Remotely-delivered cognitive remediation in multiple sclerosis (MS): protocol and results from a pilot study

Background

Cognitive impairment represents a critical unmet treatment need in multiple sclerosis (MS). Cognitive remediation is promising but traditionally requires multiple clinic visits to access treatment. Computer-based programs provide remote access to intensive and individually-adapted training.

Objective

Our goal was to develop a protocol for remotely-supervised cognitive remediation that enables individuals with MS to participate from home while maintaining the standards for clinical study.

Methods

MS participants (n = 20) were randomized to either an active cognitive remediation program (n = 11) or a control condition of ordinary computer games (n = 9). Participants were provided study laptops to complete training for five days per week over 12 weeks, targeting a total of 30 hours. Treatment effects were measured with composite change via scores of a repeated neuropsychological battery.

Results

Compliance was high with an average of 25.0 hours of program use (80% of the target) and did not differ between conditions (25.7 vs. 24.2 mean hours, p = 0.80). The active vs. control participants significantly improved in both the cognitive measures (mean composite z-score change of 0.46 ± 0.59 improvement vs. −0.14 ± 0.48 decline, p = 0.02) and motor tasks (mean composite z-score change of 0.40 ± 0.71improvement vs. −0.64 ± 0.73 decline, p = 0.005).

Conclusions

Remotely-supervised cognitive remediation is feasible for clinical study with potential for meaningful benefit in MS.

Bacillus cereus infection outbreak in captive psittacines

This study reports an uncommon epizootic outbreak of Bacillus cereus that caused the sudden death of 12 psittacines belonging to the species Anodorhynchus hyacinthinus (1 individual), Diopsittaca nobilis (1 individual), Ara severa (1 individual) and Ara ararauna (9 individuals) in a Brazilian zoo. Post-mortem examination of the animals reveled extensive areas of lung hemorrhage, hepatic congestion, hemorrhagic enteritis and cardiac congestion. Histopathological examination of the organs showed the presence of multiple foci of vegetative cells of Gram-positive bacilli associated with discrete and moderate mononuclear inflammatory cell infiltrate. Seventeen B. cereus strains isolated from blood and sterile organs of nine A. ararauna were analyzed in order to investigate the genetic diversity (assessed by Rep-PCR) and toxigenic profiles (presence of hblA, hblC and hblD; nheA, nheB and nheC as well as cytK, ces and entFM genes) of such strains. Amplification of genomic DNA by Rep-PCR of B. cereus strains generated two closely related profiles (Rep-PCR types A and B) with three bands of difference. All strains were classified as belonging to the toxigenic profile I which contained HBL and NHE gene complexes, entFM and cytK genes. Altogether, microbiological and histopathological findings and the evidence provided by the success of the antibiotic prophylaxis, corroborate that B. cereus was the causative agent of the infection that killed the birds.

Multicenter randomized clinical trial of donepezil for memory impairment in multiple sclerosis

OBJECTIVES

The goal of this study was to determine if memory would be improved by donepezil as compared to placebo in a multicenter, double-blind, randomized clinical trial (RCT).

METHODS

Donepezil 10 mg daily was compared to placebo to treat memory impairment. Eligibility criteria included the following: age 18-59 years, clinically definite multiple sclerosis (MS), and performance ≤ ½ SD below published norms on the Rey Auditory Verbal Learning Test (RAVLT). Neuropsychological assessments were performed at baseline and 24 weeks. Primary outcomes were change on the Selective Reminding Test (SRT) of verbal memory and the participant's impression of memory change. Secondary outcomes included changes on other neuropsychological tests and the evaluating clinician's impression of memory change.

RESULTS

A total of 120 participants were enrolled and randomized to either donepezil or placebo. No significant treatment effects were found between groups on either primary outcome of memory or any secondary cognitive outcomes. A trend was noted for the clinician's impression of memory change in favor of donepezil (37.7%) vs placebo (23.7%) (p = 0.097). No serious or unanticipated adverse events attributed to study medication developed.

CONCLUSIONS

Donepezil did not improve memory as compared to placebo on either of the primary outcomes in this study.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence which does not support the hypothesis that 10 mg of donepezil daily for 24 weeks is superior to placebo in improving cognition as measured by the SRT in people with MS whose baseline RAVLT score was 0.5 SD or more below average.

Lipohypertrophy: does it matter in daily life? A study using a continuous glucose monitoring system

AIMS

To use continuous glucose monitoring (CGMS) to compare glucose profiles in people with type 1 diabetes following injection of insulin into an area affected by lipohypertrophy vs. an area not affected by lipohypertrophy.

