Understanding dentatorubral-pallidoluysian atrophy (DRPLA) symptoms and impacts on daily life: a qualitative interview study with patients and caregivers

Background

Dentatorubral-pallidoluysian atrophy (DRPLA) is a rare, neurodegenerative disorder with no disease-modifying treatments. There is a dearth of information in the literature about the patient and caregiver experience living with DRPLA.

Objectives

This study aimed to (1) understand symptoms experienced by adult- and juvenile-onset DRPLA populations and their impact on daily life and (2) explore patient and caregiver treatment goals and clinical trial participation preferences.

Design

The study was a qualitative interview study.

Methods

Interviews were conducted remotely with adult patients with DRPLA and caregivers. Participants described patient symptoms and the impact of those symptoms on daily life, and they discussed treatment goals and potential clinical trial participation. There were 18 patients described in the interviews with two patients and seven caregivers. Some participants were caregivers to multiple patients with DRPLA.

Results

Interview transcripts were coded for themes, and reported symptoms were summarized with descriptive statistics. Adult-onset patients (N = 7) experienced difficulty with ataxia (100%), cognition (100%), fine motor skills (100%), gross motor skills (100%), speech (100%), personality changes (100%), and seizures (57%). Juvenile-onset patients (N = 11) experienced difficulty with ataxia (100%), sleep (100%), speech (100%), jerking/twitching (83%), behavior (82%), cognition (82%), fine motor skills (82%), gross motor skills (82%), sensory sensitivity (75%), and seizures (64%). When considering aspects of DRPLA to target for future treatment, patients prioritized ataxia/mobility (100%), juvenile-onset caregivers prioritized ataxia/mobility (60%) and independence (60%), and adult-onset caregivers prioritized personality (60%). Almost all patients (93%) would participate in a clinical trial if given the opportunity, but travel to a clinical site could pose a participation barrier for half.

Conclusion

This study found that there are symptom domains that are relevant across the DRPLA population, but there is heterogeneity within each domain based on the age of symptom onset and disease stage, which has implications for clinical trial design.

Impact of specialist ataxia centres on health service resource utilisation and costs across Europe: cross-sectional survey

BACKGROUND

Little is known about the costs of treating ataxia and whether treatment at a specialist ataxia centre affects the cost of care. The aim of this study was to investigate whether patients who attended specialist ataxia centres in three European countries reported differences in their health care use and costs compared with patients who did not attend a specialist ataxia centre. We compared mean resource use and health service costs per patient affected by ataxia in the United Kingdom, Italy and Germany over a 12-month period. Data were obtained from a survey distributed to people with ataxia in the three countries. We compared mean resource use for each contact type and costs, stratifying patients by whether they were currently attending a specialist ataxia centre or had never attended one.

RESULTS

Responses were received from 181 patients from the United Kingdom, 96 from Italy and 43 from Germany. Differences in the numbers of contacts for most types of health service use between the specialist ataxia centre and non-specialist ataxia centre groups were non-significant. In the United Kingdom the mean total cost per patient was €2209 for non-specialist ataxia centre patients and €1813 for specialist ataxia centre patients (P = 0.59). In Italy these figures were €2126 and €1971, respectively (P = 0.84). In Germany they were €2431 and €4087, respectively (P = 0.19). Inpatient stays made the largest contribution to total costs.

CONCLUSIONS

Within each country, resource use and costs were broadly similar for specialist ataxia centre and non-specialist ataxia centre groups. There were differences between countries in terms of health care contacts and costs.

Patient pathways for rare diseases in Europe: ataxia as an example

BACKGROUND

Progressive ataxias are rare and complex neurological disorders that represent a challenge for the clinicians to diagnose and manage them. This study explored the patient pathways of individuals attending specialist ataxia centres (SAC) compared with non-specialist settings. We investigated specifically how diagnosis was reached, the access to healthcare services, treatments, and care satisfaction. The focus of this study was on early intervention, coordination of treatment to understand the care provision in different countries.

METHODS

A patient survey was done in the UK, Germany and Italy to gather information about diagnosis and management of the ataxias in specialist (SAC) and non-specialist settings, utilisation of other primary and secondary health care services, and patients' satisfaction of received treatment.

RESULTS

Patients gave positive feedback about the role of SAC in understanding their condition, ways to manage their ataxia (p < 0.001; UK) and delivering care adapted to their needs (p < 0.001; UK), in coordinating referrals to other healthcare specialists, and in offering opportunities to take part in research studies. Similar barriers for patients were identified in accessing the SACs among the selected countries, UK, Germany, and Italy.

