Multiple sclerosis rehabilitation outcomes: analysis of a national casemix data set from Australia

Objective

To examine the outcomes of inpatient rehabilitation for persons with multiple sclerosis (pwMS), using the Australian Rehabilitation Outcomes Centre (AROC) database.

Method

Deidentified data from the AROC database were analyzed for all rehabilitation admissions during 2003–2007, using four classes for functional level. The outcomes included Functional Independence Measure (FIM) scores and efficiency, hospital length of stay (LOS), and discharge destination.

Results

Of 1010 case episodes, 70% were women, admitted from home ( n = 851) and discharged into the community ( n = 890), and 97% ( n = 986) were in the higher three classes for functional level (classes 216, 217, and 218). Majority of the more disabled pwMS were treated in the public hospital system, with a longer LOS compared with private facilities ( P < 0.001). The FIM for classes 216–218 showed significant functional improvement during the admission ( P < 0.001), and those in higher classes showed less change (likely due to higher FIM admission scores). FIM efficiency was significantly higher in class 217 than other classes ( P < 0.001). The year-on-year trend was toward reducing hospital LOS and FIM efficiency, but these did not reach significance ( P = 0.107, P = 0.634).

Conclusion

The AROC data set is useful for describing rehabilitation outcomes for pwMS. However, additional information needs to be collected to evaluate nature of services provided and service implications.

Characterization of lymphoid infiltrates in prostatectomy specimens post neoadjuvant hormonal therapy using quantitative immunofluorescence and RNA FISH

e16104

Background: Immunotherapy for advanced prostate cancer requires an understanding of the host response including lymphocyte subsets and cytokine expression. Using quantitative immunofluorescence (IF), image analysis and RNA FISH we examined a series of prostatectomy specimens from patients, ± neoadvjuvant hormonal therapy (NHT) and determined their baseline immune characteristics. Methods: CD4,8,25,45,68,69,86 and Foxp3 were evaluated by IF and IFNg with RNA FISH on prostatectomy specimens from 40 patients with T1c-T3 prostate cancer; 20 control and 20 post long-term NHT. Sections were analyzed with three multiplex IF assays, triplicate images acquired with spectral imaging, digitally masked and processed with IF image analysis software. IFNg RNA transcript localization was performed on all 40 patients using published protocols. Results: There was a predominance of CD8 in both control and NHT patients with a high but variable level of CD86 and 69 across the entire cohort, reflecting T cell activation. CD68 appeared reduced in NHT, but this change was not statistically significant. Number of Treg (CD4+/CD25+/Foxp3+) cells were similar between groups; however, in NHT an increased Treg population was associated with an elevated preoperative PSA compared with controls (p<0.05). IFNg transcript activity was low in the entire cohort and limited to tumor epithelial cells. Conclusions: The prominent CD8 expression and low level of IFNg in both control and NHT groups suggest an ongoing but not overly active immune response. Multiplex IF and in situ RNA FISH are useful tools for developing a disease phenotype and provide the necessary parameters for evaluating gene-protein expression especially in pharmacodynamic studies.

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Weakness in pregnancy - expect the unexpected

Guillain-Barré syndrome (GBS) is rare in pregnancy with an incidence estimated to be between 1.2 and 1.9 cases per 100,000 people annually, and it is generally accepted that it carries a high maternal risk. Delayed diagnosis is common because the initial non-specific symptoms may mimic changes in pregnancy. GBS should be considered in any pregnant patient complaining of muscle weakness, general malaise, tingling of the fingers and respiratory discomfort. This case aims to highlight the importance of early diagnosis, allowing prompt initiation of the immunomodulatory treatments which have been shown to improve outcome alongside multidisciplinary care.

Effectiveness of rehabilitation intervention in persons with multiple sclerosis: a randomised controlled trial

OBJECTIVE

A stratified, randomised, waitlist controlled study over 12 months assessed the effectiveness of rehabilitation in persons with multiple sclerosis (MS) in an Australian community cohort.

METHODS

Patients with definite MS (n = 101) recruited from a tertiary hospital database, randomised to a treatment group (n = 49) for individualised rehabilitation programme or a control waitlist group (n = 52). Functional Independence Measure (FIM) was used to assess "activity" while the Multiple Sclerosis Impact Scale (MSIS-29) and General Health Questionnaire (GHQ-28) assessed "participation" and quality of life (QoL). Assessments were at baseline and 12 months.

RESULTS

Analysis of data from 98 patients (treatment n = 48, control n = 50) showed reduced disability in the treatment group, with statistically significant differences in post-treatment FIM motor scores for the two groups (p<0.001). There was a clinical and statistically significant improvement in FIM (motor) total scores (p<0.001), and the FIM motor domains of: transfer (p<0.001), locomotion (p<0.001), self-care (p<0.001) and the FIM cognitive subscale (p<0.016). In the treated group, 70.8% improved compared with 13% of controls. Significantly more patients in the control group deteriorated over the study period (58.7% vs 16.7%; p<0.001). There were no differences between the control and treatment group scores on the MSIS-physical (p = 0.18), MSIS-psychological (p = 0.45) or GHQ subscales.

