Respiratory measurements and airway clearance device prescription over one year in amyotrophic lateral sclerosis

Objective: The rates of decline in respiratory measurements, including Peak Cough Flow (PCF) have not been established in Amyotrophic Lateral Sclerosis (ALS). Additionally, optimal prescription of cough adjuncts which aim to increase cough strength are unknown. The primary aim of this study was to quantify declines in respiratory function in ALS using PCF, Sniff Nasal Inspiratory Pressure (SNIP) and Slow Vital Capacity (SVC). Secondary aims were to measure respiratory morbidity, audit the characteristics of those prescribed cough adjuncts, and compare outcomes between treated and untreated cohorts. Methods: A prospective, longitudinal, observational, cohort study evaluated respiratory measures, morbidity, and physical function in ALS patients at three monthly intervals, over one year. Patient and disease characteristics of those prescribed cough adjuncts were profiled at the time of device prescription. Results: one hundred and eight participants with mean age 62.1 ± 11.5 years participated. PCF declined rapidly at a rate of 124.8L/min/year (p < 0.001). SNIP, SVC (%predicted), and ALSFRS-R also declined significantly at rates of 18.72cmH₂O, 17.49%, and 9.62 units per year respectively (p < 0.001). Thirty-two (29.6%) patients reported 56 incidences of chest infection and 21 died. Patients prescribed a cough adjunct (44.4%) had significantly lower average PCF, SNIP, SVC percent predicted, and ALSFRS-R (p < 0.001). Conclusions: This study identified a rapid rate of decline in PCF, a similar decline in SNIP, and slower declines in SVC and ALSFRS-R. Cough adjunct prescription was triggered by declining respiratory measures and recommended PCF thresholds, but also by respiratory symptoms. Chest infections were common in patients regardless of cough adjunct prescription and should be closely monitored.

The effects of a home-based arm ergometry exercise programme on physical fitness, fatigue and activity in Polio survivors: a randomised controlled trial

Objective:

To investigate the effect of an eight-week home-based arm ergometry aerobic exercise programme on physical fitness, fatigue, activity and quality of life in Polio Survivors.

Design:

An assessor blinded randomised controlled trial.

Setting:

Home-based exercise.

Subjects:

Fifty-five Polio survivors randomised to exercise or control groups.

Intervention:

Home-based arm ergometry at an intensity of 50%-70% maximum heart rate, compared with usual physiotherapy care.

Main measures:

The Six-minute Arm Test, Fatigue Severity Scale, Physical Activity Scale for Individuals with Physical Disabilities and SF-36. Assessments were completed at baseline and at eight weeks.

Results:

There was no significant difference in the primary outcome, exercising heart rate during the Six-minute Arm Test, between the groups at follow-up [97.6 (SD10.1) compared to 102.4 (SD13.7) beats per minute ( P=0.20)]. Blood pressure was significantly lower in the intervention group at follow-up [systolic blood pressure 132(18.6)mmHg compared to 144.1(14.6)mmHg ( P=0.002)]. There were no between group differences in the Fatigue Severity Scale ( P=0.25) or Physical Activity Scale for Individuals with Physical Disabilities ( P=0.49), with a small difference in SF-36 physical component score ( P=0.04).

Conclusions:

This home-based arm ergometry programme successfully facilitated aerobic exercise in Polio Survivors, but did not result in a significant change in physical fitness, measured by the Six-minute Arm Test.

Measles vaccination and antibody response in autism spectrum disorders

OBJECTIVE

To test the hypothesis that measles vaccination was involved in the pathogenesis of autism spectrum disorders (ASD) as evidenced by signs of a persistent measles infection or abnormally persistent immune response shown by circulating measles virus or raised antibody titres in children with ASD who had been vaccinated against measles, mumps and rubella (MMR) compared with controls.

DESIGN

Case-control study, community based.

METHODS

A community sample of vaccinated children aged 10-12 years in the UK with ASD (n = 98) and two control groups of similar age, one with special educational needs but no ASD (n = 52) and one typically developing group (n = 90), were tested for measles virus and antibody response to measles in the serum.

RESULTS

No difference was found between cases and controls for measles antibody response. There was no dose-response relationship between autism symptoms and antibody concentrations. Measles virus nucleic acid was amplified by reverse transcriptase-PCR in peripheral blood mononuclear cells from one patient with autism and two typically developing children. There was no evidence of a differential response to measles virus or the measles component of the MMR in children with ASD, with or without regression, and controls who had either one or two doses of MMR. Only one child from the control group had clinical symptoms of possible enterocolitis.

CONCLUSION

No association between measles vaccination and ASD was shown.

