Neuropsychological counseling improves social behavior in cognitively-impaired multiple sclerosis patients

We studied the effectiveness of a newly-developed cognitive-behavioral intervention in 15 patients with marked cognitive impairment and behavior disorder. The design was a single-blind test of a neuropsychological intervention, with pre- and post-treatment assessments of personality and social behavior. MS patients underwent neurological examination and neuropsychological testing at baseline. The patients were then randomly assigned to neuropsychological counseling or standard, non-specific supportive psychotherapy. The active 12-week treatment emphasized enhancement of insight through education, social skills training, and behavior modification. All patients were re-examined within 2 weeks of the termination of treatment. Neuropsychological technicians were blind to treatment condition. Both groups showed evidence of cognitive impairment and personality/behavior disorder prior to treatment and were well matched on demographic, disability, and cognitive measures. Patients who underwent neuropsychological counseling showed significant positive response on measures of social behavior (e.g. excessive ego-centric speech) compared to those who underwent standard counseling. We conclude that these data support the use of non-pharmacological, neuropsychological counseling in patients with acquired, MS-associated behavior disorder.

Prehospital blood transfusion versus crystalloid alone in the air medical transport of trauma patients

INTRODUCTION

Differences in prehospital resuscitation measures and outcomes of trauma patients transported by two air medical programs were assessed comparing the prehospital administration of crystalloid only (Group A) with the administration of 2 liters of crystalloid followed by blood (Group B).

METHODS

A 1-year retrospective review of flight and hospital records of patients taken to Level I trauma centers by two separate air medical programs was completed. Physiologic variables, total fluids infused, and flight times were compared.

RESULTS

Thirty-one patients (Group A) received crystalloids in flight, and 17 patients received in-flight blood (Group B). No statistical differences were found between the two groups when comparing age, ISS, PS, RTS, GCS, survival, and total fluid volume. Group B had statistically greater mean flight times compared with Group A (P < .05). A difference was demonstrated between groups A and B in pH and HCO3 measurements (P < .05), with Group B presenting in a more acidotic state on admission to the hospital.

CONCLUSION

Patients with lengthy flight times, despite the administration of blood products, presented to the trauma center more acidotic than trauma patients receiving only crystalloid. The true impact of blood products on outcome could not be demonstrated because of statistical differences in flight times between the groups. A multicenter study matching flight times, head injury status, and flight type of assess benefit of prehospital utilization of blood products is warranted.

Extended observations on MS patients treated with IM interferon-beta1a (Avonex): implications for modern MS trials and therapeutics

Extended observations of the pivotal phase III clinical trial of interferon-beta1a (IFNbeta1a; Avonex, Biogen) in relapsing MS patients revealed that: (1) active treatment significantly slowed the accumulation of physical disability over time, reduced clinical exacerbations and MRI brain lesions; (2) clinical efficacy did not depend on disability endpoints; (3) active treatment benefited multiple MRI measures of brain lesions; (4) cerebral atrophy occurred over 2 years in relatively mildly disabled patients; and (5) Avonex could slow the development of atrophy after the first year of treatment. Data from this study were recently used to design a new outcome measure for MS clinical trials (the Multiple Sclerosis Functional Composite), and was also the basis for two ongoing studies of IFNbeta1a: one in patients with monosymptomatic onset of MS and the other in secondary progressive MS.

A highly specific and sensitive sandwich blocking ELISA based on baculovirus expressed pseudorabies virus glycoprotein B