CONCLUSIONS

This study provides crucial information about the ataxia patients care pathways in three European countries. Overall, the results showed a trend in patients' satisfaction being better in SAC compared to non-SAC. The outcomes can be used now for policy recommendations on how to improve treatment and care for people with these very rare and complex neurological diseases across Europe.

Medical Research Charities and Biopharmaceutical Companies as Partners in Patient-Centred R&D

Life science research and development (R&D) companies are all too aware of the importance of patient perspectives but also of the barriers to engaging directly with patients, not least compliance, complex technical and regulatory issues, and the need to meet multifaceted expectations. Medical research charities (MRCs), highly technical and professional organisations, work directly with patients; they represent an expert resource for the science of their field, for disease-related patient advocacy issues and to advise and assist R&D companies in devising meaningful trials. The Pistoia Alliance, a non-profit organisation facilitating life sciences R&D, gathered a number of UK MRCs focused on complex lifelong conditions. The group used workshops and an opinion questionnaire for a snapshot of how the charities believe their knowledge and patient experiences could contribute insights and efficiencies to commercial R&D. MRCs argued that for chronic conditions, the patient perspective is vital in facilitating and de-risking trials, promoting patient motivation, compliance and study viability. MRCs and the patients they represent want to see successful trials, and it is in everyone’s interest that well considered studies can proceed. Today, with remote assessments, consumer wearables and digital health technologies, MRCs and patients are already collating substantial data sets that are relevant to quality-of-life benefits, regulatory and value assessments, all of great interest to biopharmaceutical companies. In turn, MRCs would benefit from the experience of biopharma in generating clinical data and implementing novel technologies.

The attitude of patients with progressive ataxias towards clinical trials

Background

The development of new therapies may rely on the conduct of human experimentation as well as later clinical trials of therapeutic interventions. Ethical considerations seek to protect the patient from risk but few have sought to ascertain the attitude to such risk of patients with progressive debilitating or terminal conditions, for which no mitigating or curative therapies exist. Such understanding is also important if recruitment is to be maximized. We therefore sought to define the motivations for and barriers to trial participation amongst patients with progressive ataxias, as well as their condition-specific trial preferences.

Methods

We conducted an online survey consisting of 29 questions covering four key domains (demographics, personal motivation, drug therapy and study design) relating to the design of clinical trials. Two major ataxia charities, Ataxia UK and the Friedreich’s Ataxia Research Alliance (FARA) sent the survey to their members. Responses were analysed by disease and by ambulatory status.

Results

Of 342 respondents, 204 reported a diagnosis of Friedreich’s ataxia (FRDA), 55 inherited cerebellar ataxia (CA) and 70 idiopathic CA. The most important symptoms to be addressed by a trial were considered to be balance problems and ambulation, although these were superseded by speech problems in wheelchair users. Common motivations for participation were potential benefits to self and others. Reasons for non-participation included concerns about side effects, and the burden and cost of travel. Financial reimbursement for expenses was reported to be likely to increase trial engagement, Phase two trials were the most popular to participate in, and the use of a placebo arm was seen as a disincentive. Across all disease subgroups, drug repurposing trials proved popular and just under 70% of participants would be prepared to undergo intrathecal drug administration.

Conclusions

Knowledge of motivations for and barriers to trial participation as well as the acceptability of investigations, time commitments and routes of drug administration should inform better, more patient focused trial design. This in turn may improve recruitment and retention of participants to future trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-02091-x.

Symptom burden of people with progressive ataxia, and its wider impact on their friends and relatives: a cross-sectional study

Background

Progressive ataxias are complex disorders that result in a wide variety of symptoms. Whilst we currently have a relatively good understanding of the symptom patterns associated with the various types of ataxia, and how these diseases progress over time, their impact on the person with ataxia is less well understood. In addition, little is known about how carers, friends and families are affected by them. This paper aims to provide preliminary information on the presence and impact of medical symptoms and day-to-day challenges on people with ataxia and their friends and relatives.

Method

Data were extracted from a survey by Ataxia UK for their members. The views of 366 people with ataxia and 52 friends and relatives are reported. Data were analysed for the entire groups, as well as for the three most common ataxia types represented in the sample, Friedreich's ataxia, inherited ataxia (excluding Friedreich's ataxia), and cerebellar ataxia of unknown cause.

Results

The survey confirmed the symptom patterns described in previous research, but further showed that the impact of these symptoms can vary across ataxia populations. Similar findings were observed for day-to-day challenges. Friends and relatives experienced similar challenges to people with ataxia, indicating that support provided has to consider those supporting people with ataxia as well as the patient. Respondents also highlighted limitations in terms of accessing support services, and not all services were able to cater fully to their specific needs.

