Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

The Government Budget: An Overlooked Vehicle for Advancing Strategic Health Purchasing

The most effective way to finance universal health coverage (UHC) is through compulsory prepaid funds that flow through the government budget. Public funds-including on-budget donor resources-allow for pooling and allocation of resources to providers in a way that aligns with population health needs. This is particularly important for low-income settings with fiscal constraints. While much attention is paid to innovative sources of additional financing for UHC and to implementing strategic purchasing approaches, the government budget will continue to be the main source of health financing in most countries-and the most stable mechanism for channeling additional funds. The government budget should therefore be front and center on the strategic purchasing agenda. This commentary uses lessons from Tanzania and Uganda to demonstrate that more can be done to use the government budget as a vehicle for making health purchasing more strategic, across all phases of the budget cycle, and for making greater progress toward UHC. Actions need to be accompanied by measures to address bottlenecks in the public financial management system.

SPARC the Change: What the Strategic Purchasing Africa Resource Center Has Learned about Improving Strategic Health Purchasing in Africa

Embodied in the goals of universal health coverage (UHC) are societal norms about ethics, equity, solidarity, and social justice. As African countries work toward UHC, it is important for their governments to use all available resources, knowledge, and networks to continue to bring this goal closer to reality for their populations. The Strategic Purchasing Africa Resource Center (SPARC) was established in 2018 as a "go-to" source of Africa-based expertise in strategic health purchasing, which is a critical policy tool for making more effective use of limited funds for UHC. SPARC facilitates collaboration among governments and research partners across Africa to fill gaps in knowledge on how to make progress on strategic purchasing. The cornerstone of this work has been the development and use of the Strategic Health Purchasing Progress Tracking Framework to garner insights from each country's efforts to make health purchasing more strategic. Application of the framework and subsequent dialogue within and between countries generated lessons on effective purchasing approaches that other countries can apply as they chart their own course to use strategic purchasing more effectively. These lessons include the need to clarify the roles of purchasing agencies, define explicit benefit packages as a precondition for other strategic purchasing functions, use contracting to set expectations, start simple with provider payment and avoid open-ended payment mechanisms, and use collaborative rather than punitive provider performance monitoring. SPARC has also facilitated learning on the "how-to" and practical steps countries can take to make progress on strategic purchasing to advance UHC.

Next-generation gene panel testing in adolescents and adults in a medical neuropsychiatric genetics clinic

Intellectual disability (ID) encompasses a clinically and genetically heterogeneous group of neurodevelopmental disorders that may present with psychiatric illness in up to 40% of cases. Despite the evidence for clinical utility of genetic panels in pediatrics, there are no published studies in adolescents/adults with ID or autism spectrum disorder (ASD). This study was approved by our institutional research ethics board. We retrospectively reviewed the medical charts of all patients evaluated between January 2017 and December 2019 in our adult neuropsychiatric genetics clinic at the McGill University Health Centre (MUHC), who had undergone a comprehensive ID/ASD gene panel. Thirty-four patients aged > 16 years, affected by ID/ASD and/or other neuropsychiatric/behavioral disorders, were identified. Pathogenic or likely pathogenic variants were identified in one-third of our cohort (32%): 8 single-nucleotide variants in 8 genes (CASK, SHANK3, IQSEC2, CHD2, ZBTB20, TREX1, SON, and TUBB2A) and 3 copy number variants (17p13.3, 16p13.12p13.11, and 9p24.3p24.1). The presence of psychiatric/behavioral disorders, regardless of the co-occurrence of ID, and, at a borderline level, the presence of ID alone were associated with positive genetic findings (p = 0.024 and p = 0.054, respectively). Moreover, seizures were associated with positive genetic results (p = 0.024). One-third of individuals presenting with psychiatric illness who met our red flags for Mendelian diseases have pathogenic or likely pathogenic variants which can be identified using a comprehensive ID/ASD gene panel (~ 2500 genes) performed on an exome backbone.

Reinforcing locally led solutions for universal health coverage: a logic model with applications in Benin, Namibia and Uganda

Development assistance for health programmes is often characterised as donor-led models with minimal country ownership and limited sustainability. This article presents new ways for low-income and middle-income countries to gain more control of their development assistance programming as they move towards universal health coverage (UHC). We base our findings on the experience of the African Collaborative for Health Financing Solutions (ACS), an innovative US Agency for International Development-funded project. The ACS project stems from the premise that the global health community can more effectively support UHC processes in countries if development partners change three long-standing paradigms: (1) time-limited projects to enhancing long-lasting processes, (2) fly-in/fly-out development support to leveraging and strengthening local and regional expertise and (3) static knowledge creation to supporting practical and co-developed resources that enhance learning and capture implementation experience. We assume that development partners can facilitate progress towards UHC if interventions follow five action steps, including (1) align to country demand, (2) provide evidence-based and tailored health financing technical support, (3) respond to knowledge and learnings throughout activity design and implementation, (4) foster multi-stakeholder collaboration and ownership and (5) strengthen accountability mechanisms. Since 2017, the ACS project has applied these five action steps in its implementing countries, including Benin, Namibia and Uganda. This article shares with the global health community preliminary achievements of implementing a unique, challenging but promising experience.