A direct sandwich blocking enzyme-linked immunosorbent assay (BacgB ELISA) based on the reaction between a monoclonal antibody (MAb) and a recombinant glycoprotein B (gB) of pseudorabies virus (PRV) was developed. This protein was obtained in large quantities from insect cells infected with a PRV gB recombinant baculovirus. Expression of the gB was confirmed by immunoperoxidase monolayer assay (IPMA) with gB specific MAbs. The specificity and sensitivity of the developed BacgB ELISA were evaluated and compared with two commercially available tests by using sets of sera of known PRV infection or vaccination history. For validation, 347 serum samples have been tested. The BacgB ELISA had a high sensitivity and specificity, which were comparable with those of the two commercial tests. In addition, the BacgB ELISA allows detecting anti-gB antibodies in pig serum as early as 7 days following infection. Also maternal antibodies in uninfected pig sera were detected. We conclude that the BacgB ELISA is a useful tool for the detection of as well vaccinated as infected pigs (including derivatives from gE negative vaccine strains), with the added advantage that it uses an antigen that can be produced safely and in large quantities.

A phase I trial of solubilized DR2:MBP84-102 (AG284) in multiple sclerosis

OBJECTIVE

To assess the safety, tolerability, and biologic and clinical activity of a solubilized complex comprised of human leukocyte antigen-DR2 with myelin basic protein84-102 (AG284)in patients with secondary progressive MS.

BACKGROUND

Soluble species-specific major histocompatibility complex myelin basic protein91-103 complexes ameliorate disease in a dose-dependent manner when administered to SJL/J mice with chronic relapsing experimental allergic encephalomyelitis. Preincubation with AG284 reduces the proliferative response of a DR2-restricted, myelin basic protein84-102-reactive T cell clone, derived from a MS patient, to myelin basic protein84-102 in the presence of autologous antigen-presenting cells.

METHODS

Thirty-three patients with secondary progressive MS were randomly assigned to receive three alternate day IV doses of AG284 or placebo in a double-masked dose escalation study. The primary outcome was safety and tolerability. Secondary outcomes included a comparison of pre- and post-treatment gadolinium-enhanced brain MRI activity, Kurtzke Expanded Disability Status Scale, and Nine Hole Peg Test scores.

RESULTS

The frequency of adverse events was similar in the AG284 and placebo recipients. No significant treatment effect was detected by Expanded Disability Status Scale, Nine Hole Peg Test, or number of new gadolinium-enhancing MRI lesions.

CONCLUSIONS

AG284 as administered during this study was safe and well tolerated. Further studies are warranted to determine the biologic activity and clinical efficacy of this potential treatment for MS.

A Wallerian degeneration pattern in patients at risk for MS

BACKGROUND

Demyelination alone may not explain the progressive disability that frequently develops in MS. An alternative explanation for irreversible disability assumes a contribution from axonal injury or loss. In theory, axonal injury may occur in the focal areas characterized by early inflammation, or can be more distant, as in Wallerian degeneration. However, Wallerian degeneration is thought of as a rare or a late finding in MS.

METHODS

Studies showing a classic Wallerian degeneration pattern in the corticospinal tract were selected from a review of MR studies from patients enrolled in a longitudinal treatment trial. Entry was based on first occurrence of an isolated neurologic syndrome consistent with MS and a positive MRI.

RESULTS

This report is based on five cases followed longitudinally who showed development of a classic T2-hyperintense lesion along the ipsilateral corticospinal tract, subsequent to an initial inciting event located in the white matter located in the superior aspect of the corona radiata. Lesions were evident as T2-hyperintensity persisting throughout the 12 to 18 months of observation.

CONCLUSIONS

This series suggests that Wallerian degeneration, implying axonal injury, may occur as a sequela of acute demyelinating lesions in patients presenting with their first symptoms suggestive of MS. This can produce a component of the increasing burden of T2-hyperintense lesions temporally and spatially dissociated from inflammatory or demyelinating activity. Further studies are required to determine if Wallerian degeneration is an important factor contributing to disability progression in MS.