Conclusion

This study begins to provide information that can be used in further research to explore the needs of people with ataxia and their carers, friends, and relatives. Such research will support treatment trial design, ensuring patients' needs are considered, help to tailor support services to their needs, and ensure health care professionals have the necessary skills to fully address them.

690 Intracranial Hypotension Due to CSF Leak Secondary to Ventral Thoracic Osteophyte Complex: Resolution After Transdural Thoracic Discectomy and Dural Repair

The hallmark symptom of spontaneous intracranial hypotension (SIH) is orthostatic headaches which manifests secondary to cerebrospinal fluid (CSF) hypovolaemia. Well-recognised aetiologies include trauma which includes procedures such as lumbar punctures and spinal surgery. More recently, structural defects such as bony osteophytes and calcified or herniated discs have been attributed to mechanically compromising dural integrity consequently resulting in CSF leak and symptom manifestation. A thorough literature review noted only a handful of such cases.

We report the case of a thirty-two-year-old Asian female who presented with a one-month history of new-onset progressively worsening orthostatic headaches. Workup included MRI of the thoracic spine which revealed an epidural collection of CSF consequently prompting a dynamic CT-myelogram of the spine which not only helped to confirm severe cerebral hypotension but also suggested the underlying cause as being a dorsally projecting osteophyte-complex at level T2-3. Conservative and medical management including bed rest, analgesia, mechanical compression, and epidural blood patches failed to alleviate symptoms and a permanent surgical cure was eventually sought. The surgery involved T2-T3 laminectomy and osteophytectomy and at a 3-month follow-up, complete resolution of symptoms was noted.

A master protocol to investigate a novel therapy acetyl-L-leucine for three ultra-rare neurodegenerative diseases: Niemann-Pick type C, the GM2 gangliosidoses, and ataxia telangiectasia

BACKGROUND

The lack of approved treatments for the majority of rare diseases is reflective of the unique challenges of orphan drug development. Novel methodologies, including new functionally relevant endpoints, are needed to render the development process more feasible and appropriate for these rare populations and thereby expedite the approval of promising treatments to address patients' high unmet medical need. Here, we describe the development of an innovative master protocol and primary outcome assessment to investigate the modified amino acid N-acetyl-L-leucine (Sponsor Code: IB1001) in three separate, multinational, phase II trials for three ultra-rare, autosomal-recessive, neurodegenerative disorders: Niemann-Pick disease type C (NPC), GM2 gangliosidoses (Tay-Sachs and Sandhoff disease; "GM2"), and ataxia telangiectasia (A-T).

METHODS/DESIGN

The innovative IB1001 master protocol and novel CI-CS primary endpoints were developed through a close collaboration between the Industry Sponsor, Key Opinion Leaders, representatives of the Patient Communities, and National Regulatory Authorities. As a result, the open-label, rater-blinded study design is considerate of the practical limitations of recruitment and retention of subjects in these ultra-orphan populations. The novel primary endpoint, the Clinical Impression of Change in Severity© (CI-CS), accommodates the heterogenous clinical presentation of NPC, GM2, and A-T: at screening, the principal investigator appoints for each patient a primary anchor test (either the 8-m walk test (8MWT) or 9-hole peg test of the dominant hand (9HPT-D)) based on his/her unique clinical symptoms. The anchor tests are videoed in a standardized manner at each visit to capture all aspects related to the patient's functional performance. The CI-CS assessment is ultimately performed by independent, blinded raters who compare videos of the primary anchor test from three periods: baseline, the end of treatment, and the end of a post-treatment washout. Blinded to the time point of each video, the raters make an objective comparison scored on a 7-point Likert scale of the change in the severity of the patient's neurological signs and symptoms from video A to video B. To investigate both the symptomatic and disease-modifying effects of treatment, N-acetyl-L-leucine is assessed during two treatment sequences: a 6-week parent study and 1-year extension phase.

DISCUSSION

The novel CI-CS assessment, developed through a collaboration of all stakeholders, is advantageous in that it better ensures the primary endpoint is functionally relevant for each patient, is able to capture small but meaningful clinical changes critical to the patients' quality of life (fine-motor skills; gait), and blinds the primary outcome assessment. The results of these three trials will inform whether N-acetyl-L-leucine is an effective treatment for NPC, GM2, and A-T and can also serve as a new therapeutic paradigm for the development of future treatments for other orphan diseases.

TRIAL REGISTRATION

The three trials (IB1001-201 for Niemann-Pick disease type C (NPC), IB1001-202 for GM2 gangliosidoses (Tay-Sachs and Sandhoff), IB1001-203 for ataxia telangiectasia (A-T)) have been registered at www.clinicaltrials.gov (NCT03759639; NCT03759665; NCT03759678), www.clinicaltrialsregister.eu (EudraCT: 2018-004331-71; 2018-004406-25; 2018-004407-39), and https://www.germanctr.de (DR KS-ID: DRKS00016567; DRKS00017539; DRKS00020511).