CONCLUSION

An individualised rehabilitation programme reduces disability in persons with MS compared with no intervention. The impact of rehabilitation on QoL needs further evaluation. More information on the effectiveness of the various components of the multidisciplinary rehabilitation programmes are now needed. Australian clinical trials registry: Trials registration number: ACTRNO12605000676617.

Hypoxis hemerocallidea--not merely a cure for benign prostate hyperplasia

The use of Hypoxis hemerocallidea Fisch. and C.A. Mey. (Hypoxidaceae) extracts for ailments other than benign prostate hyperplasia (BPH) is now a reality. The whole extract, the phytosterols, as well as the major constituents it contains (hypoxoside, and its active derivative rooperol) are now finding new applications in the area of anti-oxidants, anti-inflammatories, anti-diabetics, anti-convulsants, inhibitors of drug marker substances and new evidence is presented of activity against cancerous and premalignant cancer cells. In addition, the over-the-counter (OTC) trade has undergone enormous expansion.

Influence of compression pressure from the hand access device on hand microcirculation during hand-assisted laparoscopic surgery

BACKGROUND

Hand access devices in hand-assisted laparoscopic surgery depend on compression pressure to prevent air leakage. Surgeons frequently experience hand ache during surgery. This study aimed to test whether the pressure with such a device affects the microvascular function of the hand.

METHODS

Eight healthy volunteers participated in this experimental study. The hand access device, applied to the forearm, was inflated to 0, 8, 12, and 16 mmHg in a random order, and the microvascular activity of the skin of the hand dorsum was quantified using laser Doppler and iontophoresis of increasing doses of acetylcholine (endothelial-dependent vasodilator) and sodium nitroprusside (endothelial-independent vasodilator). The end point was skin erythrocyte flux ratio as a measure of microvascular skin activity.

RESULTS

No significant differences in microvascular responses to iontophoresis of acetylcholine and sodium nitroprusside were found at the four doses used when the hand access device was inflated at different pressures. The peak values for the hand allocated to acetylcholine were 3.48 +/- 1.33, 3.42 +/- 2.33, 3.38 +/- 2.55, and 2.84 +/- 3.10 arbitrary units, and the peak values for the hand allocated to sodium nitroprusside were 2.79 +/- 1.60, 2.00 +/- 1.60, 2.30 +/- 1.50, and 2.40 +/- 1.62 arbitrary units at cuff pressures of 0, 8, 12, and 16 mmHg, respectively.

CONCLUSION

The pressure in the hand access device up to 16 mmHg does not affect the hand cutaneous microcirculation.

Improvement in systemic endothelial condition following amputation in patients with critical limb ischemia

AIM

Most patients with critical limb ischemia (CLI) have co-existing coronary heart disease, which is the main cause of their increased mortality. Peripheral ischemic tissue produces circulating toxic molecules, which may worsen endothelial function systemically and contribute to the general atherosclerotic process within the body. We looked at whether markers of endothelial function improve after amputation of the ischemic limb, when this potential source of toxins has been removed.

METHODS

We measured blood levels of vascular endothelial growth factor (VEGF), homocysteine, endothelin-1, vascular cell adhesion molecule-1, E-selectin, thrombomodulin and von Willebrand factor (vWF) in 40 patients with CLI. We also assessed peripheral microvascular function in forearm skin by measuring responses to iontophoresis of acetylcholine and sodium nitroprusside. The measurements were repeated 6 months after amputation.

RESULTS

We found abnormally high levels of endothelial products in the patients, and 6 months later VEGF and vWF had both reduced significantly from previous values (by 70% and 40%, respectively; P<0.01 in both cases).

CONCLUSION

Improvements in these two markers after amputation are consistent with the hypothesis that peripheral ischemic tissue has a systemic effect on the vascular endothelium and may contribute to the progression of coronary heart disease in patients with CLI.

Evaluation of immunoglobulin purification methods and their impact on quality and yield of antigen-specific antibodies

BACKGROUND

Antibodies are the main effectors against malaria blood-stage parasites. Evaluation of functional activities in immune sera from Phase 2a/b vaccine trials may provide invaluable information in the search for immune correlates of protection. However, the presence of anti-malarial-drugs, improper collection/storage conditions or concomitant immune responses against other pathogens can contribute to non-specific anti-parasite activities when the sera/plasma are tested in vitro. Purification of immunoglobulin is a standard approach for reducing such non-specific background activities, but the purification method itself can alter the quality and yield of recovered Ag-specific antibodies.

METHODS

To address this concern, various immunoglobulin (Ig) purification methods (protein G Sepharose, protein A/G Sepharose, polyethylene glycol and caprylic acid-ammonium sulphate precipitation) were evaluated for their impact on the quality, quantity and functional activity of purified rabbit and human Igs. The recovered Igs were analysed for yield and purity by SDS-PAGE, for quality by Ag-specific ELISAs (determining changes in titer, avidity and isotype distribution) and for functional activity by in vitro parasite growth inhibition assay (GIA).

