[NeuroCogFX--a computer-based neuropsychological assessment battery for the follow-up examination of neurological patients]

Many neurological therapeutic trials require a longitudinal assessment of cognitive functions. An ideal instrument for that purpose should be in accordance to the criteria of classical testing theory and, furthermore, it should be repeatable and economic in administration and interpretation. We developed NeuroCogFX, a computerized assessment battery, according to these criteria. NeuroCogFX comprises subtests for short term memory, working memory, psychomotor speed, selective attention, verbal and figural memory and verbal fluency (mean duration: 25 minutes). Age-related normative data was obtained from 244 subjects without history of neurological or psychiatric disease (age range 16 - 75 years). Forty-two subjects were re-tested after an average of 8 weeks (range: 6 - 10 weeks) in order to assess retest reliability and training effects. Retest-reliabilities were middle-sized in all but one subtest, ranging from r (12) = 0.5 to r (12) = 0.7 (2-back Test: r (12) = 0.37). For construct validation NeuroCogFX was administered in addition to a comprehensive neuropsychological assessment battery in a group of 40 healthy subjects and in 42 patients with chronic epilepsy. The test allows a valid assessment of short-term memory, reaction speed, memory and verbal fluency. NeuroCogFX is an economic, sufficiently reliable and valid instrument for the neuropsychological follow-up examination in single patients and study groups which can be administered if a comprehensive neuropsychological assessment is unavailable.

High intake of milk, but not meat, decreases bone turnover in prepubertal boys after 7 days

OBJECTIVE

To compare the short-term effect of a high milk and a high meat intake, identical in protein amount, on bone turnover during prepuberty.

SETTING

A University department.

DESIGN AND SUBJECTS

From 28, randomly recruited, 8-year-old boys, first 14 were assigned to the milk group and next 14 to the meat group. In each group, 12 boys finished the dietary intervention.

INTERVENTION

Milk (1.5 l/day) and meat (250 g/d), both containing approximately 53 g of protein, were given together with the habitual diet for 7 days. At baseline and day-7, serum osteocalcin (s-OC), bone-specific alkaline phosphatase (s-BAP) and C-terminal telopeptides of type I collagen (s-CTX) were measured (immunoassay) and dietary intake was estimated (a 3-day weighted food record).

RESULTS

Baseline s-OC, s-BAP and s-CTX were not significantly different between the groups. After 7 days, the average protein intake increased in both groups by 47.5 g; the milk group had higher (P<0.0001) calcium intake; s-OC and s-CTX decreased (P< or =0.04) in the milk group (-30.9%; -18.7%, respectively) compared with the meat group (+6.4%; -1.0%, respectively) and s-BAP decreased (P=0.06) both in the milk (-3.9%) and the meat group (-7.5%).

CONCLUSIONS

At the equal protein intake, milk, but not meat, decreased bone turnover in prepubertal boys after 7 days. This effect was probably due to some milk-derived compounds, rather than to the total protein intake. Future studies should elucidate the mechanism(s) of milk-related decline of bone turnover and its relevance for peak bone mass during growth.

SPONSORSHIP

University PhD scholarships.

High intakes of milk, but not meat, increase s-insulin and insulin resistance in 8-year-old boys

OBJECTIVE

Our objective was to examine if a high animal protein intake from milk or meat increased s-insulin and insulin resistance in healthy, prepubertal children. A high animal protein intake results in higher serum branched chain amino acids (BCAA; leucine, isoleucine and valine) concentrations, which are suggested to stimulate insulin secretion. Furthermore, milk possesses some postprandial insulinotrophic effect that is not related to its carbohydrate content.

DESIGN

A total of 24 8-y-old boys were asked to take 53 g protein as milk or meat daily. At baseline and after 7 days, diet was registered, and insulin, glucose, and amino acids were determined. Insulin resistance and beta cell function were calculated with the homeostasis model assessment.