Detection of pseudorabies virus DNA in individual single-reactor pigs found in certified pseudorabies-free herds

During monitoring of certified pseudorabies (PRV)-free herds to confirm their PRV -free status, occasional individual gE-seropositive pigs are detected. These single-reactor pigs remain gE-seropositive when further serum samples are collected and tested. For the eradication programme to proceed, it is important to determine whether these pigs are only false positives or are; in fact, infected with field PRV. The purpose of this study was to determine whether the polymerase chain reaction (PCR) could detect field PRVDNA in single-reactor pigs and so confirm positive reactions in the serologic monitoring programme. First, DNA samples of various tissues from 15 single-reactor pigs all from different herds were examined for field PRV by PCR. Additionally, serum samples from these pigs were analyzed in a gE-confirmation enzyme linked immunosorbent assay (gE-confirmation ELISA). PCR detected PRVDNA in five of the 15 pigs, and these results were confirmed by the gE-confirmation ELISA. The remaining 10 pigs that tested negative in the PCR also tested negative in the gE- confirmation ELISA. We conclude that PCR can be used to discriminate between true and false serological positive single-reactor pigs and, moreover, that the gE-confirmation ELISA confirms these PCR results.

Use of the brain parenchymal fraction to measure whole brain atrophy in relapsing-remitting MS. Multiple Sclerosis Collaborative Research Group

BACKGROUND

Episodic inflammation in the CNS during the early stages of MS results in progressive disability years later, presumably due to myelin and axonal injury. MRI demonstrates ongoing disease activity during the early disease stage, even in some patients who are stable clinically. The optimal MRI measure for the destructive pathologic process is uncertain, however.

METHODS

In this post-hoc study, MRI scans were analyzed from patients with relapsing MS participating in a placebo-controlled trial of interferon beta-1a. The brain parenchymal fraction, defined as the ratio of brain parenchymal volume to the total volume within the brain surface contour, was used to measure whole brain atrophy. The relationship between disease features and brain atrophy and effect of interferon beta-1a were determined.

RESULTS

MS patients had significant brain atrophy that worsened during each of 2 years of observation. In many patients, brain atrophy worsened without clinical disease activity. Baseline clinical and MRI abnormalities were not strongly related to the rate of brain atrophy during the subsequent 2 years. Treatment with interferon beta-1a resulted in a reduction in brain atrophy progression during the second year of the clinical trial.

CONCLUSIONS

Patients with relapsing-remitting MS have measurable amounts of whole brain atrophy that worsens yearly, in most cases without clinical manifestations. The brain parenchymal fraction is a marker for destructive pathologic processes ongoing in relapsing MS patients, and appears useful in demonstrating treatment effects in controlled clinical trials.

A highly specific and sensitive competitive enzyme-linked immunosorbent assay (ELISA) based on baculovirus expressed pseudorabies virus glycoprotein gE and gI complex

A direct competition enzyme-linked immunosorbent assay (ELISA) based on baculovirus expressed complex of pseudorabies virus (PRV) glycoproteins E (gE) and I (gI) has been developed. For that purpose gE and gI genes of PRV were co-expressed in insect cells. Complex formation was confirmed by radioimmunoprecipitation assay. The specificity and sensitivity of the test were evaluated and compared with an ELISA using only gE as an antigen and a commercially available test. For validation, 245 negative sera and 165 positive sera have been tested. The gE/gI ELISA had a higher sensitivity and specificity when compared with the ELISA using only gE as the antigen. Both sensitivity and specificity were comparable with the commercially available test. Moreover, the test based on the baculovirus gE/gI complex allows the detection of anti-gE antibodies in pig serum as early as two weeks after infection. The gE/gI ELISA test is easy to perform; its additional advantage is that the gE/gI antigen can be produced in baculovirus system in large quantities without handling live pseudorabies virus.

The Oregon Health Plan and the political paradox of rationing: what advocates and critics have claimed and what Oregon did

The article proceeds in three sections. First, we very briefly review the original proposals and ensuing (and misleading) debate over rationing in Oregon. Next, we explore how the politics of rationing unfolded in Oregon from the enactment of OHP to its implementation. Finally, we consider the character of Oregon's innovation and the broader lessons that it holds for reform efforts elsewhere.