BAFF is increased in renal transplant patients following treatment with alemtuzumab

Alemtuzumab is a monoclonal antibody that depletes T and B cells and is used as induction therapy for renal transplant recipients. Without long-term calcineurin inhibitor (CNI) therapy, alemtuzumab-treated patients have a propensity to develop alloantibody and may undergo antibody-mediated rejection (AMR). In pursuit of a mechanistic explanation, we analyzed peripheral B cells and serum of these patients for BAFF (Blys) and BAFF-R, factors known to be integral for B-cell activation, survival, and homeostasis. Serum BAFF levels of 22/24 alemtuzumab-treated patients were above normal range, with average levels of 1967 pg/mL compared to 775 pg/mL in healthy controls (p = 0.006). BAFF remained elevated 2 years posttransplant in 78% of these patients. BAFF-R on CD19(+) B cells was significantly downregulated, suggesting ligand/receptor engagement. BAFF mRNA expression was increased 2-7-fold in CD14(+) cells of depleted patients, possibly linking monocytes to the BAFF dysregulation. Addition of recombinant BAFF to mixed lymphocyte cultures increased B-cell activation to alloantigen, as measured by CD25 and CD69 coexpression on CD19(+) cells. Of note, addition of sirolimus (SRL) augmented BAFF-enhanced B-cell activation whereas CNIs blocked it. These data suggest associations between BAFF/BAFF-R and AMR in alemtuzumab-treated patients.

Calcineurin inhibitor withdrawal after renal transplantation with alemtuzumab: clinical outcomes and effect on T-regulatory cells

To address the results of calcineurin inhibitor (CNI) withdrawal after alemtuzumab induction relative to CNI continuation, we performed a pilot randomized clinical trial in renal allograft recipients on CNI, a mycophenolic acid derivative and steroids after the first 2 months posttransplantation. Forty patients were randomized to taper off CNI or to maintain it, and followed for at least 1 year. Four patients in the withdrawal group were treated for acute rejection while no patient received antirejection treatment in the control group. Two control patients withdrew CNI due to nephrotoxicity. Estimated GFR was similar in both groups after 1 year. Flow cytometry of CD4(+)CD25(+)CTLA-4(+)FoxP3(+) regulatory T cells (Treg) demonstrated a significant increase in Treg percentages in the peripheral blood of alemtuzumab-treated patients on CNI early postransplant. Furthermore, the increased Treg percentages in the withdrawal cohort were unchanged at month 6 postenrollment, whereas they decreased significantly in those patients maintained on CNI. Patients withdrawn from CNI after alemtuzumab trend toward a higher rejection rate, but most patients can be weaned from a CNI using this regimen. With the exception of maintaining increased Treg levels, the benefits are not appreciable in this short follow-up, and a larger randomized trial is justified.

A behaviour study on the potential for direct transmission of tuberculosis from possums (Trichosurus vulpecula) to alpacas (Lama pacos), and the converse from alpacas to possums

AIMS

To evaluate the potential for the direct transmission of tuberculosis from possums to alpacas, and vice versa.

METHODS

A field study was conducted on an alpaca farm in Northland, New Zealand on 7 January 1999. Observations were recorded on the interaction of one group of male alpacas with a simulated dead possum, one male and one female alpaca group with a simulated terminally tuberculous possum, and one group of male alpacas with a normal possum in an enclosure from which the animals could not escape. The possum was sedated with ketamine as hydrochloride to simulate death (inactive; no movement), and terminal illness (active, inco-ordinated movement around the paddock). The observations were based on the focal animal sampling technique, they were un-replicated, and recorded visually and manually with intermittent still photography.

RESULTS

Both male and female alpacas showed strongly inquisitive interaction with the possum. They clustered around the possum (focal animal) very soon after it was observed by the first member of the group. The interest of the majority of both sex groups remained high for the observation periods of approximately 30 minutes, and most individuals remained within 5 metres of the possum for that time. Approximately 50% of the alpacas were within possible aerosol transmission distance of 2 metres from the sedated, erratically mobile possum with their heads towards it for approximately 50% of the two observation periods. Aggressive behaviour was recorded for a young male with stamping on the moving possum. Similar, but more vigorous and prolonged stamping behaviour was recorded for a female with a young (<1 week) offspring (cria). The stamping behaviour was accompanied by very close nose to nose contact of the alpaca and possum. At one point the female threw the possum approximately 1.5 metres in the air with her teeth. The group of male alpacas placed in an enclosure with an unsedated normal possum generally moved away from the possum during its rapid active attempts to escape. When it became inactive their approaches were cautious and only once elicited a defence reaction from the possum, from which they recoiled. One male made one attempt to stamp on the active possum. Soon after the possum became inactive in a small loose hay pile, the alpacas lost interest in it.

CONCLUSIONS

The alpaca / possum behavioural interactions show there is potential for direct aerosol transmission of tuberculosis from possums to alpacas, but probably not from alpacas to possums.

Memory impairment in schizophrenia: a study using event-related potentials in implicit and explicit tasks

Although memory impairment is recognized as a major fact of schizophrenia, only a few studies have investigated memory impairments with specifically designed event-related potential (ERP) protocols. In this study, ERPs were recorded from 15 schizophrenia patients and 15 matched control subjects during implicit and explicit memory tasks for unfamiliar faces. The results showed that patients have a reduced modulation of an N400-like component in both the implicit and explicit tasks that suggests a deficient integration of incoming information with personal knowledge. Patients also displayed an enhanced frontally distributed activity in the explicit task that may represent an impairment in the integration of intrinsic contextual information, a disturbance in the ability to inhibit proactive interference or a combination of both processes. Finally, the modulation of the late positive component did not differ from that in control subjects in both implicit and explicit tasks, suggesting that the impairment in mnemonic binding processes suggested in schizophrenia is more qualitative, i.e. incomplete or inappropriate, due to the anomalies in antecedent processes. The correlations observed between impairments of ERP modulation and symptoms further support these interpretations.