RESULTS

Protein intake increased by 61 and 54% in the milk- and meat-group, respectively. In the milk-group, fasting s-insulin concentrations doubled, which caused the insulin resistance to increase similarly. In the meat-group, there was no increase in insulin and insulin resistance. As the BCAAs increased similarly in both groups, stimulation of insulin secretion through BCAAs is not supported.

CONCLUSIONS

Our results indicate that a short-term high milk, but not meat, intake increased insulin secretion and resistance. The long-term consequences of this are unknown. The effect of high protein intakes from different sources on glucose-insulin metabolism needs further studying.

High intakes of skimmed milk, but not meat, increase serum IGF-I and IGFBP-3 in eight-year-old boys

OBJECTIVE

To examine whether a high protein intake (PI) from either milk or meat, at a level often seen in late infancy, could increase s-IGF-I and s-IGF-I/s-IGFBP-3 in healthy, prepubertal children. IGF-I levels are positively associated with growth velocity in children and some studies suggest that a high animal PI can stimulate growth. During protein deprivation IGF-I decrease, but it is unknown whether a high PI can increase s-IGF-I in well-nourished children.

DESIGN

In all, 24 8-y-old boys were asked to take either 1.5 l of skimmed milk (n = 12) or the same amount of protein as 250 g low fat meat (n = 12) daily for 7 days. The remaining diet they could choose freely. At baseline and after 7 days, anthropometrical variables were measured, diet was registered (3-day weighed records), and s-IGF-I and s-IGFBP-3 (RIA) were determined after fast.

RESULTS

PI increased by 61% in the milk group to 4.0 g/kg/day (P < 0.0001) and by 54% in the meat group to 3.8 g/kg/day (P = 0.001). The high milk intake increased s-IGF-I by 19% (P = 0.001) and s-IGF-I/s-IGFBP-3 by 13% (P < 0.0001). There were no increases in the meat group.

CONCLUSIONS

High intake of milk and not meat, increased concentrations of s-IGF-I and s-IGF-I/s-IGFBP-3 significantly. Compounds in milk and not a high PI as such seem to stimulate IGF-I. This might explain the positive effect of milk intake on growth seen in some studies.

Memory alterations during acute high-intensity vagus nerve stimulation

Left cervical vagus nerve stimulation (VNS) is an accepted add-on treatment for pharmacoresistant epilepsy. However, it also allows the investigation of the effects of peripheral nerve stimulation on central nervous functions. The impact of 4.5 min high intensity VNS (>1 mA) on material-specific memory and decision times was evaluated in an experimental 'box car' design in 11 patients with pharmacoresistant epilepsy. Results indicate reversible deterioration of figural but not verbal memory and a trend of accelerated decision times during VNS. Thus, further support of cognitive effects of VNS is provided. There are indications of a major projection of VNS to activating brain structures of and the right hemisphere. Significant cognitive side effects in clinical application are unlikely because of the reversibility of the effect and differences between experimental and therapeutic stimulation conditions. However, since the effectors and the direction of the cognitive effects of VNS seem to depend strongly on stimulation conditions, we recommend future experimental research covering a larger range of stimulation conditions.

Vagus nerve stimulation: clinical experience in a large patient series

During the last decade, intermittent electrical stimulation of the left cervical vagus nerve was established as a new add-on treatment of drug-resistant seizures. Particularly in Europe, the acceptance of vagus nerve stimulation (VNS) was tentative in the beginning because of unknown mechanisms of action. We report the outcome in a sample of 95 adult patients with drug-resistant seizures who have received implants since 1998. The last available follow-up data are included. Unavoidable medication changes (e.g., intoxication) were accepted to examine VNS under usual clinical conditions. Median percentage of reduction in seizure frequency as compared to baseline was 30%. The seizure responder rate (> or =50% reduction) was 45%. Four patients experienced total release from seizures. Adverse effects were mild in general. Seizure outcome was positively correlated with VNS duration. No potential clinical factor (e.g., syndrome, cause, or lesion) could be identified as an indicator of favorable outcome. Patients with on stimulation-on periods of 30 seconds (standard cycle) had a better outcome than patients with stimulation-on periods of 7 seconds (rapid cycle). During an embedded, randomized, controlled trial, no evidence was found for a differential outcome of initial standard cycle versus initial rapid cycle stimulation conditions. Taking into account the good cost-benefit ratio as well as positive effects on well-being, VNS has to be considered an appropriate strategy for the add-on treatment of drug-resistant seizures, particularly in cases not suitable for epilepsy surgery.