Randomized trial to compare the effect of recombinant human FSH (follitropin alfa) with or without recombinant human LH in women undergoing assisted reproduction treatment

Women undergoing intracytoplasmic sperm injection (ICSI) for male factor infertility were randomly assigned to receive ovarian stimulation in a long agonist protocol with a combination of recombinant human FSH (r-hFSH; Gonal-F) and recombinant human LH (r-hLH; Luveris) (n = 212) starting on day 6 of FSH stimulation until human chorionic gonadotrophin (HCG) at a daily fixed dose of 150 IU r-hLH, or with r-hFSH alone (n = 219). There was no significant difference in the number of metaphase II oocytes retrieved (10.3 versus 10.4) in patients treated with r-hFSH and r-hLH versus r-hFSH alone; however, more embryos were transferred in the LH-supplemented group (2.9 versus 2.8, P = 0.037). Overall, the implantation rates were 22.9 versus 27.0% in patients treated with r-hFSH and r-hLH versus with r-hFSH alone respectively (NS). The respective numbers of MII oocytes retrieved in patients <35 or >or=35 years were 11 versus 8.3 (P = 0.010) for patients treated with r-hFSH alone, and 10.7 versus 9.3 (NS) for those given supplemental r-hLH (150 IU) from day 6. Implantation rates in patients <35 years treated with r-hFSH were higher (30.7%) than those receiving r-hFSH and r-hLH, (23.5%) (P = 0.068). In patients >or=35 years, the implantation rates were 21.7% for those patients supplemented with 150 IU r-hLH from day 6 of stimulation versus 15.7% when treated with FSH alone (NS). Younger patients therefore do not seem to benefit from an LH-supplemented ovarian stimulation protocol, but women >or=35 years undergoing assisted reproduction may benefit from using r-hLH in addition to r-hFSH.

Patient and hospital delays in acute ischaemic stroke in a Dublin teaching hospital

A limiting factor for thrombolysis in ischaemic stroke is delayed presentation to hospital. Prolonged A&E stay and delayed rehabilitation affects care. We evaluated the delay in presentation, A&E stay and rehabilitation delivery in 117 consecutive stroke patients. The mean presentation delay was 16.0 +/- 23.7 hours. A prior history of TIA or stroke, a reduced Glascow Coma Scale and larger strokes were associated with shorter delays to presentation. Longer delays occurred in patients living alone. The mean time spent in A&E was 11 hours, those with larger strokes spent shorter time. There were significant delays in referral to, and assessment by certain rehabilitation disciplines. Delayed presentation in stroke is a barrier to thrombolysis. Increasing public awareness may reduce this delay. In addition, prolonged A&E stay and delayed rehabilitation may adversely affect management, outcome and duration of hospital stay. Further study is required to investigate the reasons and possible solutions for such deficiencies.

Efficacy and safety of ganirelix acetate versus leuprolide acetate in women undergoing controlled ovarian hyperstimulation

OBJECTIVE

To assess the efficacy, safety, and local tolerance of ganirelix acetate for the inhibition of premature luteinizing hormone (LH) surges in women undergoing controlled ovarian hyperstimulation (COH).

DESIGN

Phase III, multicenter, open-label randomized trial.

SETTING

In vitro fertilization (IVF) centers in North America.

PATIENT(S)

Healthy female partners (n = 313) in subfertile couples for whom COH and IVF or intracytoplasmic sperm injection were indicated.

INTERVENTION(S)

Patients were randomized to receive one COH cycle with ganirelix or the reference treatment, a long protocol of leuprolide acetate in conjunction with follitropin-beta for injection.

OUTCOME MEASURE(S)

Number of oocytes retrieved, pregnancy rates, endocrine variables, and safety variables.

RESULT(S)

The mean number of oocytes retrieved per attempt was 11.6 in the ganirelix group and 14.1 in the leuprolide group. Fertilization rates were 62.4% and 61.9% in the ganirelix and leuprolide groups, respectively, and implantation rates were 21.1% and 26.1%. Clinical and ongoing pregnancy rates per attempt were 35.4% and 30.8% in the ganirelix group and 38.4% and 36.4% in the leuprolide acetate group. Fewer moderate and severe injection site reactions were reported with ganirelix (11.9% and 0.6%) than with leuprolide (24.4% and 1.1%).

CONCLUSION(S)

Ganirelix is effective, safe, and well tolerated. Compared with leuprolide acetate, ganirelix therapy has a shorter duration and fewer injections but produces a similar pregnancy rate.

Automation for genomics, part two: sequencers, microarrays, and future trends

Automation for genomics has enabled a 43-fold increase in the total finished human genomic sequence in the world in the past four years. This is the second half of a two-part, noncomprehensive review that presents an overview of different types of automation equipment used in genome sequencing. The first part of the review, published in the previous issue, focused on automated procedures used to prepare DNA for sequencing or analysis. This second part of the review presents a look at available DNA sequencers and array technology and concludes with a look at future technologies. Alternate sequencing technologies including mass spectrometry, biochips, and single molecule analysis are included in this review.

