The Relationship between inflammation and atrophy in clinically isolated syndromes suggestive of multiple sclerosis

OBJECTIVE

To examine the relationship between inflammation and brain atrophy in patients with a clinically isolated syndrome (CIS) suggestive of multiple sclerosis (MS).

METHODS

Monthly triple-dose gadolinium (Gd/DTPA)-enhanced MRI scans over 6 months were obtained in 62 consecutive CIS patients with an abnormal baseline MRI scan. Subsequently MRI was performed at months 12 and 18. Patients who developed a clinically definite MS (i. e., a second clinical episode) ended the study at the time of the relapse. For each scan, the number and volume of newly active lesions (Gd-enhancement/new or newly enlarging T2 lesion that did not enhance), and the number and volume of T2 hyperintense lesions (T2-LL) and T1-black holes (T1-LL) were calculated. The percentage of brain volume changes (PBVC) was assessed using a fully automated technique (SIENA; Structural Image Evaluation using Normalization of Atrophy).

RESULTS

Twenty-four (39%) developed clinically definite MS by month 18. Thirty-eight (61%) were relapsefree and completed the MRI follow-up. Relapse-free patients showed a progressive median increase between baseline and month 18 in T1-LL (25%, p<0.001), but not in T2-LL (8.5%, p=ns). PBVC decreased by 1.1% (p<0.001) in a time-dependent pattern (Kendall coefficient of concordance=0.85). Exploratory subgroup analyses showed a trend towards progressive decreases in brain volume in active patients (i. e., those with at least one newly active lesion during monthly MRI scanning; Spearman's R=-0.61; p<0.001), but not among inactive patients (Spearman's R=-0.10; p=0.53). Significant differences in median brain volume changes between the active and inactive patient groups were found at months 12 and 18; the difference detected at month 6 was not significant. The cumulative number and volume of new Gd-enhancing lesions developed during the 6 months of frequent MRI scanning were highly correlated with PBVC over the 18-month period (Spearman R values were 0.73 and 0.85, respectively). The strongest predictor of PBVC at 18 months was the cumulative volume of newly active lesions during frequent MRI scanning [ss=-0. 83, standard error (SE)=0.07, p<0.001].

CONCLUSIONS

This study shows that visible inflammation as detected by monthly, triple-dose Gd-enhanced MRI is an important factor in the pathogenesis of brain tissue loss in CIS patients. However, inflammation and brain atrophy do not proceed in parallel: atrophy appeared only after a delay of months following acute inflammation. Frequent MRI scanning allows for the detection of CIS patients who will develop brain atrophy in the short-term.

Risk factors for uncontrolled hypertension in Italy

To identify factors related to poor control of blood pressure in primary care, we designed a retrospective case-control analysis of clinical and demographic data recorded in the General Practitioners (GP) database. Study data were provided on a voluntary basis by 21 GPs from a practice-based network in primary care. The study included 2519 hypertensive patients enrolled between January 1 and December 31, 2000. The interventions were antihypertensive medication, and the main outcome measures were control of systolic and diastolic blood pressure (BP). The independent variables considered were: age of patient and GP; patient gender, body mass index, history of smoking, diabetes mellitus, or cholesterol tests; family history of hypertension; previous visits for cardiologic, nephrologic, or vascular surgery evaluation; prior hospitalizations for myocardial infarction or heart failure, and number of admissions for surgery; length of patient follow-up, type of antihypertensive medication, mean daily dosage, adherence to the drug regimen, and number of other medications currently being taken by the patient. Blood pressure was uncontrolled (>140/90 mmHg) in 1525 (60%) of the 2519 hypertensive patients enrolled. The presence of diabetes mellitus, increasing patient age, and increasing GP age significantly increased the risk of uncontrolled BP. Factors significantly associated with a reduced risk of uncontrolled BP were the number of other medications currently being taken by the patient and a prior history of MI. We conclude that the failure of antihypertensive medication to adequately control BP is determined by both the patient's characteristics and factors related to the patient-doctor relationship. Successful treatment of hypertension requires patient adherence to the regimen that has been agreed on by the patient and the physician.