Neuropsychological impairments in the syndromes of schizophrenia: a comparison between different dimensional models

This study investigates the associations between the different symptom dimensions of schizophrenia and neuropsychological performances. Globally, the results replicate previously described associations. The "negative" dimension correlates with impaired sustained attention and working memory, thus suggestive of dorsolateral frontal cortex dysfunction. "Disorganization" correlates with the ability to inhibit proactive interference. thus with ventromedial frontal dysfunction. The results also add support to the view that the "psychotic" dimension described in three-dimension models includes in fact two distinct dimensions, (1) "hallucinations," here associated to episodic memory measures, and (2) "delusions", here associated to visuospatial attention, thus suggestive of mediotemporal and posterior neocortical dysfunction, respectively.

DRD3 and DAT1 genes in schizophrenia: an association study

OBJECTIVE

To investigate the role of the dopamine receptor 3 (DRD3) and transporter 1 (DAT1) genes in schizophrenia or in modulating its phenotype.

METHODS

a Ser9Gly polymorphism in codon 9 of the DRD3 and a VNTR polymorphism in the DAT1genes were examined in two groups of schizophrenic patients, one of excellent neuroleptic responders (N=42) and one of nonresponders (N=64). A group of healthy volunteers screened for major psychiatric disorders was also included (N=89). In addition, age at onset of psychotic symptoms, attention performance and family loading for schizophrenia spectrum disorders were compared between patients with different genotypes in the DRD3 and DAT1 genes.

RESULTS

No significant differences in the allelic distribution of the DRD3 and DAT1 polymorphisms were detected between schizophrenic patients and controls. A trend toward an excess of DRD3 genotype Gly/Gly was observed in neuroleptic nonresponder schizophrenic patients compared to controls (chi(2)=3. 30, df=1, p=0.07). No significant differences in age at onset of psychotic symptoms, attention task performance or family loading for schizophrenia spectrum disorders were observed between groups with different DRD3 and DAT1 genotypes.

CONCLUSION

These results do not support the role of either of these genes in increasing susceptibility to schizophrenia or in modulating its phenotype in the studied population.

Association between the methylenetetrahydrofolate reductase 677C-->T missense mutation and schizophrenia

The schizophrenia phenotype is heterogeneous with respect to clinical presentation, long-term response to medication, and outcome, possibly reflecting genetic heterogeneity and/or the presence of modifier genes. Compared to non-responders, schizophrenic patients who are responders to neuroleptic medications are characterized by a high female/male ratio, a better long-term outcome and more frequently disturbed dopamine neurotransmission. In this study, we compared two groups of schizophrenic patients selected on the basis of their long-term response to neuroleptics (excellent responders and non-responders) and a group of healthy volunteers, with regard to a missense mutation (677C-->T) in the methylenetetrahydrofolate reductase (MTHFR) gene. This polymorphism was chosen because it is functional and was previously associated with schizophrenia. The present study revealed a significant association between schizophrenia and allele T of this gene. This association was entirely due to an over-representation of allele T in responder patients compared to controls; nonresponder patients did not differ from controls. Genotype TT was more frequent in responder patients compared to controls, thus replicating the findings of Arinami et al. These results strongly suggest that the MTHFR gene is involved in the pathogenesis of schizophrenia characterized by a rapid and sustained therapeutic response to typical neuroleptics and/or a good long-term prognosis/favorable therapeutic outcome.

Analysis of 14 CAG repeat-containing genes in schizophrenia

Recently, it has been suggested that trinucleotide repeat-containing genes may be involved in the etiology of schizophrenia. This study was aimed at investigating putative associations between allelic variants or expansions of CAG repeat-containing genes (CAGrCG) and schizophrenia or its variability with respect to responsiveness to conventional neuroleptics. CAG repeat allelic variants of 14 expressed sequences were compared among three groups of subjects: neuroleptic-responder (R; n = 43) and neuroleptic-nonresponder (NR; n = 63) schizophrenic patients, and a control group (C; n = 122). No CAG expansions, in the range of those observed in neurodegenerative diseases, were identified in these 14 expressed sequences. The sizes of CAG repeat for the hGT1 gene were marginally different among the three groups of subjects (Kruskal-Wallis H (2, 456) = 10.48, Bonferroni corrected P = 0.047). Comparisons among the different groups indicated that neuroleptic responders have shorter alleles compared to controls (Mann-Whitney adjusted Z = -3.23, P = 0.0012). NR patients were not different from controls. These preliminary results suggest that the hGT1 gene, or a gene in its vicinity, may be involved in the etiology of schizophrenia or in modifying the disease phenotype with regard to outcome and/or neuroleptic responsiveness. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 88:694-699, 1999.

Prostaglandin E2 enhancement of interferon-gamma production by antigen-stimulated type 1 helper T cells

Prostaglandin E2 (PGE2) is a potent mediator generated in immune tissues by cyclooxygenation of arachidonic acid. PGE2 affects T cell functions through four homologous G protein-coupled receptors termed EP1R, EP2R, EP3R, and EP4R that differ in tissue distribution and signaling. Antigen-evoked secretion of interferon-gamma (IFN-gamma) by sperm whale myoglobin-specific Th1 cells of DBA/2 mouse I-Ed-restricted clones, that express EP3Rs and EP4Rs, was enhanced a maximum of 3-fold by 10(-10) to 10(-8) M PGE2 and 2.5-fold each for the EP1R/EP3R-directed agonist sulprostone (10(-8) and 10(-7) M) and for the EP4R/EP3R/EP2R agonist misoprostol (10(-9) M). Neither PGE2 nor the synthetic analogs affected secretion of IFN-gamma by PMA plus ionomycin-stimulated clones of Th1 cells. Antigen-evoked secretion of IFN-gamma by influenza hemagglutinin-specific mouse lymph node Th1 cells, that also express EP3Rs and EP4Rs, was increased a maximum of 12-fold by 10(-9) to 10(-8) M PGE2, 14-fold by 10(-9) M sulprostone, and 10-fold by 10(-9) M misoprostol. Production of IFN-gamma by either type of Th1 cell was not affected significantly by 10(-6) M PGE2 alone. The generation of IFN-gamma by antigen-stimulated Th1 cells thus is significantly enhanced by physiologically relevant concentrations of PGE2.

