS

A clinical rating instrument, the Unified Batten Disease Rating Scale (UBDRS), was developed by the authors to assess motor, behavioral, and functional capability in JNCL. Children with verified JNCL were evaluated independently by three neurologists. Intraclass correlation coefficients (ICCs) were used to estimate the interrater reliability for total scores in each domain. Interrater reliability for scale items was assessed with weighted kappa statistics.

RESULTS

Thirty-one children with confirmed JNCL (10 boys, 21 girls) were evaluated. The mean age at symptom onset was 6.1 +/- 1.6 years, and the mean duration of illness was 9.0 +/- 4.4 years. The ICCs for the domains were as follows: motor = 0.83, behavioral = 0.68, and functional capability = 0.85.

CONCLUSIONS

The Unified Batten Disease Rating Scale (UBDRS) is a reliable instrument that effectively tests for neurologic function in blind and demented patients. In its current form, the UBDRS is useful for monitoring the diverse clinical findings seen in Batten disease.

Behavioral symptoms associated with Huntington's disease

In addition to the abnormal movements most commonly associated with HD, cognitive impairment and psychiatric symptoms occur in almost all patients. These behavioral symptoms contribute to morbidity and augment what is often an overwhelming caregiver burden. Behavioral interventions may be useful in managing some HD patients with behavioral symptoms, especially irritability and apathy. Patients should be evaluated for underlying medical illness that might contribute to psychiatric symptoms, especially if onset of behavioral change is rapid. According to clinical observation, HD patients with psychiatric symptoms respond to standard pharmacotherapy. Controlled studies are needed to determine the true efficacy of these agents for use in treating people with HD.

Effects of nonuniform illumination on implosion asymmetry in direct-drive inertial confinement fusion

Target areal density (rhoR) asymmetries in OMEGA direct-drive spherical implosions are studied. The rms variation <deltarhoR>/<rhoR> for low-mode-number structure is approximately proportional to the rms variation of on-target laser intensity <deltaI>/<I> with an amplification factor of approximately 1/2(C(r)-1), where C(r) is the capsule convergence ratio. This result has critical implications for future work on the National Ignition Facility as well as OMEGA.

Dependence of shell mix on feedthrough in direct drive inertial confinement fusion

The mixing of cold, high-density shell plasma with the low-density, hot spot plasma by the Rayleigh-Taylor instability in inertial confinement fusion is experimentally shown to correlate with the calculated perturbation feedthrough from the ablation surface to the inner shell surface. A fourfold decrease in the density of shell material in the mix region of direct drive implosions of gas filled spherical plastic shells having predicted convergence ratios approximately 15 was observed when laser imprint levels were reduced and the initial shell was thicker, corresponding to a reduction in the feedthrough rms level by a factor of 6. Shell mix is also shown to limit the spherical compression of the implosion.

Shell mix in the compressed core of spherical implosions

The Rayleigh-Taylor instability in its highly nonlinear, turbulent stage causes atomic-scale mixing of the shell material with the fuel in the compressed core of inertial-confinement fusion targets. The density of shell material mixed into the outer core of direct-drive plastic-shell spherical-target implosions on the 60-beam, OMEGA laser system is estimated to be 3.4(+/-1.2) g/cm(3) from time-resolved x-ray spectroscopy, charged-particle spectroscopy, and core x-ray images. The estimated fuel density, 3.6(+/-1) g/cm(3), accounts for only approximately 50% of the neutron-burn-averaged electron density, n(e)=2.2(+/-0.4)x10(24) cm(-3).

Evolution of shell nonuniformities near peak compression of a spherical implosion

The evolution of shell modulations near peak compression of direct-drive spherical-target implosions has been measured using the 60-beam, 30-kJ UV OMEGA laser system. The spatial size and amplitude of shell-areal-density modulations decrease during the target compression, then increase during its decompression as expected. The shell uniformity at peak compression has been increased by reducing single-beam, laser-drive nonuniformity.

The placebo response in Parkinson's disease. Parkinson Study Group

Our objective was to study the placebo response in Parkinson's disease (PD). We conducted a literature search in which placebo response was measured in all studies of PD from 1969 to April 1996. Strict criteria were defined to include or exclude published reports in our survey. The Parkinson Study Group database for Deprenyl & Tocopherol Antioxidative Therapy of Parkinsonism (DATATOP) was reviewed and placebo "responders" were compared to placebo "nonresponders" by age, race, religion, level of education, duration of PD, and gender. A significant difference between the efficacy of placebo and that of active drug was reported in 61% (22 of 36) of the articles meeting the required criteria; DATATOP analysis showed no statistically significant epidemiologic differences between 140 placebo responders and 58 placebo nonresponders except in PD effect on current job. Although there is clearly a placebo response in PD patients, our review suggests that the variation in placebo response does not correlate with demographic factors such as age, gender, religion, level of education, or duration of PD.