METHODS

Eight patients with type 1 diabetes underwent 72 h of CGMS while following a standardized diet and injecting all insulin either into an area with or without lipohypertrophy. Patients underwent two testing periods in random order, separated by 4 days. On day 1 of each test subjects were admitted for measurement of insulin and plasma glucose levels immediately prior to, and hourly for 4 h following, a standardized lunch.

RESULTS

Insulin area under the curve (AUC)(0-4 h) was similar for both test periods; 656; interquartile range (IQR): 518-1755 (normal tissue) vs. 602; IQR: 382-1436 (lipohypertrophic tissue), z = 1.7, p = 0.09. There was also no difference in the median time to maximal insulin concentration (Time(max) 2 h; IQR: 2-3 h; z = 0.6; p = 0.6). There was a 37.5% increase in mean plasma glucose levels following a standardized meal; however this was not significant between sites (AUC(0-4 h)t = -1.7; p = 0.1). Moreover, there was no difference in CGMS profiles (AUC(1-72 h)t = -0.9; p = 0.4) across the 72-h monitoring period. Overall the prevalence of hypoglycaemia (CGMS readings < 4 mmol/l) was similar between injection sites (11.6 vs. 10.6%, p = 0.1).

CONCLUSION

The pharmacokinetic and pharmacodynamic effect of injecting into lipohypertrophic tissue is small in comparison to the usual clinical variation observed with insulin injections.

OCORRÊNCIA DA DERMATOFILOSE (DERMATOPHILUS CONGOLENSIS) EM SUÍNOS CRIADOS NO ESTADO DE SÃO PAULO, BRASIL

RESUMO Descreveu-se a ocorrência da Dermatofilose em suínos adultos atendidos pela Clínica de Bovinos do Centro de Pesquisa e Diagnóstico de Enfermidades de Ruminantes da Faculdade de Medicina Veterinária e Zootecnia da Universidade de São Paulo. Os animais enfermos apresentaram uma epidermite exsudativa caracterizada pela formação de crostas que se destacavam com facilidade e que apresentavam uma secreção com aspecto purulento, principalmente nas regiões do dorso e nas orelhas dos animais. Os esfregaços das crostas e secreções revelaram a presença de estruturas similares a cocos que se arranjavam em filamentos, morfologicamente semelhantes ao zoósporo do Dermatophilus congolensis, sendo a confirmação do diagnóstico realizada por biopsia de pele e isolamento do agente etiológico da doença em amostras colhidas dos dois animais enfermos.

Donepezil improved memory in multiple sclerosis in a randomized clinical trial

OBJECTIVE

To determine the effect of donepezil in treating memory and cognitive dysfunction in multiple sclerosis (MS).

METHODS

This single-center double-blind placebo-controlled clinical trial evaluated 69 MS patients with cognitive impairment who were randomly assigned to receive a 24-week treatment course of either donepezil (10 mg daily) or placebo. Patients underwent neuropsychological assessment at baseline and after 24 weeks of treatment. The primary outcome was change in verbal learning and memory on the Selective Reminding Test (SRT). Secondary outcomes included other tests of cognitive function, patient-reported change in memory, and clinician-reported impression of cognitive change.

RESULTS

Donepezil-treated patients showed significant improvement in memory performance on the SRT compared to placebo (p = 0.043). The benefit of donepezil remained significant after controlling for various covariates including age, Expanded Disability Status Scale, baseline SRT score, reading ability, MS subtype, and sex. Donepezil-treated patients did not show significant improvements on other cognitive tests, but were more than twice as likely to report memory improvement than those in the placebo group (p = 0.006). The clinician also reported cognitive improvement in almost twice as many donepezil vs placebo patients (p = 0.036). No serious adverse events related to study medication occurred, although more donepezil (34.3%) than placebo (8.8%) subjects reported unusual/abnormal dreams (p = 0.010).

CONCLUSIONS

Donepezil improved memory in MS patients with initial cognitive impairment in a single center clinical trial. A larger multicenter investigation of donepezil in MS is warranted in order to more definitively assess the efficacy of this intervention.