Lack of association between the hSKCa3 channel gene CAG polymorphism and schizophrenia

Genetic anticipation, a phenomenon characterized by increased severity of symptoms and earlier age at onset of a disease in successive generations, is believed to be present in schizophrenia. In several neurodegenerative diseases showing anticipation, the mutation causing the disease is an expanded trinucleotide repeat. Therefore, genes containing trinucleotide repeats prone to expansion have become a suitable family of candidate genes in schizophrenia. A human calcium-activated potassium channel gene (hSKCa3), possibly mapping to chromosome 22q11-13, a region previously linked to schizophrenia, was recently described. This gene contains two contiguous expressed CAG repeat stretches. Recently, long allelic variants of one of these CAG repeats were found to be overrepresented in schizophrenic patients compared to normal controls. In this study we attempted to replicate this result and to study the relationship between the length of this CAG repeat on the one hand and the severity and age at onset of the disease on the other hand. No association with the disease or correlation with the severity of schizophrenia was identified. In addition, hSKCa3 was mapped to chromosome 1. Our results do not support the involvement of this particular CAG repeat-containing gene in schizophrenia.

T102C polymorphism in the 5HT2A gene and schizophrenia: relation to phenotype and drug response variability

Although genes play a major role in the etiology of schizophrenia, no major genes involved in this disease have been identified. However, several genes with small effect have been reported, though inconsistently, to increase the risk for schizophrenia. Recently, the 5HT2A 2 allele (T102C polymorphism) was reported to be over-represented in patients with schizophrenia. Other reports have found an excess of allele 2(C) only in schizophrenic patients who are resistant to clozapine, not in those who respond to clozapine. In this study, the 5HT2A receptor allele 2 frequencies were compared between 2 groups of patients with schizophrenia (39 responders and 63 nonresponders) based on long-term outcome and response to typical neuroleptics. A control group of 90 healthy volunteers screened for mental disorders was also included. Genotype 2/2 tended to be more frequent in patients with schizophrenia with poor long-term outcome and poor response to typical neuroleptics (Bonferroni corrected p = 0.09). This difference was significant in men (Bonferroni corrected p = 0.054) but not in women. In addition, the age at first contact with psychiatric care was significantly younger in the patients with schizophrenia with genotype 2/2 than in patients with genotype 1/1. These result suggest that the 5HT2A-receptor gene may play a role in a subset of schizophrenia characterized by poor long-term outcome and poor response to neuroleptics.

Enhancement by vasoactive intestinal peptide of gamma-interferon production by antigen-stimulated type 1 helper T cells

Vasoactive intestinal peptide (VIP) is a neuroendocrine mediator in immune tissues that affects many T cell functions through two homologous high-affinity G-protein-coupled receptors, termed VIPR1 and VIPR2. Antigen-stimulated secretion of gamma-interferon (IFN-gamma) by sperm whale myoglobin-specific Th1 cells of DBA/2 mouse I-Ed-restricted clones, which express VIPR1 and VIPR2, was enhanced by 10(-10) M to 10(-7) M VIP. Enhancement of IFN-gamma secretion reached a mean maximum of fourfold for VIP and threefold for a VIPR2-selective agonist, without any effect of a VIPR1-selective agonist. Secretion of IFN-gamma by PMA and ionomycin-stimulated clones of Th1 cells was not altered by VIP. Antigen-stimulated secretion of IFN-gamma by T cell receptor-transgenic, influenza hemagglutinin-specific, and cytokine-differentiated mouse lymph node Th1 cells, which also express VIPR1 and VIPR2, was enhanced by 10(-10) M to 10(-8) M VIP. Enhancement of IFN-gamma secretion increased to a maximum of 14-fold for VIP, 14-fold for the VIPR2-selective agonist, and 20-fold for the VIPR1-selective agonist. In contrast to VIP suppression of interleukin production and lack of effect on IFN-gamma production by T cells stimulated with anti-CD3 antibody or a mitogenic lectin, generation of IFN-gamma by antigen-stimulated T cells is enhanced significantly by physiological concentrations of VIP.

Atypical presentation of Clostridium difficile colitis in patients with cystic fibrosis

OBJECTIVE

This report describes the unusual presentation of Clostridium difficile colitis in five patients with cystic fibrosis and the role of CT in first suggesting the correct diagnosis in this group of patients. Because of the absence of watery diarrhea and the presence of abdominal bloating and decreased stooling, cystic fibrosis patients with C. difficile colitis will be treated for stool impaction, meconium ileus equivalent, or distal intestinal obstruction syndrome. CT of the abdomen, performed in these five patients because of their lack of improvement after standard therapy for stool impaction, showed an extensive pancolitis later confirmed to be caused by C. difficile infection.

CONCLUSION

In patients with cystic fibrosis, imaging findings of a pancolitis should raise the possibility of C. difficile colitis despite the lack of watery diarrhea. Anticlostridial treatment can be initiated before bacteriologic confirmation is obtained.

