Multidisciplinary rehabilitation for adults with multiple sclerosis

BACKGROUND

Multidisciplinary rehabilitation (MD) is an important component of symptomatic and supportive treatment for Multiple sclerosis (MS), but evidence base for its effectiveness is yet to be established.

OBJECTIVES

To assess the effectiveness of organized MD rehabilitation in adults with MS. To explore rehabilitation approaches that are effective in different settings and the outcomes that are affected.

SEARCH STRATEGY

The sources used included: Cochrane Central Register of Controlled Trials "CENTRAL", MEDLINE (1966- 2005), CINAHL (1982- 2005), PEDro (1990- 2005), EMBASE (1988- 2005), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register (NRR).

SELECTION CRITERIA

Randomized and controlled clinical trials that compared MD rehabilitation with routinely available local services or lower levels of intervention; or trials comparing interventions in different settings or at different levels of intensity.

DATA COLLECTION AND ANALYSIS

Three reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis based on methodological quality was performed. Trials were grouped in terms of setting and type of rehabilitation and duration of patient follow up.

MAIN RESULTS

Eight trials (7 RCTs; 1 CCT) (747 participants and 73 caregivers) were identified. Seven RCTs scored well and one CCT scored poorly on the methodological quality assessment. There was 'strong evidence' that despite no change in the level of impairment, inpatient MD rehabilitation can produce short-term gains at the levels of activity (disability) and participation for patients with MS. For outpatient and home-based rehabilitation programmes there was 'limited evidence' for short-term improvements in symptoms and disability with high intensity programmes, which translated into improvement in participation and quality of life. For low intensity programmes conducted over a longer period there was strong evidence for longer-term gains in quality of life; and also limited evidence for benefits to carers. Although some studies reported potential for cost-savings, there is no convincing evidence regarding the long-term cost-effectiveness of these programmes. It was not possible to suggest best 'dose' of therapy or supremacy of one therapy over another. This review highlights the limitations of RCTs in rehabilitation settings and need for better designed randomized and multiple centre trials.

AUTHORS' CONCLUSIONS

MD rehabilitation programmes do not change the level of impairment, but can improve the experience of people with MS in terms of activity and participation. Regular evaluation and assessment of these persons for rehabilitation is recommended. Further research into appropriate outcome measures, optimal intensity, frequency, cost and effectiveness of rehabilitation therapy over a longer time period is needed. Future research in rehabilitation should focus on improving methodological and scientific rigour of clinical trials.

Chimerism monitoring following allogeneic hematopoietic stem cell transplantation

Information regarding the chimeric status of hematopoietic stem cell transplantation (HSCT) recipients is of great significance when comparing different conditioning and prophylactic therapies. In recent years, short tandem repeats/variable number tandem repeats (STRs/VNTRs) have emerged as the best tool for chimerism monitoring. However, the polymorphisms of STR/VNTR markers vary within and between ethnic groups. The issue is further complicated in a heterogeneous population such as occurs in the Indian subcontinent. In the present study, we attempted to devise a robust scheme to identify a set of polymorphic STRs/VNTRs most suitable for chimerism evaluation in north Indian HCST recipients. At first, we did genotyping of 11 STR and one VNTR in 1000 randomly chosen north Indian individuals to quantify different diversity parameters. Resulting data indicated that ApoB3'HVR, FES, VWA, D3S1358 and D16S310 were most polymorphic loci with the average heterozygosity being 0.756+/-0.17. Furthermore, all markers were genotyped in 77 HLA-matched donor-recipient pairs to evaluate the informativeness in differentiating donor's and recipient's cells. A panel of seven markers (ApoB3HVR-D3S1358-HUM-THO1-VWF-1-D16S310-FES-VWA) differentiated 98.70% of donor-recipient pairs. This set of markers also successfully monitored the graft status in 14 HSCT cases during multiple time points following HSCT. The results were compared to the commercially available AmpF/STR SGM Plus multiplex PCR kit (Applied Biosystems, Foster City, CA, USA). Our findings established that the panel of seven markers we identified was more cost-effective and informative.