Automation for genomics, part one: preparation for sequencing

In the past four years, automation for genomics has enabled a 43-fold increase in the total finished human genomic sequence in the world. This two-part noncomprehensive review will provide an overview of different types of automation equipment used in genome sequencing. Part One focuses on equipment involved in DNA preparation, DNA sequencing reactions, and other automated procedures for preparing DNA for running on sequencers or subsequent analysis; it also includes information on the development of these machines at various genome centers. Part Two, to be published in the next issue, will cover sequencing machinery and array technology, and conclude with a look at the future technologies that will revolutionize molecular biology. "Alternate" sequencing technologies (including mass spectrometry, biochips, and single-molecule analysis) will also be examined.

Role of vascular endothelial cell growth factor in Ovarian Hyperstimulation Syndrome

Controlled ovarian hyperstimulation with gonadotropins is followed by Ovarian Hyperstimulation Syndrome (OHSS) in some women. An unidentified capillary permeability factor from the ovary has been implicated, and vascular endothelial cell growth/permeability factor (VEGF) is a candidate protein. Follicular fluids (FF) from 80 women who received hormonal induction for infertility were studied. FFs were grouped according to oocyte production, from group I (0-7 oocytes) through group IV (23-31 oocytes). Group IV was comprised of four women with the most severe symptoms of OHSS. Endothelial cell (EC) permeability induced by the individual FF was highly correlated to oocytes produced (r2 = 0.73, P < 0.001). Group IV FF stimulated a 63+/-4% greater permeability than FF from group I patients (P < 0. 01), reversed 98% by anti-VEGF antibody. Group IV fluids contained the VEGF165 isoform and significantly greater concentrations of VEGF as compared with group I (1,105+/-87 pg/ml vs. 353+/-28 pg/ml, P < 0. 05). Significant cytoskeletal rearrangement of F-actin into stress fibers and a destruction of ZO-1 tight junction protein alignment was caused by group IV FF, mediated in part by nitric oxide. These mechanisms, which lead to increased EC permeability, were reversed by the VEGF antibody. Our results indicate that VEGF is the FF factor responsible for increased vascular permeability, thereby contributing to the pathogenesis of OHSS.

Confirmation of interrater reliability of the Marley Differential Diagnostic Scoring System for the Bender-Gestalt Test

The Bender-Gestalt test has been one of the most popular clinical instruments for the past four decades. Much controversy has surrounded the use of this test as a screening instrument for organicity (brain dysfunction). Marley's Differential Diagnostic Scoring System was recently developed to improve the validity of the test for detecting organicity. The original standardization of the system reported very high interrater reliability. To provide an independent assessment of interscorer reliability, three raters were trained in the system and separately rated 40 protocols. Kappa coefficients for the three raters ranged from .94 to .98. Substantial interscorer reliability was obtained, Mdn = 92.5% for specific scores with three scores attaining 100% agreement, although some values were lower. These results suggest that there is a strong empirical basis for the scoring system and encourage further refinement of the scoring system to reflect central nervous system dysfunction.

Outcome of pregnancies complicated by early vaginal bleeding

Obstetrical and neonatal data were analysed for pregnancy outcome in 259 deliveries complicated by first or second trimester vaginal bleeding. There was a high incidence of low birth weight, low gestational age, perinatal death, asphyxia, breech delivery, placental infarcts and small-for-dates term infants. Fetal anomalies were slightly though not significantly increased. Combined suboptimal pregnancy outcome occurred in 29.7 per cent of these deliveries compared to 15.2 per cent of 25 118 concurrent deliveries without reported early pregnancy bleeding (p less than 0.0001). The combined risk remained approximately doubled even for primigravidae and for women without prior illness or pregnancy complications. The highest combined risk, 61.5 per cent, was for women with at least two prior abortions, premature births or perinatal deaths and no prior term births. These findings suggest that early gestational vaginal bleeding is one predictor of suboptimal pregnancy outcome.

Suboptimal pregnancy outcome among women with prior abortions and premature births

Data from 25,958 consecutive UCLA deliveries were analyzed to determine the effect of prior abortions and premature births on current pregnancy outcome. Perinatal death rate, combining stillbirths and neonatal deaths, increased more than threefold among women with at least one prior premature in birth and at least one prior abortion and approached 18 per cent of current deliveries when there were three or more prior premature births. Abnormal live births, defined as infants with either birth weight under 2,501 grams, gestational age less than 37 weeks, or congenital anomalies, significantly increased as the number of prior abortions and premature births increased, each in a range of 0 through 3 or more. For example, among women with at least three prior premature births, there were greater than 50 per cent abnormal live births. The risk was mostly that of low birth weight and low gestational age, although there was a slight increase in congenital anomalies. The risk was reduced considerably when there were previous term births and was influenced variably by race, clinic classification, maternal illness, and prior pregnancy complications. This empirical data on pregnancy outcome should be useful in reproductive counseling among women with pregnancy losses and premature births.