RESULTS

This comparison demonstrated that overall polyethylene glycol purification of human serum/plasma samples and protein G Sepharose purification of rabbit sera are optimal for recovering functional Ag-specific antibodies.

CONCLUSION

Consequently, critical consideration of the purification method is required to avoid selecting non-representative populations of recovered Ig, which could influence interpretations of vaccine efficacy, or affect the search for immune correlates of protection.

Surgical treatment of chondrosarcoma of the sternum

Purpose: We reviewed all tumours of the sternum referred to The London Bone and Soft Tissue Tumour Service between 1956 and 1997 inclusive.

Patients and results: There were eight patients with this pathology, the male to female ratio was 3:1 and their mean age was 53 years. Of these patients, three are alive and disease free, one is alive with recurrence, and four have died, two of the consequences of the disease and two of unrelated causes. Surgery is the principal treatment of these tumours both for excision and subsequent reconstruction.

Discussion: Extended disease-free survival is possible with correct diagnosis, complete excision at the first operation, appropriate skeletal reconstruction, adequate skin cover and appropriate postoperative support and follow-up.

Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy

BACKGROUND

Joint replacements are common procedures and treatment of choice for those with intractable joint pain and disability arising from arthropathy of the hip or knee. Multidisciplinary rehabilitation is considered integral to the outcome of joint replacement.

OBJECTIVES

To assess the evidence for effectiveness of multidisciplinary rehabilitation on activity and participation in adults following hip or knee joint replacement for chronic arthropathy.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL up to September 2006.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared organised multidisciplinary rehabilitation with routine services following hip or knee replacement, and included outcome measures of activity and participation in accordance with the International Classification of Functioning, Health and Disability (ICF).

DATA COLLECTION AND ANALYSIS

Four authors independently extracted data and assessed methodological quality of included trials.

MAIN RESULTS

Five trials (619 participants) met the inclusion criteria; two addressed inpatient rehabilitation (261 participants) and three (358 participants) home-based settings. There were no trials addressing outpatient centre-based programmes. Pooling of data was not possible due to differences in study design and outcomes used. Methodological assessment showed all trials were of low quality. For inpatient settings early commencement of rehabilitation and clinical pathways led to more rapid attainment of functional milestones (disability) (Functional Independence Measure (FIM) transfer WMD 0.5, 95% CI 0.15, 0.85, number needed to treat to benefit (NNTB) = 6, FIM ambulation WMD 1.55 (95%CI 0.96, 2.14), NNTB = 3), shorter hospital stay, fewer post-operative complications and reduced costs in the first three to four months. Home-based multidisciplinary care improved functional gain (Oxford Hip Score (OHS) WMD at 6 months -7.00 (95%CI -10.36, -3.64), NNT = 2 and quality of life (QoL) and reduced hospital stay in the medium term (six months). No trials addressed longer-term outcomes following hip replacement only.

AUTHORS' CONCLUSIONS

Based on the heterogeneity and the low quality of the included trials that precluded pooled meta-analysis, there is silver level evidence that following hip or knee joint replacement, early multidisciplinary rehabilitation can improve outcomes at the level of activity and participation. The optimal intensity, frequency and effects of rehabilitation over a longer period and associated social costs need further study. Future research should focus on improving methodological and scientific rigour of clinical trials, and use of standardised outcome measures, so that results can be pooled for statistical analysis.

Intensive insulin therapy improves endothelial function and microvascular reactivity in young people with type 1 diabetes

AIMS/HYPOTHESIS

Macrovascular disease is an important cause of the increased morbidity and mortality rates associated with type 1 diabetes, and this vascular impairment begins in childhood. The aim of this study was to determine whether introducing intensive diabetes management [intensive insulin therapy (IIT) and 'Sweet Talk' text-messaging support] produces measurable improvements in endothelial function.

METHODS

One hundred and twenty-six patients fulfilled the eligibility criteria (type 1 diabetes for >1 year; on conventional insulin therapy (CIT); aged between 8 and 18 years), of whom 92 enrolled. Patients were randomised to group 1, CIT only (n=28); group 2, CIT and Sweet Talk (n=33); or group 3, IIT and Sweet Talk (n=31). Vascular assessments (including measures of endothelial damage, activation, dysfunction and oxidative stress) and HbA1c were performed at baseline and repeated after 12 months of the study.

RESULTS

Glycaemic control deteriorated in patients on CIT, but improved significantly in patients allocated to IIT (p=0.007). IIT was associated with significantly greater improvements in E-selectin (p<0.0001) than CIT (group 1, p=0.026 and group 2, p=0.053). Vascular responses to acetylcholine improved in patients on IIT (p=0.017), but not in patients receiving CIT. These changes were all independent of HbA1c level.

CONCLUSIONS/INTERPRETATION

IIT appears to be associated with improvements in vascular markers, independently of changes in HbA1c, suggesting that IIT may confer vascular protection in addition to improving glycaemic control.