Mechanisms influencing the vasoactive effects of lidocaine in human skin

The vasodilator properties of lidocaine are believed to be due mainly to the inhibition of action potentials via sodium channel blocking in vasoconstrictor sympathetic nerves. However, mechanisms involving the vascular endothelium may also play a role, and in this study we investigated the potential influences of nitric oxide release, the cyclo-oxygenase pathway and the beta-adrenoceptors of vascular smooth muscle. Laser Doppler imaging was used to measure microvascular blood flow responses to intradermal injection of lidocaine 2%, with or without the addition of preservatives, in eight healthy, male volunteers. Co-injection of the nitric-oxide-synthase inhibitor Nomega-nitro-L-arginine methyl ester caused a 60% reduction in the response after about 20 min, and this reduction was enhanced with the lidocaine solution containing the preservatives methylhydroxybenzoate and propylhydroxybenzoate. No reduction in response was seen after blocking the cyclo-oxygenase or beta-adrenoceptor pathways. Nitric oxide release contributes to the vasoactivity of lidocaine in human skin.

Measurement and significance of 3-nitrotyrosine in systemic lupus erythematosus

Nitration of free and protein associated tyrosine represents, in vivo, a mechanism that can severely compromise the cell function. The detection of 3-nitrotyrosine (3-NT) in pathological tissues is suggestive of the occurrence of nitrating pathways and has been identified as a marker of inflammation and a stable end product of increased reactive nitrogen intermediate production. Protein nitration occurs in many disease conditions including systemic lupus erythematosus (SLE). In this study we show that the level of both free and protein bound 3-NT, which is produced by reactive nitrogen species (RNS)-dependent oxidative damage, is elevated in patients with SLE and that there is a possible role of RNS-modified epitopes in the aetiology of the disease. Commercially available poly L-tyrosine was exposed to nitrating species, inducing nitration in tyrosine residues. Immunoglobulin-G (IgG) purified on Protein-A-Sepharose matrix from 24 SLE patients was studied for their recognition of native and nitrated poly L-tyrosine by direct binding and competition enzyme-linked immunosorbent assay (ELISA). The formation of immune complex between SLE IgG and nitrated poly L-tyrosine was visualized by gel retardation assay. Free 3-NT in patients' sera was detected and quantitated by high performance liquid chromatography whereas protein-bound 3-NT was analysed by Western blotting and the concentration was calculated by sandwich ELISA. The concentration of free 3-NT was found to be 1.4 +/- 0.09 microm whereas the concentration of protein bound 3-NT was 96.52 +/- 21.12 microm nitrated bovine serum albumin equivalents/mg protein, which was significantly higher when compared with healthy controls. Elevated level of 3-NT was observed in SLE patients using two different techniques, when compared with healthy subjects confirms the overproduction of RNS in the pathogenesis of human SLE.

Local delivery of angiotensin receptor blocker into the kidney ameliorates progression of experimental glomerulonephritis

Intrarenally synthesized angiotensin II (Ang II) may be involved in the progression of glomerulonephritis, leading to irreversible glomerulosclerosis. There is increasing evidence that systemic angiotensin receptor blocker (ARB) treatment has beneficial effect on the prognosis of progressive glomerulonephritis and diabetic nephropathy. However, the cellular and molecular mechanisms behind this therapeutic effect of ARB remain unclear. In this study, we used a novel strategy of local ARB delivery via type-1 collagen sponge, to treat progressive glomerulonephritis that would result in irreversible glomerulosclerosis in our previously established rat model. At days 9 and 14 after disease induction, mild proteinuria, 20.7+/-4.7 and 10+/-1.3 mg/day, was found. Local ARB treatment reduced proteinuria significantly to 3.19+/-3.2 and 5.25+/-0.95 mg/day (P < 0.01), respectively. Scoring of glomerular matrix expansion and sclerotic index revealed that local ARB treatment significantly ameliorated glomerular pathology. Ang II type 1 receptor mRNA expression was remarkably enhanced in the Ang II group and ARB treatment reversed this effect at 14 days. Local delivery of ARB significantly improved glomerular blood flow levels, compared to the untreated disease control group, from 710+/-18.25 to 859.44+/-22.86 microm/s, respectively. Local delivery of ARB into the kidney affected local RAS and thus improved the renal injury and function in the potentially progressive glomerulosclerosis of rat model.

Effects of poor glucose handling on arterial stiffness and left ventricular mass in normal children

AIM

Cardiovascular risk factors can be present in children and young adults. We previously found abnormal microvascular function in children who had glucose intolerance and insulin resistance. The aim of the present study was to investigate whether they also have abnormalities in left ventricular mass (LVM) and arterial stiffness.