Diagnosis and management of progressive ataxia in adults

Progressive ataxia in adults can be difficult to diagnose, owing to its heterogeneity and the rarity of individual causes. Many patients remain undiagnosed (‘idiopathic’ ataxia). This paper provides suggested diagnostic pathways for the general neurologist, based on Ataxia UK’s guidelines for professionals. MR brain scanning can provide diagnostic clues, as well as identify ‘structural’ causes such as tumours and multiple sclerosis. Advances in molecular genetics, including the wider and cheaper availability of ‘next-generation sequencing’, have enabled clinicians to identify many more cases with a genetic cause. Finally, autoimmunity is probably an under-recognised cause of progressive ataxia: as well as patients with antigliadin antibodies there are smaller numbers with various antibodies, including some associated with cancer. There are a few treatable ataxias, but also symptomatic treatments to help people with the spectrum of complications that might accompany progressive ataxias. Multidisciplinary team involvement and allied health professionals’ input are critical to excellent patient care, including in the palliative phase. We can no longer justify a nihilistic approach to the management of ataxia.

Guidelines on the diagnosis and management of the progressive ataxias

The progressive ataxias are a group of rare and complicated neurological disorders, knowledge of which is often poor among healthcare professionals (HCPs). The patient support group Ataxia UK, recognising the lack of awareness of this group of conditions, has developed medical guidelines for the diagnosis and management of ataxia. Although ataxia can be a symptom of many common conditions, the focus here is on the progressive ataxias, and include hereditary ataxia (e.g. spinocerebellar ataxia (SCA), Friedreich’s ataxia (FRDA)), idiopathic sporadic cerebellar ataxia, and specific neurodegenerative disorders in which ataxia is the dominant symptom (e.g. cerebellar variant of multiple systems atrophy (MSA-C)). Over 100 different disorders can lead to ataxia, so diagnosis can be challenging. Although there are no disease-modifying treatments for most of these entities, many aspects of the conditions are treatable, and their identification by HCPs is vital. The early diagnosis and management of the (currently) few reversible causes are also of paramount importance. More than 30 UK health professionals with experience in the field contributed to the guidelines, their input reflecting their respective clinical expertise in various aspects of ataxia diagnosis and management. They reviewed the published literature in their fields, and provided summaries on “best” practice, including the grading of evidence available for interventions, using the Guideline International Network (GIN) criteria, in the relevant sections.

A Guideline Development Group, consisting of ataxia specialist neurologists and representatives of Ataxia UK (including patients and carers), reviewed all sections, produced recommendations with levels of evidence, and discussed modifications (where necessary) with contributors until consensus was reached. Where no specific published data existed, recommendations were based on data related to similar conditions (e.g. multiple sclerosis) and/or expert opinion. The guidelines aim to assist HCPs when caring for patients with progressive ataxia, indicate evidence-based (where it exists) and best practice, and act overall as a useful resource for clinicians involved in managing ataxic patients. They do, however, also highlight the urgent need to develop effective disease-modifying treatments, and, given the large number of recommendations based on “good practice points”, emphasise the need for further research to provide evidence for effective symptomatic therapies.

These guidelines are aimed predominantly at HCPs in secondary care (such as general neurologists, clinical geneticists, physiotherapists, speech and language therapists, occupational therapists, etc.) who provide care for individuals with progressive ataxia and their families, and not ataxia specialists. It is a useful, practical tool to forward to HCPs at the time referrals are made for on-going care, for example in the community.

Diabetic ketoacidosis secondary to L-asparaginase in acute lymphoblastic leukaemia

We describe a case of severe hyperglycaemia resulting in diabetic ketoacidosis secondary to L-asparaginase. There are few reports of this potentially life-threatening complication, particularly in the English literature. Awareness and recognition of this preventable and manageable problem will improve safe delivery of this anti-leukaemic drug.

Trouble with ataxia: A longitudinal qualitative study of the diagnosis and medical management of a group of rare, progressive neurological conditions

OBJECTIVES

An exploratory investigation of diagnosis and management in progressive ataxias: rare neurological conditions usually affecting balance, mobility and speech.

METHODS

A longitudinal qualitative study into the experiences of people with ataxia and neurologists. Thematic analysis and follow-up interviews were used to determine diagnosis and management issues over time.