Cost-Analysis of Relapsing-Remitting Multiple Sclerosis in Italy after the???Introduction of New Disease-Modifying Agents

BACKGROUND AND OBJECTIVE

During the last decade, several agents have proven to be effective in the treatment of relapsing-remitting multiple sclerosis (RRMS), for example interferon-beta (IFNβ) and glatiramer acetate. This study aimed to perform a cost-analysis of the treatment of patients with RRMS in Italy after the introduction of these new agents.

STUDY DESIGN

This was a retrospective observational study with systematic patient inclusion.

METHODS AND RESULTS

Data gathered from 630 patients with confirmed RRMS over a 2-year period were evaluated. Overall, the direct cost over 2 years reached €11 073 100 thousand, corresponding to a per-patient cost of €17 576 (year of costing, 2001). The cost of disease-modifying agents represented approximately 77% of the total expenditure. IFNβ accounted for 94% of the expense of disease-modifying agents, corresponding to a 2-year cost per patient of €20 223. Although glatiramer acetate and immunoglobulins were also associated with a high level of expense, these were prescribed in only 3.8% and 1.1% of patients, respectively. Using regression analyses, IFNβ therapy, disability, number of days spent in hospital per year and the frequency of magnetic resonance imaging procedures were the main predictors of total costs.

CONCLUSION

Based on the results of this study, IFNβ treatment considerably modified the management of RRMS and was associated with a rise in cost of treatment per patient.

Pulmonary infection with microsporidia after allogeneic bone marrow transplantation

Microsporidia are obligate, intracellular protozoal parasites that can be pathogenic in immunocompromised individuals. The majority of cases of microsporidiosis have been documented in patients with HIV, and only a few case reports exist of infection in solid organ transplant patients. We report the first case of pulmonary microsporidial infection in an allogeneic bone marrow transplant recipient in the US. The patient was a recipient of a T-cell-depleted graft who succumbed to complications from respiratory failure 63 days post transplant. The diagnosis was made post mortem by electron microscopy and confirmed with PCR. Although rare, microsporidial infection should be considered in the differential diagnosis of unexplained pulmonary infection in bone marrow transplant patients.

Studies on the Safety and Immunogenicity of the South African Bluetongue Virus Serotype 2 Monovalent Vaccine: Specific Detection of the Vaccine Strain Genome by RT-PCR

In order to study the safety and the immunogenicity of the South African vaccine against the serotype 2 bluetongue virus, two groups of seven sheep were vaccinated with the vaccine used in the French island of Corsica. Vaccinated and non-vaccinated sheep were observed clinically and their rectal temperatures were recorded daily. The serological response in vaccinated animals confirmed the immunogenicity of the vaccine. Post-vaccinal viraemia was investigated and the vaccine genome was detected by reverse transcription polymerase chain reaction (RT-PCR). No viraemia was observed at post-vaccination days 4, 7 and 11 but the vaccine strain of virus was detected by RT-PCR throughout the experiment. The thermostability of the vaccine was also evaluated. The vaccine titre strongly decreased at temperatures higher than 35 degrees C.

Introducing colposcopy and vulvovaginoscopy as routine examinations for victims of sexual assault