METHODS

We measured heart dimensions and LVM using echocardiography, and arterial stiffness using pulse wave analysis in 23 children with good glucose handling (postfeeding glucose: 3.9 to 5 mmol/L) and 21 with poor glucose handling (7.7 to 11.4 mmol/L).

RESULTS

The time to pulse reflection was slightly shorter in the poorer glucose handlers (mean+/-SD: 143+/-10 vs 153+/-20 ms, P=0.04), suggestive of increased arterial stiffness. Also in this group, there were significant relationships between intraventricular septal thickness, blood pressure and body mass index, but not in the normal glucose handlers.

CONCLUSIONS

We have found that normal children who are in the lowest quintile of glucose tolerance in comparison with their peers are exhibiting the first signs of arterial stiffening. In addition, we have seen the beginnings of a relationship between blood pressure, body mass index and left ventricular enlargement in this group. While these changes may not yet be clinically significant, their emergence might be further evidence of early predisposition to cardiovascular disease.

Design, synthesis and in vivo anticonvulsant screening in mice of Novel phenylacetamides

A set of seven novel N-substituted 2-anilinophenylacetamides were designed by pharmacophore generation and using flexible alignment module of MOE software. The novel molecules were synthesized and screened for anticonvulsant activity in Swiss albino mice by MES and ScPTZ induced seizure tests. Test compounds were found to be potent in MES test. Compounds 12 and 14 were found to be more potent with ED(50) values 24.0 and 8.0 mg kg(-1), respectively, and their activity was comparable to standard drugs (Phenytoin, Carbamazepine). Test compounds did not show significant activity in ScPTZ test. Compounds 12 and 14 also exhibited higher protective indices (20.3 and 87.5, respectively) when assessed for neurotoxicity by rotarod test as compared to the standards.

Angiotensin converting enzyme gene polymorphism in Indian children with steroid sensitive nephrotic syndrome

CONTEXT

Nephrotic syndrome is one of the commonest renal problem encountered in children. It is difficult to predict at onset, the clinical course in terms of steroid responsiveness or resistance. Angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism has been studied as a predictor of clinical course in common multi-factorial diseases including focal segmental glomerulosclerosis. There is no study available from our country till date to find out any correlation of the steroid response in idiopathic nephrotic syndrome and ACE gene polymorphism.

AIM

To study distribution and correlation of ACE gene I/D polymorphism in idiopathic steroid sensitive nephrotic syndrome.

SETTINGS & DESIGN

Case-control retrospective study.

SUBJECTS & METHODS

We studied ACE gene polymorphism in 90 consecutive patients (82% males, 18% females) with steroid sensitive idiopathic nephrotic syndrome and 300 normal controls (NC).

STATISTICAL ANALYSIS

Chi-square test and Fisher's exact test (for cases with insufficient expected cell frequencies).

RESULTS

The mean age of onset was 5.3 +/- 4 years. Steroid sensitive (SS) patients showed II (SS-48%, NC-26%) genotype was more frequent than normal controls (p=0.002). There was no significant difference in genotype frequencies among steroid SS subgroups.

CONCLUSIONS

In our study II genotype was more frequent in steroid sensitive nephrotic syndrome children in comparison to normal controls. Further functional studies with large number of children are required to investigate the role of II genotype in steroid sensitive nephrotic syndrome. Comparison of the genotypic frequency with steroid resistant patients may provide information, which might be useful in clinical practice.

Endothelin-1 levels predict 3-year survival in patients who have amputation for critical leg ischaemia

BACKGROUND

Most patients with critical leg ischaemia (CLI) have co-existing coronary heart disease, which is the main cause of their increased mortality rate. The aim of this study was to investigate whether any markers of endothelial function could predict death in these patients.

METHODS

In a cohort of 39 patients with CLI who were scheduled for lower-limb amputation, blood levels of vascular endothelial growth factor, homocysteine, endothelin (ET) 1, von Willebrand factor and vascular cell adhesion molecule 1 were measured, as well as forearm vascular responses to the endothelium-dependent vasodilator acetylcholine.

RESULTS

Levels of ET-1 were significantly higher in patients who subsequently died within 3 years than in those who were still alive (P = 0.002) and Cox proportional hazards regression analysis demonstrated that ET-1 was an independent predictor of all-cause mortality:hazard ratio 3.53 (95 per cent confidence interval (c.i.) 1.29 to 9.70; P = 0.007) and cardiovascular mortality:hazard ratio 4.15 (95 per cent c.i. 1.30 to 13.23); P = 0.014.