RESULTS

People with ataxia recruited via two hospital departments and Ataxia UK were interviewed at baseline (n = 38) and 12-month follow-up (n = 31). Eight consultant neurologists were interviewed once. Patient accounts were diverse, but many expressed frustration at having an incurable condition and dissatisfaction with service outcomes. At follow-up, there was variation in their contact and satisfaction with helping agencies. Service issues regarding continuity of care and the primary/secondary care interface were evident. Neurologists' accounts also varied. One-half reported that there is nothing that can be done, and one-half favoured specialist referral to increase the likelihood of finding an underlying aetiology within budget constraints.

CONCLUSIONS

Diagnostic uncertainties existing at baseline remained for patients at follow-up interviews, although some had learned to deal with the uncertainties brought by the diagnosis of a largely untreatable condition. Care pathways only seemed to operate in the case of defined conditions, such as Friedreich's Ataxia, the most commonly inherited cause. The findings point to a need to develop the evidence base to inform the relative utility of diagnostic procedures in the context of finite resources for patient care and support.

"Six sessions is a drop in the ocean": an exploratory study of neurological physiotherapy in idiopathic and inherited ataxias

OBJECTIVE

An exploratory study to examine specialist neurological physiotherapy service provision and utilisation for people with progressive ataxia.

DESIGN

Qualitative study involving thematic analysis of accounts in semi-structured interviews with physiotherapists and patients.

SETTING

People with ataxia and specialist neuro-rehabilitation physiotherapists in Greater Manchester, UK.

PARTICIPANTS

38 people with ataxia and 8 neurological-physiotherapists working in academic and hospital and community-based services in NHS and private settings. Recruiting physiotherapists experienced in working with the patient group was a challenge.

INTERVENTIONS

One hour cross-sectional semi-structured interview at physiotherapists' workplaces or in patients' own homes.

RESULTS

Neurological physiotherapy was experienced by 25 (66%) of the 38 people with ataxia. The overarching themes emerging from the analysis were 'making a difference,' engagement and service provision. A majority of both samples felt that services should be organised so as to provide longer term therapy and support that goes beyond short care packages followed by provision of home exercise programme. Engagement with services was linked to patient expectations, adherence and perception of outcomes. The most predominant codes in the data set were encapsulated by the theme 'making a difference,' which further included concerns about how to measure perceived clinical improvement (as experienced by patients) in the context of progressive decline.

CONCLUSIONS

The findings suggest a model of idealised service provision involving a holistic, open-access service including research efforts to improve the evidence base. Special attention needs to be paid to measuring improvements following therapy.

Transformation zone sampling rate used as a performance indicator for cervical liquid-based cytology sample-takers

OBJECTIVE

To investigate the sampling performance of individual cervical cytology practitioners using the transformation zone sampling rate (TZSR) as a performance indicator and to assess the impact of dedicated on site training for those identified with a low TZSR.

METHODS

The TZSR was calculated for all practitioners submitting ThinPrep(®) cervical cytology specimens to the Conquest laboratory between January 2010 and November 2011. After excluding those with less than 30 qualifying samples the 10th percentile of the TZSR was calculated. Practitioners with a TZSR below the 10th percentile were visited by a specialist cervical cytology screening facilitator after which the TZSR of these practitioners was closely monitored.

RESULTS

After exclusions there were 175 practitioners who had collected 24 358 qualifying liquid-based cytology (LBC) samples. The average TZSR was 70% (range 12-96%). The 10th percentile was 44%; 18 scored below the 10th percentile. Failure to apply sufficient pressure when sampling was identified as the most common reason for a low TZSR. In some cases there was suspicion that the cervix was not always adequately visualized. Continuous monitoring after assessment identified improvement in the TZSRs of 13/18 practitioners.

CONCLUSIONS

Identification of practitioners with low TZSRs compared with their peers allows these individuals to be selected for personalized observation and training by a specialist in cervical cytology which can lead to an improvement in TZSR. As previous studies show a significant correlation between the TZSR and the detection rate of cytological abnormality it is useful to investigate low TZSRs.

'You don't get told anything, they don't do anything and nothing changes'. Medicine as a resource and constraint in progressive ataxia

BACKGROUND

Progressive ataxias are neurological disorders affecting balance, co-ordination of movement and speech.

OBJECTIVE

A qualitative study was undertaken to discover patients' experiences of ataxia and its symptoms.

PARTICIPANTS

Thirty-eight people with ataxia recruited from patient support groups and two hospital outpatients departments.

DESIGN

Cross-sectional qualitative study with thematic analysis.