Polyglutamine-containing proteins in schizophrenia

Genetic anticipation, manifested by increased severity and earlier age-at-onset of the disease over successive generations, is reported in schizophrenia. The molecular basis of anticipation in several neurodegenerative diseases is unstable coding CAG repeat expansions. Anticipation was reported in schizophrenia. Recently, studies suggested that enlarged CAG/CTG repeats are over represented in schizophrenic patients compared to normal controls. Together, these observations suggest that unstable CAG repeats may play a role in the etiology of schizophrenia. The purpose of this study is to test for the presence of polyglutamine-expanded tracts, encoded by CAG repeats, in total protein extracts derived from lymphoblastoid cell lines of schizophrenic patients. Proteins from schizophrenic patients (n = 59) and normal controls (n = 73) were separated by means of SDS-polyacrylamide gel electrophoresis, wet blotted onto nitrocellulose membrane and probed with a monoclonal antibody (mab 1C2) recognizing expanded polyglutamine arrays. Three abnormal bands corresponding to protein(s) of molecular weight of approximately 50 kDa were identified in two unrelated schizophrenic patients and in a sibling of one of these patients. None of the normal controls tested positive for this abnormal band. These results suggest that expanded polyglutamine-containing proteins, though rare, may play a role in the pathogenesis of schizophrenia.

Event-related brain potentials during an extended visual recognition memory task depict delayed development of cerebral inhibitory processes among 6-month-old infants with Down syndrome

Development of cerebral inhibitory processes among individuals with Down syndrome (DS) may be delayed at an early age. In support of this hypothesis, sensory-evoked potentials (EPs) and event-related brain potentials (ERPs) have previously delineated altered habituation to stimuli among infants with DS. The purpose of the current study was to provide extended experience with visual stimuli among 6-month-old infants with and without DS (nDS) to determine if altered ERP and behavioral response decrements would be evident even after repeated presentations of stimuli. An 80/20% oddball paradigm was employed. Infants with DS and nDS were matched according to age and gender. Infants with DS demonstrated significantly larger Nc areas, Nc peak amplitudes, Nc2 areas and, inversely, significantly smaller peak Pb amplitudes when compared to infants nDS. Contrasts of the two study groups were most robust within ERP measures from frontal (Fz) and parietal (Pz) recording sites. Infants with DS also demonstrated a significantly slower decrement of most ERP components with repetitive stimulus experience. Most noteworthy was the observation of little or no decrement of ERP components at Fz among infants with DS. Both infants with DS and nDS demonstrated significantly larger Nc peak amplitudes, Nc areas, Nc2 areas, Pb peak amplitudes and NSW areas to rare stimuli. While significant probability and experiential trends were observed in visual fixation measures across both study groups, there were no significant differences of visual attention between infants with DS or nDS. These data demonstrate the value of ERPs within the study of atypical cognitive development during infancy and support the concept of altered inhibitory processes in the brain of infants with DS.

An intertypic herpes simplex virus helicase-primase complex associated with a defect in neurovirulence has reduced primase activity

R13-1 is an intertypic recombinant virus in which the left-hand 18% of the herpes simplex virus type 1 (HSV-1) genome is replaced by homologous sequences from HSV-2. R13-1 is nonneurovirulent and defective in DNA replication in neurons. The defect was localized to the UL5 open reading frame by using marker rescue analysis (D. C. Bloom and J. G. Stevens, J. Virol. 68:3761-3772, 1994). To provide conclusive evidence that UL5 is the only HSV-2 gene involved in the restricted replication phenotype of R13-1, we have characterized the phenotype of a recombinant virus (IB1) in which only the UL5 gene of HSV-1 was replaced by HSV-2 UL5. Data from 50% lethal dose determinations and the in vivo yields of virus suggested that IB1 has the same phenotypic characteristics as R13-1. UL5 is the helicase component of a complex with helicase and primase activities. All three subunits of this complex (UL5, UL8, and UL52) are required for viral DNA replication in all cell types. The intertypic complex HSV-2 UL5-HSV-1 UL8-HSV-1 UL52 was purified and biochemically characterized. The primase activity of the intertypic complex was 10-fold lower than that of HSV-1 UL5-HSV-1 UL8-HSV-1 UL52. The ATPase activity was comparable to that of the HSV-1 enzyme complex, and although the helicase activity was threefold lower, this did not interfere with the synthesis of leading strands by the HSV polymerase. One explanation for these findings is that the interactions between the subunits of the helicase-primase intertypic complex that are important for the full function of each subunit are inappropriate or weak.

Neuropsychological and neurophysiological indices of auditory processing impairment in children with multiple complex developmental disorder

OBJECTIVE

To evaluate whether children with borderline disorder (also referred to as multiple complex developmental disorder) (BD/MCDD) and comorbid attention-deficit hyperactivity disorder (ADHD) demonstrate evidence of abnormal attention and/or auditory processing impairments as indexed by both behavioral and physiological measures.

METHOD

Three groups of children were compared in two different experiments on behavioral rating scales (Conners Parent Rating Scale and Child Behavior Checklist), behavioral accuracy to auditory and visual target detection tasks, selected neuropsychological tests, and brain physiology (event-related potentials) collected during auditory and visual target detection tasks.

RESULTS

The results demonstrate that children with BD/MCDD differ from children with ADHD in the (1) prevalence of internalizing and externalizing behaviors, (2) neuropsychological deficits related to auditory processing, and (3) event-related potential brain physiology associated with auditory cognitive target attention tasks.

CONCLUSION

Some of the pervasive pathology described in children with BD/MCDD may be due to biological vulnerabilities, particularly problems with auditory processing. Auditory processing impairments in such children deserves special attention with respect to both understanding their behavioral symptoms and developing a comprehensive treatment plan.