CONCLUSION

ET-1 was an independent predictor of death in these patients with CLI.

Pilot study of the effects of local pressure on microvascular function in the diabetic foot

AIM

The aim of the study was to determine whether areas of the diabetic foot that experience high pressures during normal activity also demonstrate reductions in cutaneous microvascular flow and/or endothelial function.

METHODS

Sixteen patients with diabetes mellitus and eight healthy, age-matched control subjects were recruited. Maps of dynamic pressure on the plantar aspect of both feet were recorded during a normal gait cycle, and the skin microvascular blood flow response to the endothelium-dependent vasodilator acetylcholine was assessed at the sites of highest and lowest plantar pressure over the metatarsal heads.

RESULTS

Patients with diabetes had higher plantar pressures than control subjects (P = 0.002), but there were no significant differences in basal skin blood flow or acetylcholine response between the groups. In the patients, baseline flow was increased (P = 0.041) but the acetylcholine response reduced (P = 0.03) at the high-pressure compared with the low-pressure site; this was most apparent in those who were particularly at risk of ulceration due to high plantar pressures.

CONCLUSIONS

Chronically raised plantar pressure in the diabetic foot is associated with increased basal skin blood flow, compared with lower pressure areas on the same foot. Further work is required to determine whether, and under what conditions, this additional hyperaemia is protective or maladaptive. In addition, high-pressure areas have a reduced responsiveness to an endothelium-dependent vasodilator, although the clinical significance of these changes is not clear.

Angiotensin converting enzyme gene polymorphism in Indian children with steroid sensitive nephrotic syndrome

CONTEXT

Nephrotic syndrome is one of the commonest renal problem encountered in children. It is difficult to predict at onset, the clinical course in terms of steroid responsiveness or resistance. Angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism has been studied as a predictor of clinical course in common multi-factorial diseases including focal segmental glomerulosclerosis. There is no study available from our country till date to find out any correlation of the steroid response in idiopathic nephrotic syndrome and ACE gene polymorphism.

AIM

To study distribution and correlation of ACE gene I/D polymorphism in idiopathic steroid sensitive nephrotic syndrome.

SETTINGS & DESIGN

Case-control retrospective study.

SUBJECTS & METHODS

We studied ACE gene polymorphism in 90 consecutive patients (82% males, 18% females) with steroid sensitive idiopathic nephrotic syndrome and 300 normal controls (NC).

STATISTICAL ANALYSIS

Chi-square test and Fisher's exact test (for cases with insufficient expected cell frequencies).

RESULTS

The mean age of onset was 5.3 +/- 4 years. Steroid sensitive (SS) patients showed II (SS-48%, NC-26%) genotype was more frequent than normal controls (p=0.002). There was no significant difference in genotype frequencies among steroid SS subgroups.

CONCLUSIONS

In our study II genotype was more frequent in steroid sensitive nephrotic syndrome children in comparison to normal controls. Further functional studies with large number of children are required to investigate the role of II genotype in steroid sensitive nephrotic syndrome. Comparison of the genotypic frequency with steroid resistant patients may provide information, which might be useful in clinical practice.

Enhanced recognition of hydroxyl radical modified plasmid DNA by circulating cancer antibodies

Reactive oxygen species have been implicated in various human diseases which are also responsible for the elimination of invading pathogens. In disease state and inflammatory responses, the excess of these radicals damage cellular macromolecules. DNA is susceptible to attacks by OH-induced damage. Oxidative DNA damage is an important factor in mutagenesis and carcinogenesis. In the present study, purified plasmid Bluescript DNA was modified by hydroxyl radical. Modifications incurred in DNA were characterized by physico-chemical techniques. Sera from patients of cancer were studied for their binding to native and hydroxyl radical modified plasmid DNA. Direct binding ELISA and competition binding results indicated that autoantibodies in cancer showed higher recognition to ROS-plasmid DNA as compared to the native form. Retarded mobility of the immune complex formation between IgG isolated from cancer sera using native and ROS-plasmid DNA as antigens reiterated preferential recognition of modified plasmid DNA by cancer autoantibodies. Therefore, it can be concluded that circulating autoantibodies in cancer sera bind preferentially to ROS-plasmid DNA as compared to native polymer. The data presented in the present communication suggest a role of ROS in the etiology of cancer.