Victims of sexual assault require appropriate care, follow-up and information regarding their legal rights. Clinicians are faced with the challenging responsibility of identifying victims and providing effective interventive and preventive counselling. The most pressing medical task is to confirm the assault and to undertake correct documentation and exhibition of biological traces. Performing colposcopy and vulvovaginoscopy does not allow us to diagnose a sexual assault trauma, but it can help us to identify those microscopic lesions (due to the enhanced visualization and the higher resolution under which the genital areas are examined) that may not be seen during a normal clinical examination. The colposcopic and vulvovaginoscopic examination starts from the vulvar region looking for superficial lacerations and ecchymosis; the labia majora and minor are examined scrupulously, then the posterior forchette, the perineum and the hymen where it is possible to report microulcerations, contusions and even possible scars due to a precedent defloration. Recent advances in clinical forensic medicine show that trained examiners using colposcopy obtain evidence of genital trauma in 87% to 92% of rape victims. Colposcopy and vulvovaginoscopy must be performed within 48 hours from the sexual assault, because most of the lesions heal rapidly. Colposcopy and vulvovaginoscopy may be seen as a stressful invasion of a woman who is already vulnerable and at risk of the rape trauma syndrome. Prior information about colposcopy may reduce the level of anxiety experienced by many women undergoing this procedure. Incorporating colposcopy and vulvovaginoscopy into the routine assessment of sexual assault victims could be a valid way of identifying genital injuries; moreover the medical report will be more detailed and precise.

Pharmacoutilization and costs of osteoarthritis: changes induced by the introduction of a cyclooxygenase-2 inhibitor into clinical practice

OBJECTIVE

To establish whether the introduction of a cyclooxygenase-2 inhibitor has led to changes in pharmacoutilization in the treatment of osteoarthritis (OA) in clinical practice.

METHODS

Administrative and general practice databases were cross-linked to analyse the use of non-steroidal anti-inflammatory drugs (NSAIDs) and gastroprotective agents (GPAs) before and after the introduction of rofecoxib. Costs of treatment and costs of hospitalization for gastrointestinal events were also considered.

RESULTS

A total of 3090 patients were evaluated. A significant reduction in the use of GPAs in the rofecoxib group was observed, corresponding to reductions of 64 and 59.7% compared to NSAIDs among patients in incident and prevalent cases respectively. The weighted mean daily cost of therapy with rofecoxib in incident cases was 1.88 euro, 7.4% lower than that of NSAIDs (2.03), and in prevalent cases it was 1.87 euro, 28.1% higher than that of NSAIDs (1.46). Although the rate of hospitalization was similar, there was an additional daily cost per patient of 186.6 for patients being treated with NSAIDs and 21.6 euro for those being treated with rofecoxib.

CONCLUSIONS

The cyclooxygenase-2 inhibitor rofecoxib determined substantial changes in the pharmacoutilization and costs of OA.

TNF increases camptothecin-induced apoptosis by inhibition of NF-kappaB

rHuTNF potentiates CPT-cytotoxicity in human ovarian A2780 cells. In this study, we examined the role of NF-kappaB in this potentiation. A pulse-labelled DNA study indicated that the combination CPT+TNF had little effect on the rate of DNA elongation at 6 h after drug removal, whereas CPT alone produced a complete inhibition for at least 6 h after drug removal. Flow cytometry analyses showed that CPT+TNF arrested cells in the G2-M phase, whereas CPT blocked cells in S phase. Looking at the persistence of the NF-kappaB complexes in cells, it appeared that they were still present at 24 h in TNF-treated cells. In contrast, in CPT-treated cells they persisted for 6 h. In CPT+TNF-treated cells, the NF-kappaB complexes disappeared quickly and became undetectable at 6 h. The induction of apoptosis was detected only in the CPT+TNF treated cells (using flow cytometry, a filter binding assay and ApopTag staining). These findings show that TNF, in combination with CPT, reduces the time that NF-kappaB complexes persist in cells likely resulting in the induction of apoptosis.

Bayesian cost-effectiveness analysis based on the persistence with antihypertensive treatment

An observational study was performed to compare five compounds as initial therapy to evaluate the persistence with antihypertensive treatment and drug cost. Over a 1-year follow-up period on the entire population (approximately 360,000 residents) of the Ravenna Local Health Unit. The presence of five major antihypertensive agents between January 1st, and December 31st, 1997 was investigated. There were 4614 patients enrolled. The annual average cost of treatment ranged between euro 44.27 (95% confidence interval, 38.18-52.06) for patients started on atenolol to euro175.65 (150.37-205.10) for those started on losartan. Patients who began losartan showed a higher posterior probability of an effective antihypertensive treatment. On average, these patients turned to produce cost-effective treatment with an average probability of 0.70.