A novel multilocus genotyping assay to identify genetic predictors of stroke in sickle cell anaemia

We describe a novel multilocus genotyping assay permitting simultaneous identification of 60 candidate markers for stroke in sickle cell anaemia (SCA). Based on cerebral magnetic resonance imaging (MRI), 69 patients were divided into stroke and control groups. The variant allele, CBS 278thr, showed protection from stroke, whereas the apoE3 allele showed a trend towards association with increased stroke risk. Several other variant alleles [TNFalpha (-308)A, CETP (-628)A, apoCIII (-641)A] showed a trend towards significant associations with stroke risk. These preliminary results on a small group of patients suggest that a multilocus genotyping assay may be valuable in identifying genes that increase the risk of stroke in SCA.

No evidence for cognitive side effects after 6 months of vagus nerve stimulation in epilepsy patients

Vagus nerve stimulation (VNS) can reduce seizure frequency in epilepsy patients and may affect central mechanisms of brain functioning. Experimental studies have provided evidence of cognitive alterations during VNS on phases. This single-arm follow-up study evaluates the potential of VNS to affect cognitive performance following long-term treatment. Thirty-six adult patients with medication-resistant epilepsies enrolled. Cognition was assessed before and at least 6 months after implantation of the stimulation device by a comprehensive neuropsychological assessment battery comprising tests on attention, motor functioning, short-term memory, learning and memory, and executive functions. Neither multiple testing of single score changes nor multivariate testing of cognitive domains revealed significant pre-post changes. Improvements in attentional performance were completely explained by practice effects as is usually expected. In particular, no negative side effects were revealed. These findings are in line with the clinical impression that VNS does not affect cognitive performance.

Self-Reported Mood Changes following 6 Months of Vagus Nerve Stimulation in Epilepsy Patients

Vagus nerve stimulation (VNS) for treatment of drug-resistant epileptic seizures has been reported to have additional positive mood effects as obtained by psychiatric ratings. To avoid rater bias effects, this study used self-report questionnaires and examined changes in self-reported mood and health-related quality of life following 6 months of VNS treatment. From 40 adult patients treated with VNS since the beginning of the study, 28 patients (mean age: 35.4 years) with unchanged medication were included. Repeated-measures MANOVA revealed a significant general mood improvement. Post hoc univariate tests obtained improvements of tenseness and dysphoria but not of depression, level of activity, or health-related quality of life. Mood and seizure outcome were correlated. VNS may improve unspecific states of indisposition and dysphoria. Absolute seizure reduction contributes to this antidysphoric effect. Since baseline depression scores were low, findings do not contradict but complement earlier reports of an antidepressive effect of VNS.

[Sexual satisfaction of women--development and results of a questionnaire]

In sexology the existing questionnaires do not sufficiently consider the experiencing of sexuality and the extent of sexual satisfaction. That is why a questionnaire was developed which includes, besides the frequency and duration of sexual activities, the satisfaction with frequency and duration of these activities and the desired sexual behaviour. A first study with this questionnaire was carried out on 112 women with heterosexual behaviour, aged 20 to 48 years. The frequent desire with regard to coital orgasm as one result of our investigation confirms the centering of orgasm in other studies. But half of the women do not describe orgasm as the favoured feeling during sexual intercourse. For 37% of the women the emotional and physical closeness to the partner is explicitly more important than experiencing an orgasm. According to the comparison of extreme groups sexual satisfaction particularly correlates with self-determination realized in partnership and with satisfaction of communicational desires and need for tenderness within the partnership.