ANÁLISE MICROBIOLÓGICA, TESTE DE TAMIS E CALIFORNIA MASTITIS TEST REALIZADOS EM AMOSTRAS DE LEITE DE FÊMEAS BUBALINAS PERTENCENTES A REBANHOS DO ESTADO DE SÃO PAULO

RESUMO O presente trabalho teve como objetivo a análise dos testes de tamis, CMT e do exame microbiológico de amostras de leite de fêmeas bubalinas. Os quartos mamários foram submetidos ao teste de tamis e CMT, sendo colhidas 262 amostras de leite de fêmeas bubalinas primíparas e pluríparas para análise microbiológica. No teste do tamis, 99,6% das amostras apresentaram resultado negativo. No CMT, observamos resultado negativo em 88,2% das amostras; traços (8%), positivo 1+ (1,5%); positivo 2+ (1,15%); positivo 3+ (1,15%). A análise microbiológica apresentou amostras sem crescimento de microrganismos (75,6%); com isolamento de Staphylococcus spp. (11,8%), Corynebacterium spp. (7,3%), Streptococcus spp. (3,1%) e com crescimento de microrganismos em associações (1,2%). Concluiu-se que nos rebanhos bubalinos estudados, os índices de mastite clínica e subclínica são muito baixos. A análise dos resultados obtidos no CMT e no exame microbiológico nos leva a inferir que a freqüência de animais portadores nos rebanhos estudados é elevada ou que o teste de CMT não pode ser considerado um bom teste de triagem para mastite em bubalinos, o que evidencia a importância da adoção de medidas preventivas a fim de assegurar a qualidade e inocuidade do produto e de seus derivados.

Study and treatment of post Lyme disease (STOP-LD): a randomized double masked clinical trial

OBJECTIVE

To determine whether post Lyme syndrome (PLS) is antibiotic responsive.

METHODS

The authors conducted a single-center randomized double-masked placebo-controlled trial on 55 patients with Lyme disease with persistent severe fatigue at least 6 or more months after antibiotic therapy. Patients were randomly assigned to receive 28 days of IV ceftriaxone or placebo. The primary clinical outcomes were improvement in fatigue, defined by a change of 0.7 points or more on an 11-item fatigue questionnaire, and improvement in cognitive function (mental speed), defined by a change of 25% or more on a test of reaction time. The primary laboratory outcome was an experimental measure of CSF infection, outer surface protein A (OspA). Outcome data were collected at the 6-month visit.

RESULTS

Patients assigned to ceftriaxone showed improvement in disabling fatigue compared to the placebo group (rate ratio, 3.5; 95% CI, 1.50 to 8.03; p = 0.001). No beneficial treatment effect was observed for cognitive function or the laboratory measure of persistent infection. Four patients, three of whom were on placebo, had adverse events associated with treatment, which required hospitalization.

CONCLUSIONS

Ceftriaxone therapy in patients with PLS with severe fatigue was associated with an improvement in fatigue but not with cognitive function or an experimental laboratory measure of infection in this study. Because fatigue (a nonspecific symptom) was the only outcome that improved and because treatment was associated with adverse events, this study does not support the use of additional antibiotic therapy with parenteral ceftriaxone in post-treatment, persistently fatigued patients with PLS.

Cognitive performance and MR markers of cerebral injury in cognitively impaired MS patients

OBJECTIVE

To relate neuropsychological performance to measures of cerebral injury in persons with MS selected for cognitive impairment.

METHODS

Participants were 37 individuals with relapsing-remitting (59.5%) and secondary progressive (40.5%) MS. They were tested at baseline as part of a clinical trial to enhance cognition with an acetylcholinesterase inhibitor. Eligibility criteria included at least mild cognitive impairment on a verbal learning and memory task. A modified Brief Repeatable Battery of Neuropsychological Tests formed the core of the behavioral protocol. Neuroimaging measures were central (ventricular) cerebral atrophy, lesion volume, and ratios of N-acetyl aspartate (NAA) to both creatine and choline.

RESULTS

A clear, consistent relation was found between cognitive and MR measures. Among neuroimaging measures, central atrophy displayed the highest correlations with cognition, accounting for approximately half the variance in overall cognitive performance. NAA ratios in right hemisphere sites displayed larger correlations than those on the left. Multiple regression models combining the MR measures accounted for well over half the variance in overall cognitive performance. The Symbol Digit Modalities Test was the neuropsychological task most strongly associated with the neuroimaging variables.

CONCLUSIONS

If a strong and stable association can be firmly established between cognitive and MR variables in appropriate subsets of MS patients, it might aid in the investigation of interventions to enhance cognition and modify the course of the disease.