MRI artifacts following anterior cervical diskectomy

BACKGROUND

Magnetic resonance imaging (MRI), despite being an excellent imaging technique in neurosurgical practice, is unfortunately susceptible to numerous artifacts. Some of these artifacts are easily identifiable and do not interfere; however, others are more subtle and can be easily mistaken for false pathology. Postoperative MRI can further complicate the imaging interpretation, by producing another group of artifacts. It is imperative for practicing neurosurgeons, as well as neuroradiologists, to have a clear understanding of these postoperative artifacts.

METHODS

We discuss four cases who had been operated for anterior cervical decompression with bony fusion. All the patients had a postoperative MRI of the cervical region that showed a "false compression" of the cervical cord. The normal computed tomography (CT) scan in some cases and the discrepancy with the clinical condition of the patients excluded the diagnosis of compression of the cervical cord.

RESULTS

The overall appearance of the postoperative MRI can be very difficult to interpret. The artifact seen following anterior cervical diskectomy is an example of such a situation. We have confirmed that the postoperative MRIs showing artifacts do not indicate cord or root compression; a routine postoperative plain X ray or CT scan of the operated area can also confirm the absence of compression.

CONCLUSION

These are examples of cases in which the postoperative MRI had an unexpected metallic artifact that not only caused difficulty in the interpretation of the images but at times suggested a clinical problem when actually there was none. Very thin cut CT scans may not show these artifacts that are picked up by the sensitive MRI study. A proper clinical evaluation and selection of the appropriate MRI techniques and the MRIs can eliminate or at least decrease the incidence of the artifacts. Above all, further education of practicing physicians is needed to avoid false alarms caused by these metallic artifacts.

Individual differences in dopamine release but not rotational behavior correlate with extracellular amphetamine levels in caudate putamen in unlesioned rats

It has been postulated that differences in pharmacokinetics do not contribute to the well-known individual variability in response to amphetamine (AMPH), but this is yet to be investigated thoroughly. Therefore, rotational behavior of outbred rats (Sprague-Dawley, 4 months old) was recorded during microdialysis sessions and striatal microdialysate was analyzed concomitantly for AMPH and dopamine concentrations after a single injection of 2.5 mg/kg AMPH SC. Three hours later these rats received three doses of 5 mg/kg AMPH SC (spaced 2 h apart) and their brain temperature was recorded every 20 min. The most important findings were: 1) the increase in extracellular dopamine was highly correlated with the corresponding peak AMPH levels in the microdialysate; 2) the peak dopamine level in response to 2.5 mg/kg AMPH was predictive of the hyperthermic response observed during 3 x 5 mg/kg AMPH and 3) high versus low rotators differed neither in their AMPH nor in their dopamine extracellular striatal concentrations.

Sibling reflux: a dual center retrospective study

PURPOSE

Siblings of index patients with vesicoureteral reflux are known to have an increased incidence of reflux. Previous reports may be biased due to significantly more female siblings undergoing screening. In addition, it has been suggested that screening is unnecessary in older children.

MATERIALS AND METHODS

We retrospectively reviewed the records of probands with vesicoureteral reflux. A total of 422 families comprising 622 siblings was identified at our centers from 1985 to 1994. Of the 255 boys and 277 girls newborn to 16 years old (mean age 6.2 years) 85% were evaluated. Almost 43% of the probands (225) were older than 7 years.

RESULTS

Vesicoureteral reflux was noted in 144 siblings (52 boys and 92 girls, 27%). The majority had low grade reflux but in 111 (77%) maximum reflux grade was II or III. Reflux nephropathy was demonstrated on a nuclear renal scan in 18 of the 132 tested siblings (13.6%). In all of these children reflux was grades II to IV and 27% were older than 10 years.

CONCLUSIONS

When vesicoureteral reflux is discovered, all siblings should be considered for screening. The evaluation of older siblings remains controversial, since they comprise only a small fraction of all siblings with reflux but may have a significant portion of reflux nephropathy. There was a 27% overall incidence with a 33% rate in girls. The incidence of reflux in siblings decreased after age 7 years but reflux nephropathy was identified even in the older children.

An open study of tolerability and pharmacokinetics of raclopride extended release capsules in psychiatric patients: a Canadian study

The tolerability and pharmacokinetics of raclopride extended release (ER) capsules have been evaluated after a single oral dose and at steady state, with 3 different daily doses in 4 male patients requiring neuroleptic treatment. In this 3-week open study, the drug was administered to patients in increasing bid doses of 8 mg, 12 mg and 16 mg, respectively, for each 1-week treatment period, following a 1-week placebo washout. With this limited number of patients, assessments of clinical chemistry, hematology, cardiovascular variables and adverse symptoms suggest that raclopride is safe and well-tolerated in the group studied. The administration of repeated doses of raclopride showed linear pharmacokinetics based on parameter values which are either constant (effective elimination half-life, total plasma clearance, and dose-normalized area under the plasma concentration-time curve) or varying proportionally (trough plasma concentration, peak plasma concentration, average plasma concentration and the area under the plasma concentration-time curve for a dosage interval at steady state) with the doses. The linear 1-compartment open model with zero-order absorption was the most appropriate pharmacokinetic model describing the raclopride plasma concentration profile after a single 8 mg dose of raclopride ER capsules. The ER formulation reduced the fluctuation between peak and trough plasma drug concentrations which has been reported before with instant release dosage forms. In this study, the increase of plasma prolactin concentrations above the normal limit was transient and returned to normal levels. Although the plasma prolactin concentration tended to increase with the drug dose, no direct relationship between raclopride dose and prolactin plasma concentrations was found. The correlation of plasma prolactin response with the plasma raclopride concentration showed a low level of hysteresis.