Vagus nerve stimulation is associated with mood improvements in epilepsy patients

Vagus nerve stimulation (VNS) has gained increasing acceptance for treatment of drug-resistant seizures. The aim of this study was to evaluate effects of VNS on depressed mood in epilepsy patients during the first 6 months after implantation of the stimulation device. This study was conducted as an addition to the international multisite randomized and double-blind controlled trial on anti-seizure effects of VNS (EO3). Only adult patients with >4/month medication-resistant complex-partial seizures were included (N=11). During the acute phase of the study (3 months after implantation), patients were randomly assigned to low (stimulation detection) versus high stimulation (maximal tolerability, maximum 1.75 mA). Mood and mood changes were recorded based on standardized psychiatric rating scales and self-report questionnaires. Patients were assessed 4 weeks before (baseline) as well as 3 and 6 months after implantation. Significant positive mood effects were observed in most scales and subscales at the 3-month follow-up (P<0.05). Mood improvements were sustained at the 6-month follow-up and were independent of effects on seizure activity (9/11 mood responders versus 2/11 seizure responders). Mood effects appeared more pronounced in the high stimulation group after the acute study phase, but findings were not significant (P<0.10). VNS is associated with mood improvements in patients with epilepsy, but to confirm VNS dose effects, studies with more statistical power are needed.

Use of hydroxyurea in children ages 2 to 5 years with sickle cell disease

The efficacy and side effects of hydroxyurea in young children with sickle cell disease are unknown. The authors followed-up eight young children (mean age 3.7 years) during therapy with hydroxyurea for an average of 137 weeks. Total and fetal hemoglobin levels rose with hydroxyurea therapy. Hospital admission rates and total hospital days decreased during hydroxyurea therapy. No unexpected toxicity occurred, and growth and development were unaffected. This pilot study suggests that hydroxyurea is safe and effective in young children with sickle cell disease.

Evidence for HLA-related susceptibility for stroke in children with sickle cell disease

Cerebral infarction occurs in one quarter of all children with sickle cell anemia (SCA). There is an increased risk of stroke in siblings with SCA, suggesting genetic factors may influence risk of stroke. The authors investigated whether HLA type was associated with risk of stroke in children with SCA. Fifty-three patients with SCA underwent complete HLA typing at both HLA class I (HLA-A, B) and HLA class II (HLA-DR, DQ, DP) loci. Of the 53 patients, 22 had magnetic resonance imagining (MRI)-documented evidence of cerebral infarction, and the remaining 31 patients had negative MRI scans. Comparison of the results of HLA typing between the SCA patients with a positive and those with a negative MRI documented that the 2 groups differed with respect to the class I HLA-B (P =.012), and the class II HLA-DRB1 (P =.0008) and DQB1 (P =.029). Susceptibility associations at the HLA-DRB1 locus included both DR3 alleles, where DRB1*0301 and *0302 were both associated with an increased risk of stroke. Protective associations were found in the DR2 group, where DRB1*1501 was protective for stroke. DQB1*0201, which is in linkage disequilibrium with DRB1*0301, was also associated with stroke. Similarly, DQB1*0602, in linkage disequilibrium with DRB1*1501, was protective. Specific HLA alleles may influence the risk of stroke in children with SCA. HLA typing may prove useful in identifying SCA patients at higher risk for stroke.

Bone size and bone mass in 10-year-old Danish children: effect of current diet

Lifestyle factors, such as diet, are believed to be involved in modifying bone health, although the results remain controversial, particularly in children and adolescents. The objective of the study was to identify associations between dietary factors and whole body bone measurements in 10-year-old children. The study was a cross-sectional analysis of a random sample of 105 healthy Danish children, aged 10 years (9.97+/-0.09). Whole body bone mineral content (BMC) and bone area (BA) were determined by dual-energy X-ray absorptiometry. The influence of diet (7 day food records) on BMC and BA were examined in bi- and multivariate analyses. The mean intakes of calcium, protein, phosphorus and sodium were 1226 mg, 78 g, 1523 mg and 3.3 g, respectively. In bivariate analyses, BMC and BA were strongly positively correlated with height (p<0.001) and weight (p<0.001), and with intakes of energy (p<0.005) and several nutrients. BMC was adjusted for size by including BA, height and weight in the multiple linear regression, and BA was adjusted for size by including height and weight in the multiple linear regression. In multivariate analyses, size-adjusted BMC was positively associated with calcium intake (p=0.02). Size-adjusted BA was positively associated with dietary protein (p=0.003), and negatively associated with intakes of sodium (p = 0.048) and phosphorus (p=0.01). In conclusion, calcium intake was positively associated with bone mineralization. There was a positive association between protein and BA, while for phosphorus and sodium the association was negative.