RESULTS

These accounts highlight the limits of medicine in the context of a rare, incurable and disabling disorder, and the embodied uncertainties brought by slowly progressive diseases that lie at the boundaries of mainstream medical knowledge. The existential crises faced by people with ataxia are seemingly magnified by sometimes idiopathic aetiologies and the limited number of inherited conditions identifiable by the available genetic tests. Interviewees were drawn into a medical system that was focused mainly on the diagnosis process, with widely varying results. However, when asked, most had rather valued the provision of disability aids and physical therapies. Only one informant reported overcoming the myriad uncertainties of progressive ataxia, and their account supported the notion of 'biographical repair' in chronic illness.

CONCLUSIONS

Clinical uncertainties in ataxia constrained people's attempts to deal with their condition. The construction of the proactive, informed, medical consumer who is assumed to be a partner in care is problematic in the context of a rare and difficult-to-diagnose disease for which there is usually no cure. Service providers should be mindful of the need to manage patient expectations in relation to diagnosis and cure. More focus might usefully be placed on the provision of physical therapies and disability aids.

Getting a diagnosis v. learning to live with it? The case of the progressive ataxias

OBJECTIVES

To examine the perceptions and experiences of the diagnosis process in people with a progressive ataxia, a group of rare complex neurological conditions usually leading to disturbances in balance and speech.

METHODS

An explorative qualitative study involving analysis of public accounts posted to specialist Internet discussion forums by people with symptoms of ataxia. Internet data were utilized partly because ataxia is a rare condition.

RESULTS

The main themes that emerged were diagnosis as an arduous process, achieving diagnosis as a privilege, the importance of getting a medical label, being believed with regard to symptoms and 'idiopathic' diagnosis as a non-diagnosis. The accounts of people who were not able to secure a definitive diagnosis suggested that their priorities had changed from getting a diagnosis to managing and learning to live with their progressive disabilities.

CONCLUSIONS

The diagnosis of the progressive ataxias presents challenges for patients, clinicians and in terms of the extensive use of finite healthcare resources. Our findings suggest there are varied views on the importance of diagnosis to people with progressive ataxia. This warrants further in-depth research to understand how people rate the relative utility of diagnostics.

New Insulin Analogues and Perioperative Care of Patients with Type 1 Diabetes

While insulin remains the mainstay of managing type 1 diabetes, much has changed over the last 15 years. These changes should help in managing patients with type 1 diabetes during the perioperative period. More flexible insulin therapy has three components: 1) basal, 2) prandial and 3) corrective. Many patients, particularly younger patients, are using genetically modified recombinant human insulin analogues. Two of these analogues, aspart and lispro insulin, are rapid-acting with faster onset and offset than subcutaneous regular insulin, allowing both prandial and corrective boluses. Other insulin analogues, particularly glargine and possibly detemir, have a flat profile of up to 24 hours, providing improved basal insulin delivery. Basal insulin can also be provided by a continuous subcutaneous infusion of rapid-acting insulin via a computerised pump that also provides boluses on demand. There is little evidence to help choose the best management of patients with type 1 diabetes during surgery. Some authors still recommend glucose-potassium-insulin infusions for all patients with type 1 diabetes. We challenge this approach, given the flexibility of the newer insulin analogues and delivery systems. We suggest that for many procedures, patients’ usual regimens can be maintained in the perioperative period, providing less disruption and, possibly, greater safety. Both hyperglycaemia and hypoglycaemia reflect poor management: we suggest a target glucose range of 5 to 10 mmol/l. The importance of frequently measuring blood glucose and appropriate responses cannot be overemphasised.

Towards a non-invasive interictal application of hypothermia for treating seizures: a feasibility and pilot study

OBJECTIVES

To evaluate the feasibility and safety of head-neck cooling in conscious normal volunteers (10) and patients with medically refractory epilepsy (5) without causing shivering.

PATIENTS AND METHODS

We used a non-invasive head-neck cooling system (CoolSystems Inc., Lincoln, CA, USA). The tympanic temperature (TT) and intestinal temperature (IT) were measured as two measurements of 'core temperature' (CT), and multi-site external temperatures, several physiologic variables and EEG were monitored. Seizure counts over 4-week precooling, treatment and follow-up phases were compared.

RESULTS

All 15 participants completed all the cooling sessions without significant complaints. At the end of 60 min of cooling, scalp temperature fell on average by 12.2 degrees C (P < 0.001), TT by 1.67 degrees C (P < 0.001), and IT by 0.12 degrees C (P = NS). Average weekly seizure frequency decreased from 2.7 to 1.7 events per patient per week (MANOVA: P < 0.05).

CONCLUSIONS

Non-invasive head-neck cooling is safe and well-tolerated. Initial pilot data in patients suggest that additional therapeutic studies are warranted.