Efficiency of water and nutrient use in containerised plants irrigated by overhead, drip or capillary irrigation

This paper reports an assessment of the potential of an irrigation system based on capillary matting in comparison to the industry standard, overhead irrigation, and to drip irrigation, for plants growing in pots. The systems were evaluated on the basis of the dry weights of the plants grown, water-use efficiency (volume of runoff) and the environmental impact of the systems. The environmental impact was assessed by the volumes of runoff and the amounts of nitrate nitrogen and phosphate phosphorus in the runoff. Rose and tomato grew on capillary mat as large as or larger than (dry weight) with drip or overhead irrigation when controlled-release fertiliser (Osmocote Plus, 5–6 month release) was mixed through the medium. Lavender and pansy showed no significant difference between the irrigation systems. However, when the fertiliser was applied to the surface or in the dibble hole, pansy, dianthus and anisodontea grew larger with overhead than with capillary irrigation.The volumes of water used by the drip and capillary systems were about equal at 2.6 and 3.3 L/pot.week, respectively, as were the volumes of runoff produced, 0.43 and 0.39 L/pot.week, but both were far lower than the corresponding values for the overhead system, where water use was 7.13 L/pot.week, and the runoff 3.00�L/pot.week. At the end of the trial, plants grown with capillary irrigation had a high electrical conductivity in the surface layers of the pots when controlled-release fertiliser was either mixed evenly through (1997, EC 2.04 dS/m) or was applied to the top of the mix (1998, EC 0.87 dS/m). On the other hand, with overhead watering the EC was more evenly distributed (1997, EC range 0.30–0.36 dS/m) or highest at the bottom of the pot (1998, EC 0.97 dS/m). The concentrations of nutrients in the runoff from the capillary mat system, nitrate nitrogen 6.2 mg/L and phosphate phosphorus 0.12 mg/L, were lower than those for either of the other systems, overhead giving 9.7 and 0.49 mg/L and drip 11.5 and 0.49 mg/L of nitrogen and phosphorus, respectively. Total nutrient leaching per week for nitrate and phosphate, respectively, was 320 and 16.2 mg/m2 for overhead, 53.9 and 3.1 mg/m2 for drip and 26.4 and 0.50 mg/m2 for capillary irrigation. Thus, capillary irrigation gave more efficient water and nutrient use and reduced nutrient contamination of the environment compared with the drip or overhead irrigation systems.

Phase II trial of procarbazine, vincristine and lomustine (POC) chemotherapy in metastatic cutaneous malignant melanoma

40 patients with symptomatic metastatic melanoma were treated with procarbazine, vincristine and lomustine (POC). 4 patients had received chemotherapy previously. Responses were seen in 8 patients (20%), 4 of whom had a complete remission. All responding patients had some tumour shrinkage after one cycle. The median duration of response was 27 weeks, with 2 patients remaining in complete remission at 6 and 6.5 years. The median survival for the whole group was 22 weeks, whilst that of the responding patients was 35 weeks. Using conventional anti-emetics, the principal toxicities were nausea and vomiting, severe in 15% of cycles. Other nonhaematological toxicity was uncommon. Neutropenia (WHO grade 3 or 4) occurred in 11% of cycles and thrombocytopenia in 8%. The response rate of metastatic melanoma to POC chemotherapy was similar to other cytotoxic regimens though toxicity, other than nausea and vomiting, was minimal. The rapid response allows patients with unresponsive disease to be identified early, avoiding continuing toxicity.

Patient assessment of a combined medical and nursing preparation to cytotoxic chemotherapy

At Auckland hospital there is a combined medical and nursing preparation for patients receiving cytotoxic chemotherapy. The aim of the current study was to assess whether patients felt that this combined approach had prepared them adequately for chemotherapy. Patients were asked to complete three questionnaires anonymously at different times in their treatment programme: immediately prior to chemotherapy, after three cycles of chemotherapy and 2 months after completion of chemotherapy. A high level of satisfaction with the programme was demonstrated: 68% of patients thought the orientation programme had prepared them "very well", 32% "adequately" and none "poorly" for their chemotherapy. Separate interviews with medical and nursing staff were thought a "good idea" by 86% of patients and only 1 of 100 medical and 100 nursing interviews was assessed as "not worthwhile". This study suggests that a combined medical and nursing preparation is a worthwhile practice in preparing patients for cytotoxic chemotherapy.

Interviews of medical school entrants: to what purpose?

Students entering the Faculty of Medicine at The University of New South Wales are selected by one of two methods. Most of the students are selected solely on the basis of results of higher school certificate examinations, the remainder under a special category for mature-age entrants. After they have been accepted into the school, all students are invited to attend a brief interview. This paper is a report of a retrospective analysis of some of the impressions recorded by interviewers over a four-year period. Over a period of three years, interviewers would have rejected from 18% to 29% of students who had been selected on academic criteria. The use of interviews as a screening or rejection procedure rather than a selection procedure is discussed and some future research questions are outlined.