Outcome assessment of physiologic and clinical predictors of survival in patients after traumatic injury with a trauma score less than 5

OBJECTIVE

To define those physiologic and clinical variables that have a positive or negative predictive value in discriminating survivors from nonsurvivors with traumatic injuries and a Trauma Score of 5 or less.

METHODS

A retrospective review of 2,622 trauma patients transported by an air medical service from the scene of injury to a Level I trauma center was performed. Demographic, physiologic, and clinical variables were evaluated.

RESULTS

One hundred thirty-six patients were studied; 14 patients survived trauma resuscitation. Survivors had statistically significant improvement in the Glasgow Coma Scale from the field to arrival in the emergency room. Revised Trauma Score, probability of survival, pulse, respiratory rate, cardiac rhythm, central nervous system activity, and signs of life were statistically more favorable in survivors.

CONCLUSION

In patients who survived to discharge, signs of central nervous system activity in the field was a positive predictor of survival, and severe head injury served as a negative predictor of survival.

The chemical control of biofouling in industrial water systems

Oxidising and non-oxidising biocides are commonly used in an attempt to control biofouling in industrial water systems. Many of these programmes, however, fail due to the incorrect selection and application of these chemical compounds. Knowledge of the organisms to be eliminated and system hydraulics are important operational parameters in ensuring the successful application of chemical control programmes. A further complicating factor is the build up of bacterial resistance to many of these compounds. One way of limiting resistance is the alternation of oxidising and non-oxidising biocides at the correct miminum inhibitory concentration and using these in combination with surface active compounds to dislodge any biofilm. A variety of surface monitoring techniques are in use in order to monitor the success of biofouling control programmes. Unfortunately none of these techniques are ideal and results have to be considered very carefully.

Purification and characterization of a flavoprotein involved in the degradation of epoxyalkanes by Xanthobacter Py2

Recently a newly discovered pyridine nucleotide-disulfide oxidoreductase was reported to be essential for the degradation of epoxyalkanes by the Xanthobacter Py2 [Swaving, J., De Bont, J. A. M., Westphal, A. & De Kok, A. (1996) J. Bacteriol. 178, 6644-6646]. The disulfide oxidoreductase has now been purified from propene-grown Xanthobacter Py2. This enzyme (component II) is a NADPH-dependent FAD-containing homodimeric protein. The physiological substrate for this enzyme is unknown. The enzyme was active with the following dithiol substrates in decreasing order: 1,3-propanedithiol, reduced lipoamide and dithiothreitol, and inactive with glutathione and monothiols. In the reversed direction, only activity with 5,5'-dithiobis(2-nitrobenzoate) could be measured. Compared with other disulfide reductases it has a high activity with 5,5'-dithiobis(2-nitrobenzoate) and a low diaphorase and oxidase activity. Steady-state kinetic studies at pH 8.5 with 1,3-propanedithiol show that the enzyme operates by a ternary complex mechanism in the direction of NADP+ reduction. Anaerobic incubation of the enzyme with 1,3-propanedithiol resulted in slow reduction of the enzyme to yield the thiolate-FAD charge-transfer complex, the rate depending on the pH. At pH 7, where reduction was not detectable within 2 h, rapid mixing of NADP+ with the enzyme-propanedithiol mixture resulted in the formation of a complex between the reduced enzyme and NADP+ within the dead time of the instrument (5.6 ms). This is followed by slow formation of NADPH, concomitant with the appearance of the flavin C(4a)-thiol adduct, as judged from the spectral changes. This suggests that the rate-limiting step is the transfer of a hydride ion from the half-reduced enzyme to NADP+. Stopped-flow experiments involving reduction by NADPH show a biphasic behavior. The rapid formation (k(obs) = 40 s(-1)) of a transient intermediate with little absorption decrease at 460 nm and long wavelength absorption was followed by the slow formation (k(obs) = 4 s(-1)) of a species characterized as the thiolate-FAD charge-transfer complex with bound NADP+. Some formation of the FAD C(4a)-thiol adduct was also observed. Photoreduction in the presence of deazaflavin results in rapid bleaching at 450 nm, followed by the slow formation of a stable semiquinone. Full reduction could not be achieved, either by photoreduction or with NADPH, and was incomplete even with dithionite or NADPH in the presence of arsenite. The results indicate a low redox potential of the FAD and a slow rate of electron transfer from the pyridine nucleotide to the redox active disulfide and vice versa. From a sequence alignment with other disulfide reductases, it appears that the active site His-Glu diad is absent in this enzyme. The kinetic and spectral features described above will be discussed in this context.

Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries

BACKGROUND

Recognizing the significant mortality and complications inherent in the operative management of blunt hepatic injuries, hepatic arterial embolization was evaluated as a bridge between operative and nonoperative interventions in patients defined as hemodynamically stable only with continuous resuscitation.

METHODS

Seven of 11 patients with grade IV or V hepatic injuries identified by computed tomography underwent hepatic arterial embolization. A prospective evaluation of hepatic embolization based on subsequent hemodynamic parameters was assessed by matched-pair analysis. A summary of this study population's demographic data and outcomes is presented, including age, Glasgow Coma Scale score, Injury Severity Score, Revised Trauma Score, computed tomography grade, intensive care unit and hospital length of stay, transfusion requirements, complications, and mortality.

RESULTS

No statistical difference was demonstrated between pre-embolization and postembolization hemodynamics and volume requirements. After embolization, however, continuous resuscitation was successfully reduced to maintenance fluids. Hepatic embolization was the definitive therapy for all seven patients who underwent embolization.

CONCLUSION

Results of this preliminary investigation suggest that hepatic arterial embolization is a viable alternative bridging the therapeutic options of operative and nonoperative intervention for a subpopulation of patients with hepatic injury.

Trauma 24-hour observation critical path

BACKGROUND

The 24-hour observation critical pathway for trauma is a clinical tool developed to expedite health care delivery to minimally injured patients. The use of patient care, BS, guidelines and physician-approved standing orders was implemented in a Level I trauma center.

METHODS

A retrospective chart review was performed of 122 patients admitted via the emergency department between December 1, 1993, and May 31, 1994. All patients were evaluated in the emergency department by emergency medicine and trauma physicians and deemed appropriate for 24-hour observation. The information collected included patient demographics, hospital charges, injuries, length of stay, diagnostic tests, consultations, and variances from the critical pathway.

RESULTS

During the 6-month study period, there were 600 trauma admissions. Of those admissions, 122 patients (20%) were evaluated in the emergency department and deemed appropriate for enrollment in the 24-hour observation pathway. The charts of these patients were reviewed. Fourteen admissions were determined inappropriate for the critical pathway because of the severity of injuries or discharge against medical advice. One hundred eight charts were evaluated further. Eighty-nine patients (80%) completed the critical pathway with a length of stay of 24 hours.

CONCLUSION

The 24-hour observation critical pathway was designed and used appropriately as exemplified by an overall 80% completion rate. The critical pathway offers a mechanism to streamline care of the minimally injured trauma patient. It also serves as a quality-improvement tool for increasing efficiency, decreasing utilization of resources, and decreasing length of stay.

Splenosis of the mesoappendix: case report and review of the literature

The development of splenosis is a known consequence of splenic rupture. A case is presented of acute appendicitis in a patient with a past history of abdominal trauma who required laparotomy for unknown reasons. During appendicectomy a mass was found in the mesoappendix which proved to be evidence of splenosis.

Evaluation of mechanism of increased intracranial pressure with insufflation

BACKGROUND

Previous studies have documented an increase in intracranial pressure with abdominal insufflation, but the mechanism has not been explained.