Centres of Excellence for the care of people with progressive ataxias

This article provides a description of the progressive ataxias and how such a diagnosis impacts on a person's life. The nurse's role in helping these patients, who can face numerous difficulties in everyday life, is highlighted. Moreover, the authors discuss the development of Ataxia Specialist Centres of Excellence for the diagnosis and management of people with ataxia, and the benefits believe these centres will bring to the care of these patients.

Dominance, gender, and cardiovascular reactivity during social interaction

Associations between trait dominance and cardiovascular reactivity were examined in previously unacquainted healthy men and women. Subjects participated in three mixed-gender dyadic interactions with the same partner while their cardiovascular responses were assessed. Among men, but not women, trait dominance was positively and significantly associated with systolic blood pressure reactivity. For men and women, diastolic blood pressure reactivity was positively and significantly associated with trait dominance while participants prepared to interact and with partner's trait dominance while they interacted. All effects held after controlling for trait hostility. Dominance merits attention as a correlate of cardiovascular reactivity, a finding that parallels emerging patterns in the cardiovascular disease literature. Gender and gender-related social factors as potential moderators of this relationship are discussed.

Electroencephalographic findings in patients with mucolipidosis type IV

OBJECTIVE

To describe the electroencephalographic findings in mucolipidosis type IV (ML IV), a lysosomal storage disease of unknown etiology characterized clinically by corneal clouding, retinal degeneration and severe psychomotor retardation. Most patients are of Ashkenazi-Jewish ancestry. The EEG findings in this syndrome have not been characterized.

METHODS

We analyzed the EEGs of 10 patients with the diagnosis of ML IV, aged between of 2.5 and 21 years. All patients had 21 channel recordings in the international 10/20 system without sedation.

RESULTS

Six of the 10 patients had slowing of the background in the theta frequency range, and 4 had excessive beta frequency activity without the administration of medications. Two patients were able to reach stage 2 sleep, and were noted to have both synchronous and asynchronous spindles and vertex waves. Of the 10 patients, 6 had epileptiform spikes, all of which were noted frequently. The location of the spikes varied, from the frontal and temporal regions to the central regions, although location was consistent in each patient. Only one patient with epileptiform spikes had a history of clinical seizures. None of the other patients had a history of seizures.

CONCLUSIONS

These findings imply that epileptiform discharges are common in patients with ML IV, but are infrequently associated with clinical seizures.

14 and 6 Hz positive spikes preceding 3 Hz generalized spike and wave in a 15 year old patient with absence: a case report

A 15 year old girl with a history of childhood absence seizures underwent a prolonged EEG recording. Twelve bursts of 3 Hz generalized spike and wave were recorded during drowsiness and light sleep, all of which were preceded by 14 and 6 Hz positive spikes with a latency of under 1 s. Nine bursts of polyspike-wave, not preceded by 14 and 6 Hz positive spikes, were recorded during deeper sleep (stage 3). The bursts of polyspike-wave were significantly longer when preceded by 14 and 6 Hz spikes than when observed in isolation. The close association between these paroxysmal events in our patient is intriguing, may be coincidental, and has never before been reported.

Isolation and characterization of the human and mouse homologues (SUPT4H and Supt4h) of the yeast SPT4 gene

To study gene regulation mediated by chromatin in mammals, we isolated the human (SUPT4H) and murine (Supt4h) counterparts of the yeast gene encoding SPT4; the product of this gene presumably interacts with the products of the mammalian homologues (which we have also cloned) of yeast SPT5 and SPT6, thereby modulating chromatin formation and activity. We isolated two different sized human SUPT4H cDNA clones (1464 and 728 nt) and one murine Supt4h (688 nt) cDNA clone; all three encode the same 117-amino-acid protein with conservation of the zinc finger motif found in SPT4. Conservation of this zinc finger motif from yeast to mouse and human implies functional importance. Although the overall sequence homology at the DNA level between the human 728-nt transcript and the murine 688-nt transcript is only 78.4%, the DNA sequence homology is 97.7% within the coding region. At the protein level, the amino acid sequences of the translated murine Supt4h and the human SUPT4H gene products are identical. The likely functional copy of SUPT4H, which has at least two introns, maps to human chromosome 17, with candidate intronless pseudogenes on chromosomes 2, 12, and 20. Buttressing the hypothesis that this is a gene required constitutively, both the human SUPT4H transcripts and the murine Supt4h transcript are expressed widely, although not at equal levels (e.g., such as most histones), in all fetal and adult tissues that we examined.