Hydroxyurea and sodium phenylbutyrate therapy in thalassemia intermedia

Hydroxyurea (HU) and sodium phenylbutyrate (SPB) have been shown to increase fetal hemoglobin (Hb F) levels in patients with thalassemia intermedia. The reported effects of these agents in increasing total Hb, however, have been inconsistent and there have been no studies on the combination of these medications. We describe the clinical response, as determined by increases in total Hb and decreased transfusion needs, in five patients with thalassemia intermedia treated with HU alone or in combination with SPB. All of the patients responded with increased levels of Hb F, but the responses in total Hb varied. Of the five patients, two had a marked response in total Hb in excess of 3 g/dl, two responded modestly with an increase in total Hb of 1-2 g/dl, and one did not respond. Prolonged responses were achieved with low doses of HU (3-10 mg/kg/day) and higher doses were associated with mild reversible hematologic or hepatic toxicity and no further increases in Hb. Sodium phenylbutyrate was added to treatment with HU in two patients, but failed to produce an increase in total Hb despite increasing Hb F levels. Of the four patients who responded to HU with an increase in total Hb, all reported symptomatic improvement and three have not required further transfusions. We conclude that low-dose HU therapy in patients with thalassemia intermedia may increase total Hb levels sufficiently to eliminate the need for transfusions. We, therefore, recommend a trial of HU for thalassemia intermedia patients in whom chronic transfusion therapy is being contemplated.

Growth retardation in Turner syndrome: aneuploidy, rather than specific gene loss, may explain growth failure

The etiology of short stature (SST) in Turner syndrome (TS) is still a subject of speculation. A variety of hypotheses have been put forward, from SST as a result of increased intrauterine tissue pressure after fetal lymphedema to haploinsufficiency of a specific growth gene(s). These hypotheses have various statistical-auxological implications on the growth distribution in TS. Empirical research has provided no clear evidence for any of these theories, but the well known correlation between patients' and midparental height (MPH) could be established. The influence of undetected mosaic status has often been cited as a major problem in the investigation of growth in TS. However, an assessment of mosaic status (simultaneous analysis of karyotype and phenotype) and its effect on growth with inclusion of MPH has been not yet carried out for a large sample. The aim of this study was to evaluate growth and its complex relationship to mosaic status and MPH in TS. In a mixed cross-sectional and longitudinal study we retrospectively analyzed the auxological and clinical data of 447 patients with a pure loss of X-chromosomal material (n = 381 with 45,X0; n = 66 mosaics). The 447 patients were selected from a series of 609 consecutive patients with TS. To assess the effect of mosaic status on growth, we computed a bifactorial analysis of variance (phenotype, karyotype), including MPH as a covariate. In line with the mosaic hypothesis, we found a correlation between individual loss of X-chromosomal material and phenotypical expressivity. In contrast, no correlation was found with respect to growth. With respect to MPH, we found growth retardation (GR) even in those patients with "normal" height above the third percentile (-2 or more SD score). The interindividual variance of GR in TS (comparable to growth variance in the normal population) seems to be unrelated to other TS-specific factors (e.g. mosaic status or single gene loss). Instead, both interindividual variance and the global growth shift distribution are best explained by the presence of an unspecific aneuploidic effect. Furthermore, consideration of patient height in relation to MPH should lead to a better understanding of the nature of GR in TS than the commonly used, strictly qualitative definition of SST.