Vestibular morphology in relation to age and circling behavior

The DBA/2 strain of mice have genetically induced vestibular dysfunction that presents grossly at an early age as circling behavior and abnormal righting reflexes. The vestibular morphology of this strain has not previously been examined. DBA/2 mice of different ages that showed circling behavior were sacrificed and then had their inner ears immediately removed and fixed in glutaraldehyde. The specimens were prepared for light, transmission and scanning electron microscopy. Additional specimens at 10 months of age were fixed with paraformaldehyde for immunohistochemical investigation and labelling of alpha-actinin. Non-circling litter mates served as controls. The morphology and immunohistochemistry of the vestibular end-organs were evaluated as a function of age and circling behavior. The sensory epithelium of the ampulla and utricle in the circling mice showed softening of the cuticle, hair cell cytoplasmic herniation, expelled cellular debris, fused stereocilia and giant hair cells that progressively increased in severity with age. The non-circling litter mates showed similar but less severe pathology of the vestibular sensory epithelium. The immunohistochemical analysis showed no differences at a magnification of 400 x.

Clinical assessment of urethral sphincter function

Measurements of urethral pressures, such as maximum urethral pressure, are widely believed to have relevance in the management of urinary incontinence despite evidence to the contrary. In this study maximum urethral pressure and the abdominal pressure required to cause stress incontinence were measured in 125 women with stress incontinence. In women the abdominal pressure required to cause stress incontinence was unrelated to maximum urethral pressure. These findings indicate that maximum urethral pressure has little relationship to urethral resistance to abdominal pressure. In the 9 children with myelodysplasia we compared the detrusor pressure with the abdominal pressure required to induce urethral leakage. These values also were quite different, indicating that as far as the urethra is concerned abdominal pressure and detrusor pressure are not equivalent forces.

Reduction of hospital days in chronic schizophrenic patients treated with risperidone: a retrospective study

Hospital costs for chronic schizophrenic patients consume a major share of the cost of mental health care. Despite the success of numerous community mental health programs, repeated hospital admission of schizophrenic patients is a significant problem. Effective therapy and compliance with that therapy are two important factors in reducing hospitalization. Adverse effects of antipsychotic agents, particularly extrapyramidal symptoms (EPS), negatively influence compliance. A new antipsychotic agent, risperidone, has demonstrated efficacy against both positive and negative symptoms of schizophrenia and has been associated with a low incidence of EPS. To assess the potential of risperidone therapy to reduce the number of days in the hospital, a retrospective analysis was undertaken of data from a year-long clinical trial of risperidone. For 27 patients who had completed 365 days of open-label therapy with risperidone, the number of hospital days during this period was compared with the number of hospital days in the preceding 365-day period, when the patients were receiving conventional antipsychotic medication. The mean number of hospital days was reduced from 106 to 85 days, for a 20% reduction (P = 0.003) after the initiation of risperidone. Three subgroups of patients were apparent: (1) those who had spent no time in the hospital in the pre-risperidone year, (2) those who had been continuously hospitalized in the pre-risperidone year, and (3) those who had spent part of the pre-risperidone year (3 to 165 days) in the hospital. A 73% reduction (P = 0.0009) in mean hospital days (from 49 to 13 days) was achieved in the third subgroup (n = 14). These findings suggest that risperidone may have a role in reducing hospital days for the chronic schizophrenic population.

Replacement of chlorpromazine with other neuroleptics: effect on abnormal skin pigmentation and ocular changes

This paper describes the outcome of 15 patients with chlorpromazine (CPZ)-induced abnormal skin pigmentation (ASP) in whom CPZ was replaced with other neuroleptics for three to 13 years. Complete resolution of ASP occurred over a period of six months to five years following substitution with haloperidol (four patients), levomepromazine (three patients), trifluoperazine (one patient), thioproperazine (one patient) as the sole neuroleptic, by a combination of two of the three phenothiazines (four patients) or haloperidol plus pipotiazine (one patient). Resolution was maintained during the remainder of the follow-up period. In one patient, at final follow-up, marked improvement was present three years after CPZ was replaced with levomepromazine. Bilateral lenticular pigmentary deposits persisted in all eight patients examined 3.3 to 13 years after replacing CPZ and less than three months to nine years after resolution of ASP; improvement was noted in only one of these patients. Bilateral endothelial corneal deposits, present in five patients while on CPZ therapy, had disappeared in two patients seven and 13 years, respectively, after replacing CPZ; improvement was noted in two other patients. These findings indicate that: 1. CPZ-induced ASP is completely reversible in most, if not all, patients if CPZ is withdrawn; 2. a variety of neuroleptics including other phenothiazines can be used to replace CPZ without risk of re-emergence of ASP; 3. CPZ-induced lenticular changes persist whereas corneal changes may resolve slowly over a period of many years following replacement of CPZ; 4. ASP and ocular changes induced by CPZ may be subserved by two different pathophysiological mechanisms.

Resolution of chlorpromazine-induced cutaneous pigmentation following substitution with levomepromazine or other neuroleptics

Eleven chronic schizophrenic patients with abnormal skin pigmentation associated with neuroleptic treatment were withdrawn from chlorpromazine (CPZ), which was replaced by levomepromazine (n = 4), trifluoperazine (n = 1) or thioproperazine (n = 1) as the sole neuroleptic, by a combination of these phenothiazines (n = 4) or with haloperidol plus pipotiazine (n = 1). Seven patients showed complete resolution of abnormal skin pigmentation over a period of 1-5 years and 4 markedly improved over 2.0-2.6 years of follow-up. Our observations suggest that neuroleptic-induced abnormal skin pigmentation is (i) predominantly, if not exclusively, a side effect of CPZ and (ii) reversible, providing that CPZ is withdrawn and sufficient time is allowed to elapse.