A beta-turn rich barley seed protein is correctly folded in Escherichia coli

Wild-type and cysteine-containing mutant C hordeins from barley were expressed in Escherichia coli at high levels (> or = 30mg/liter). N-terminal sequence analysis, SDS-PAGE, RP-HPLC, cd spectroscopy, and small angle X-ray scattering demonstrated that their physicochemical properties were similar to those of C hordeins isolated from barley grain. This indicates that the expressed proteins were correctly folded. The cysteine-containing mutant showed evidence of polymer formation in E. coli, nonreduced preparations of the protein showing the presence of polymers that were replaced by a single protein when a reducing agent was added.

d-Fenfluramine suppresses the increased calorie and carbohydrate intakes and improves the mood of women with premenstrual depression

The ability of d-fenfluramine, a drug that releases brain serotonin and blocks its reuptake, to relieve premenstrual depression and excessive calorie and carbohydrate intakes was examined in 17 women with premenstrual syndrome. Subjects received d-fenfluramine (15 mg twice daily) or placebo, in random order, during the luteal phases of six menstrual cycles; ie, for three control and three treatment cycles each. Behavior was assessed with the Hamilton Rating Scale for Depression and its Addendum, and intakes of calories and nutrients were measured by allowing subjects unlimited access to isocaloric meal and snack foods rich in carbohydrates or protein. Pre-treatment follicular scores using the Hamilton Rating Scale for Depression and its Addendum were 2.0 +/- 0.5 and 0.5 +/- 0.5 (mean +/- SEM), respectively; corresponding luteal scores were 21.2 +/- 0.8 and 10.2 +/- 0.6 (P less than .0001). Luteal phase intakes of kilocalories, carbohydrates, and fats were also increased above follicular levels (P less than .01). d-Fenfluramine decreased premenstrual Hamilton Rating Scale for Depression and Addendum scores by 62% (P less than .001) and 60% (P less than .001), respectively; placebo reduced them by only 28% (P less than .02) and 30% (P less than .02). d-Fenfluramine also fully suppressed the premenstrual rise in kilocalorie, carbohydrate, and fat intakes (P less than .01).

Serum levels of dehydroepiandrosterone sulfate as determined by commercial kits and reagents

We measured serum dehydroepiandrosterone sulfate (DHEA-S) levels by nine different radioimmunoassay (RIA) methods. Although each method was adequate for determining the amount of authentic DHEA-S, there were marked differences observed between the methods when serum samples were tested. Further, the pattern of these differences varied in different clinical situations. We suggest that the differences in the apparent DHEA-S content resulted from the presence of structurally related compounds which differ in their cross-reactivity in the different RIAs. One of these cross-reacting materials may be a functional androgen.

Morton's interdigital neuroma. Indications for treatment by local injections versus surgery

A retrospective study of 67 patients in whom Morton's neuroma had been diagnosed showed that 78% were women. The average age was 58 years (range, 19-85 years). Pain in the forefoot, which worsened with walking, was relieved by removal of shoes. The presence of local interdigital tenderness led to the diagnosis. Modification of shoes was helpful in two patients. The other 65 patients received a series of interdigital Xylocaine-steroid injections at one- to three-week intervals, which immediately relieved the pain in 30% of the patients and gave partial relief in 50%. At a two-year follow-up examination, 80% of the patients indicated complete relief of pain or had only slight pain. Surgical excision was indicated in those who failed to respond to the injections. Of 11 patients, surgical excision successfully relieved pain in four, effected partial relief in four, and failed in three. As a result of this retrospective study of patients with Morton's neuroma, the authors recommend therapeutic injections prior to surgery.

Eradication of Aleutian disease of mink by eliminating positive counterimmunoelectrophoresis test reactors

The counterimmunoelectrophorsis test was applied on three Aleutian disease virus-infected mink ranches for the detection of specific Aleutian disease virus antibody. All mink on the ranches were tested during the pelting season and before the breeding season for 4 consecutive years. Aleutian disease has been eliminated from the three commercial mink ranches by culling out all mink that were positive for Aleutian disease virus antibody.

Acute cervical strain. Evaluation and short term prognostic factors

An independent examiner evaluated 179 consecutive private ambulatory litigant patients with soft tissue neck injuries (whiplash) from automobile injuries. Treatment of all patients consisted of neck and shoulder exercises with the exclusion of cervical collars, cervical traction and hospitalization. Forty-three patients had intermittent cervical traction in addition to the exercises. All patients were encouraged to resume their usual work and other activities. The presence of interscapular or upper back pain prognosticated a less favorable result. The average length of treatment was 7.4 weeks. Thirty-seven per cent of the patients with asymptomatic; 16 per cent showed no significant recovery. Older patients recovered as well as younger patients. There was no relation between X-ray findings of flattening or reversal of the cervical lordotic curve and the degree of recovery.