Pinhole-array x-ray spectrometer for laser-fusion experiments

A pinhole-array x-ray spectrometer for laser-fusion experiments is demonstrated. An array of approximately 300 pinholes is placed in front of a flat-crystal spectrometer, yielding target images at photon energies ~10 eV apart (for photon energies of ~4 to 5 keV). For wideband radiation the images are two dimensional, whereas when a single spectral line is used, the field of view in the direction of dispersion is limited. However, single spectral line images can have a field of view sufficient for imaging the compressed target core. We show the image at the Ti-Kalpha-line fluorescence from a Ti-doped shell, which we show to be excited by continuum radiation from the compressed core. The Kalpha image delineates the cold, compressed shell at peak compression, which can otherwise be obtained only through backlighting. In addition, the array provides spectra of high spectral resolution because of the reduction in the effective source size.

Clinical research in neurology. From observation to experimentation

Clinical research in neurology may be based on observation or intervention. Basic science and observational clinical studies often address questions of cause and pathogenesis, whereas interventional clinical experiments normally are required to establish the safety, tolerability, and efficacy of therapies. This article outlines various study paradigms and discusses the concepts of intervention, randomization, blinding, and control in the context of clinical trial design. Accurate interpretation of trial results is predicated on the care with which experimental therapeutic studies are designed and conducted.

Monochromatic backlighting as a laser-fusion diagnostic

The case of an x-ray radiographed (backlit) image of a CH-shell laser-fusion target to be imploded by the Omega Upgrade laser system is studied. The goal is to obtain information on the conditions at peak compression, where the experimental constraints due to target self-emission and required spatial resolution are maximal. Particular attention is devoted to the problem of discriminating against the target self-emission. It is shown that a way to selectively image the target with radiation from a backlight source is to obtain a monochromatic image at a single spectral line emitted by the backlighter. Two experimental configurations are discussed: (a) an x-ray microscope with a flat crystal monochromator, and (b) pinhole imaging in conjunction with a curved crystal monochromator. Useful images are obtained with simple CH-shell targets and without the need for a short-pulse backlighter beam.

Effect of variable doses of dexamethasone on posttreatment endodontic pain

One hundred six patients with pretreatment pain presenting for endodontic treatment participated in a controlled double blind study. After root canal therapy, the patients were given an intraoral intramuscular injection of either a saline placebo or various dosages of dexamethasone. Posttreatment pain incidence and severity were evaluated at 4, 8, 24, 48, and 72 h. Injection of the various dosages of dexamethasone, taken as a group, was shown to significantly reduce the severity of pain at 4 and 8 h, and 0.07 to 0.09 mg/kg dosage alone significantly reduced pain at 8 h. Patients who received dexamethasone took significantly fewer posttreatment pain medications than those who received the placebo. Although there was a trend toward a reduction in the incidence of posttreatment pain for patients who received dexamethasone, the difference was not statistically significant.

A 24-week study of the microleakage of four retrofilling materials using a fluid filtration method

The microleakage after retrofillings of amalgam, amalgam with cavity varnish, silver-containing glass ionomer cement, and intermediate restorative material was compared in vitro. Thirty-six extracted human incisors and canines were instrumented, obturated with gutta-percha without sealer, subjected to apicoectomy, and retrofilled with the materials described above. After removal of the gutta-percha filling, the microleakage from both directions (apically and coronally) was measured quantitatively and longitudinally for 24 wk after filling by a fluid filtration technique. All four retrofilling materials revealed some apical and coronal leakage at all time periods. The amalgam group showed statistically significant (p less than 0.001) apical leakage at 1.5 h. The use of cavity varnish significantly reduced the apical leakage of the amalgam group at 1.5 h. The silver-containing glass ionomer cement and intermediate restorative material groups showed significantly (p less than 0.05) less coronal leakage compared with the amalgam group at 1.5 h. Scanning electron microscopy of selected samples showed marginal defects of approximately 5 microns between the root dentin and the retrofilling material.

In vitro quantification of the apical sealing ability of retrograde amalgam fillings

Retrograde amalgam fillings were placed in 12 extracted human canines. The microleakage from the both directions (coronally and apically) was determined using pressurized fluid filtration at 90 min, 6 h, 1 day, 2 days, and 1,2,4, and 8 wk after amalgam filling. Leakage from either direction decreased markedly in the 90-min to 6-h interval after filling. At intervals between 1 day and 8 wk, only small changes in leakage were noted. After any time period, leakage from the coronal direction was greater than leakage from the apical direction. However, this difference was not statistically significant except at 90 min when the coronal leakage was significantly greater. This experimental system was shown to reliably measure microleakage in retrograde amalgam fillings.