A Canadian multicenter placebo-controlled study of fixed doses of risperidone and haloperidol in the treatment of chronic schizophrenic patients

In a double-blind study, 135 inpatients with a diagnosis of chronic schizophrenia were randomly assigned to 8 weeks of treatment with one of six parallel treatments: risperidone (a new central 5-hydroxytryptamine2 and dopamine D2 antagonist), 2, 6, 10, 16 mg/day; haloperidol, 20 mg/day; or placebo, after a single-blind placebo washout period. Doses were increased in fixed increments up to a fixed maintenance dose reached after 1 week. On the Clinical Global Impression-Severity of Illness and Improvement, all active medications were superior to placebo except for risperidone (2 mg) on the Clinical Global Impression-Improvement. On the total Positive and Negative Syndrome Scale (PANSS) score and positive subscale, superiority to placebo was observed for all treatment groups except for haloperidol and risperidone (2 mg), which tended to be superior to placebo on total PANSS and the positive subscale, respectively. On the PANSS negative subscale, only risperidone (6 mg/day) was significantly better than placebo. Risperidone (6 mg) was superior to haloperidol on the total PANSS, General Psychopathology, and Brief Psychiatric Rating Scale subscales. Although there was a linear increase in parkinsonism with increasing risperidone dosage, there were no statistically significant differences between risperidone (2, 6, and 16 mg/day) and placebo. At doses of 6 to 16 mg, risperidone displayed a marked antidyskinetic effect compared with placebo. This effect was more pronounced in patients with severe dyskinesia. By contrast, haloperidol produced significantly more parkinsonism than placebo and risperidone (2, 6 and 16 mg), with no effect on tardive dyskinesia. These data suggest that risperidone, at the optimal therapeutic dose of 6 mg/day, produced significant improvement in both positive and negative symptoms without an increase in drug-induced parkinsonian symptoms and with a significant beneficial effect on tardive dyskinesia.

Adventitious knots in urethral catheters: report of 5 cases

Urethral catheterization with 5 or 8F feeding tubes in 5 boys was complicated by stochastic knotting within the bladder thereby impeding removal. The common factor in these patients was insertion of excessive length within the bladder. Percutaneous endoscopic retrieval was done successfully in 1 child. This technique may avoid urethral trauma associated with catheter removal, particularly in younger boys.

A dose-finding study with remoxipride in the acute treatment of schizophrenic patients

Two hundred and forty-two patients with acute schizophrenia were enrolled in a double-blind, comparative, dose-finding study of a novel antipsychotic, remoxipride. Remoxipride was evaluated in a low (30 to 90 mg), medium (120 to 240 mg) and a high (300 to 600 mg) dose range and compared with a haloperidol (15 to 45 mg), which was administered to a similar group of patients. The results support the antipsychotic effect of remoxipride, with maximum efficacy occurring at daily doses between 120 mg and 600 mg. Side-effects were more frequent at doses of remoxipride over 300 mg. In all groups, remoxipride caused consistently fewer extrapyramidal side-effects than haloperidol. The antipsychotic effect of remoxipride may be derived from specific blockade of dopamine D2 receptors in the mesolimbic tract. The findings also suggest that remoxipride may have a therapeutic effect on negative symptoms of schizophrenia.

Magnetic resonance imaging of pathologic conditions of the Achilles tendon

The advent of magnetic resonance imaging (MRI) has improved imaging of the Achilles tendon. Various pathologic conditions of the Achilles tendon and their MRI characteristics are described. The superior resolution of the tendon provided by MRI can aid in the diagnosis of Achilles tendon disorders, which include complete or partial rupture of the tendon as well as postoperative assessment of tendinous healing, tendinitis and tenosynovitis, and various tumors of the Achilles tendon.

Bloom's syndrome XI. Progress report for 1983

During the 30 years since its description as a clinical entity, Bloom's syndrome has been diagnosed in more than 100 persons. It is believed that most of these have been accessioned to the Bloom's Syndrome Registry, which now includes 103 persons. Of those 103, 80 are alive, with a mean age of 18.2 years. Twenty-eight malignant neoplasms have been detected, at a mean age of 20.7 years. Periodically, progress reports are being made in this journal of the long-term surveillance of affected families.

High doses of diazepam improve neuroleptic-resistant chronic schizophrenic patients

According to the two currently most popular biological hypotheses, schizophrenic symptoms result from a hyperactivity in dopaminergic neurotransmission or from a hypoactivity in GABAergic neurotransmission. Since diazepam is known to reduce dopamine release and to potentiate GABA, the possible beneficial effects of diazepam were tested in ten hospitalized chronic schizophrenic patients who were resistant to standard neuroleptic treatment. High doses of diazepam, up to 200 mg/day initially, but smaller maintenance doses (less than 55 mg/day diazepam in eight of the ten patients) were added to the previous neuroleptic medication of these patients. The diazepam dose was adjusted daily to avoid oversedation. The effects of diazepam treatment on the mental status were assessed weekly for 12 weeks by the Brief Psychiatric Rating Scale (BPRS), the physician's Clinical Global Impressions Scale (CGI), and the Psychotic Inpatient Profile Scale (PIP). For additional documentation, videotapes of mental status interviews were obtained at baseline and during diazepam treatment. These videotapes were rated blind by an independent psychiatrist. The addition of diazepam produced a marked improvement in three, a moderate improvement in four, a mild improvement in one and no change in two of the ten patients. Four of the ten patients were so much improved that they were discharged from the hospital. No side effects were noted, except for one patient who became confused and disoriented on 160mg diazepam/day.(ABSTRACT TRUNCATED AT 250 WORDS)