METHODS

Nine 30-35-kg domestic pigs underwent carbon dioxide insufflation at 1.5 l/min. Intracranial pressure (ICP), lumbar spinal pressure (LP), central venous pressure (CVP), inferior vena cava pressure (IVCP), heart rate, systemic arterial blood pressure, pulmonary arterial pressure, cardiac output, heart rate, respiratory rate, temperature, and end-tidal CO2 were continuously measured. Mechanical ventilation was used to maintain a constant pCO2. Measurements were recorded at 0, 5, 10, and 15 mmHg of abdominal pressure with animals in supine, Trendelenburg (T), and reverse Trendelenburg (RT) positions. Prior to recording measurements, the animals were allowed to stabilize for 40 min after each increase in abdominal pressure and for 20 min after each position change.

RESULTS

The animals showed a significant increase in ICP (mmHg) with each 5-mmHg increase in abdominal pressure (0 mmHg: 14 +/- 1.7; 5 mmHg: 19.8 +/- 2.3, p < 0.001; 10 mmHg: 24.8 +/- 2.5, p < 0.001; 15 mmHg: 29.8 +/- 4.7, p < 0.01). The ICP at 15 mmHg abdominal pressure increased further in the T position (39 +/- 4, p < 0.01). Insufflating in the RT position did not significantly reduce the increase in ICP. The IVCP (mmHg) increased with increased abdominal pressure (0 mmHg: 11.5 +/- 6.2, 15 mmHg: 22.1 +/- 3.5, p < 0.01). This increase correlated with the increase in ICP and LP (r of mean pressures >/=0.95). There was no significant change in CVP.

CONCLUSIONS

This study suggests that care may be needed with laparoscopy in patients at risk for increased ICP due to head injury or a space occupying lesion. The mechanism of increased ICP associated with insufflation is most likely impaired venous drainage of the lumbar venous plexus at increased intraabdominal pressure. Further studies of cerebral spinal fluid movement during insufflation are currently underway to confirm this hypothesis.

Painless osteoid osteoma of the middle phalanx

A 12-year-old girl with a painless swollen finger was a clinical puzzle as her presentation and X-rays were not typical of osteoid osteoma. Computed tomography and histology confirmed the diagnosis. This case is reported for its atypical presentation, difficulty in diagnosis and rare occurrence in the middle phalanx.

Detection of wild-type Aujeszky's disease virus by polymerase chain reaction in sheep vaccinated with a modified live vaccine strain

An outbreak of Aujeszky's disease occurred in a flock of sheep which had been housed together with pigs. After the death of five sheep with clinical signs of Aujeszky's disease, the remaining sheep were vaccinated with the Bartha vaccine strain, and the pigs were vaccinated with the 783 vaccine strain of Aujeszky's disease virus. Despite vaccination, however, more sheep died. Brain tissues from four sheep were collected for virus isolation and for immunohistological examinations. Only vaccine virus (gE-negative) was detected in the tissue. After DNA restriction enzyme analysis of the isolated virus, DNA of one or both of the vaccine strains was detected in all sheep. In one sheep field virus DNA was also detected. However, when the polymerase chain reaction was performed on samples prepared from paraffin-embedded tissues, DNA of field virus (gE-positive) was detected in all four sheep. It was probable that the sheep had not yet mounted a sufficient immune response to the vaccine virus, or were already infected with field virus at the time of vaccination. We concluded that the sheep died from field virus infection and not from vaccine virus infection and that only the polymerase chain reaction made it possible to specifically detect even very small amounts of field virus DNA among vaccine virus DNA in all investigated sheep.

Pseudorabies virus infections in pigs. Role of viral proteins in virulence, pathogenesis and transmission

This paper reviews new findings on the biological functions of pseudorabies virus (PRV) proteins. It focuses on the role of PRV proteins in the pathogenicity, immunogenicity and transmission of PRV vaccine strains in pigs. Furthermore, it evaluates potential risks that are connected with the use of PRV vector strains. Special emphasis is placed upon the spread of genetically engineered vaccine strains within pigs or between pigs.