Impact of known and unknown diabetes on in-hospital mortality from ischemic stroke

BACKGROUND AND AIMS

The effect of known diabetes on in-hospital mortality from ischemic stroke is still debated whereas the role of unknown diabetes is virtually unexplored. This study evaluates the impact of known and unknown diabetes on in-hospital mortality from ischemic stroke.

METHODS AND RESULTS

We have retrospectively evaluated the records of 286 consecutive cases of ischemic stroke hospitalized from January 1998 to December 2000 at the Department of Internal Medicine of the General Hospital located in the western area of Naples. Fasting plasma glucose level < 7 mmol/L identified non diabetic subjects. Known diabetes mellitus was diagnosed by history of diabetes and/or hypoglycemic therapy, unknown diabetes was defined as a random plasma glucose level > or = 11 mmol/L and/or in-hospital fasting glucose > or = 7 mmol/L on two or more occasions. Severity of stroke was defined using the Canadian Neurological Score (CNS). According to these criteria, 144 subjects were non diabetics, 99 had known diabetes and 43 had unknown diabetes. Subjects with known diabetes showed a higher prevalence of female sex, hypertension and increased triglyceride levels as compared with non diabetic subjects (p < 0.01). Subjects with unknown diabetes were older (p < 0.01) and showed a more severe CNS (3.4 +/- 2.7) than non diabetic and diabetic subjects (5.8 +/- 2.6 and 5.8 +/- 2.6, respectively; p < 0.01). In-hospital mortality was significantly higher in the unknown diabetic group (44%) as compared with known diabetic (15%) and non diabetic groups (12%) (p < 0.001). This finding was independent of neurological deficit, age, atrial fibrillation and history of previous stroke.

CONCLUSIONS

Our study shows that unknown diabetes, more than known diabetes, is a strong risk factor for in-hospital mortality in subjects with acute ischemic stroke.

Synthesis of paucidisperse poly(gamma-benzyl-alpha,L-glutamate) oligomers and star polymers with rigid arms

The synthesis of highly uniform gamma-benzyl-alpha,L-glutamate (BLG) oligomers via a convergent solution phase approach is reported. BLG oligomers were produced with designed lengths of 4, 8, 12, and 16 as a first step to production of BLG-4-mer and BLG-8-mer rod stars. The star oligomers were purified by size-exclusion chromatography and reversed phase HPLC, and characterized by MALDI-TOF mass spectrometry and reversed phase HPLC. These star-shaped BLG oligomers could be used as initiators for growing larger stars.

Interferon alpha in the treatment of chronic hepatitis C in children: a meta-analysis [correction of metanalysis]

Children with chronic hepatitis C may be ideal candidates for treatment with interferon alpha (IFNalpha) as they have liver disease at an early stage. However, adverse drug reactions need to be considered. The aim of this study was to conduct a systematic review of literature on interferon therapy of chronic hepatitis C in children, and to perform a meta-analysis of pooled data. A computerized search gave 18 articles on IFNalpha therapy in children with chronic hepatitis C; after exclusion of uncontrolled trials and of trials including patients with comorbidities, data from two studies could be pooled (48 patients). The outcomes assessed were biochemical, defined as normalization of alanine transaminase, and virologic, defined as HCV-RNA loss, both sustained at 24 months after enrollment. Results of the studies were homogenous. Risk difference was 37% (95%CI: 12.9-61) in favour of IFNalpha treated children for sustained biochemical response, and 36.8% (95%CI: 14.3-59.3) in favour of treated children for sustained HCV clearance, respectively. The differences were highly significant (P = 0.007 and P = 0.004, respectively). The histological end-point, as well as side-effects, could not be analysed, due to lack of data. This review identifies the poor methodology of the majority of the published trials. The study provides support for the efficacy of IFNalpha in improving both biochemical and virologic outcomes in chronic hepatitis C in children, but evidence is confined to these surrogate end-points.