Cellular source of serum lactate dehydrogenase elevation in patients with thrombotic thrombocytopenic purpura

Elevated serum lactate dehydrogenase (LDH) is a characteristic finding in patients with thrombotic thrombocytopenic purpura (TTP). It is widely accepted that total serum LDH principally rises due to the release of red blood cell LDH as a consequence of intravascular hemolysis. To identify the cellular source of serum LDH in TTP, we prospectively analyzed total serum LDH and LDH isoenzyme profiles in 10 consecutive patients with classic, acute idiopathic TTP within 5 days of clinical presentation. Total LDH was quantitated on a Hitachi 911 Analyzer (Indianapolis, IN), using the lactate to pyruvate reaction. LDH isoenzymes were measured by serum protein electrophoresis, using the Beckman LDH Isoenzyme Kit (Anaheim, CA). Isoenzymes attributable to erythrocytes (LDH1, LDH2) were not disproportionately elevated in 9 of 10 patients. LDH3 was below or within normal limits for all 10 patients, and one patient showed a slightly increased LDH4. Serum LDH5, the isoenzyme derived primarily from liver and skeletal muscle, was elevated 1-2 times normal in all patients. Evidence supporting hemolysis as the major contribution to the elevated total serum LDH frequently encountered in acute TTP was not identified in this study. The isoenzyme fractions LDH and LDH2 elevated by erythrocyte injury were not disproportionately elevated in this series. LDH 5, the isoenzyme found in skeletal muscle and liver, was consistently 1- to 2-fold greater than normal in all patients. We propose that the elevation of serum LDH seen in patients with TTP is due to release of LDH from a variety of tissues damaged as a result of systemic ischemia.

Extended use of glatiramer acetate (Copaxone) is well tolerated and maintains its clinical effect on multiple sclerosis relapse rate and degree of disability. Copolymer 1 Multiple Sclerosis Study Group

When 251 relapsing-remitting patients with multiple sclerosis were randomized to receive daily subcutaneous injections of glatiramer acetate, previously called copolymer 1 (Copaxone; n = 125) or placebo (n = 126) for 24 months, there were no laboratory abnormalities associated with glatiramer acetate treatment and it was well tolerated with few side effects. Patients receiving glatiramer acetate had significantly fewer relapses and were more likely to be neurologically improved, whereas those receiving placebo were more likely to worsen. This study was extended for 1 to 11 months (mean of 5.2 months for the glatiramer acetate group and 5.9 months for the placebo group). The blinding and study conditions used during the core 24-month study were unchanged throughout the extension. The results of this extension study confirm the excellent tolerance and safety profile of glatiramer acetate for injection. The clinical benefit of glatiramer acetate for both the relapse rate and for neurologic disability was sustained at the end of the extension trial.

Glycated albumin stimulates fibronectin gene expression in glomerular mesangial cells: involvement of the transforming growth factor-beta system

Albumin modified by Amadori glucose adducts, formed in increased amounts in diabetes, stimulates collagen IV production and gene expression in renal glomerular mesangial cells, and induces mesangial matrix accumulation accompanied by increased mRNA encoding alpha 1 (IV) collagen and fibronectin in diabetic animals. These effects contribute to the pathogenesis of diabetic nephropathy, and resemble biologic activities of the cytokine TGF-beta 1, which also has been causally implicated in diabetic renal disease. We postulated that Amadori-modified glycated albumin modulates TGF-beta 1 expression in mesangial cells, and that TGF-beta 1 participates in mediating the glycated albumin-induced increases in mesangial cell matrix production. To test this hypothesis, we measured mRNA encoding TGF-beta 1, the TGF-beta Type II receptor and fibronectin, a key matrix component of the TGF-beta 1 tissue response, after incubation of mesangial cells with glycated albumin. Steady state levels of the mRNAs encoding for these proteins were stimulated when mesangial cells were cultured in the presence of albumin containing Amadori glucose adducts compared with levels in cells cultured with the nonglycated, glucose-free counterpart. The glycated protein-induced changes in mRNA expression were observed with concentrations of glycated albumin encompassing those found in clinical specimens and in media containing physiologic (5.5 mM) glucose concentrations, indicating that they were due to the glucose-modified protein and not to a hyperglycemic milieu. Further, they were accompanied by increased translated fibronectin protein, which was prevented with TGF-beta neutralizing antibody, as was the glycated albumin-induced increase in fibronectin mRNA. The findings indicate that Amadori-modified glycated albumin stimulates mesangial cell TGF-beta 1 gene expression by mechanisms that are operative under normoglycemic conditions. These data provide the first link between elevated glycated serum albumin concentrations and increased TGF-beta 1 bioactivity in the pathogenesis of mesangial matrix accumulation in diabetes.

Risks for sensorimotor peripheral neuropathy and autonomic neuropathy in non-insulin-dependent diabetes mellitus (NIDDM)

Identification of risk factors for development of diabetic sensorimotor peripheral neuropathy (DSPN) and diabetic autonomic neuropathy (DNA) may help to prevent or modify these complications. The ABCD Trial, a prospective study of diabetic complications, has identified risk factors of the presence and staging of peripheral neuropathy based on neurological symptom scores, neurological disability scores, autonomic function testing and quantitative sensory examination. DSPN is independently associated with diabetes duration [odds ratio (OR) = 1.5 per 10 years], body weight (OR = 1.1 per 5 kg), age (OR = 1.8 per 10 years), retinopathy (OR = 2.3), overt albuminuria (OR = 2.5), height (OR = 1.2 per 10 cm), duration of hypertension (OR = 1.1 per 10 years), insulin use (OR = 1.4), and race/ethnicity [African American vs. non-Hispanic white (OR = 0.4) and Hispanic vs. non-Hispanic white (OR = 0.8)]. DAN is independently associated with diabetes duration (OR = 1.2 per 10 years), body weight (OR = 1.1 per 5 kg), glycosylated hemoglobin (OR = 1.1 per 2.5%), overt albuminuria (OR = 1.6), and retinopathy (OR = 1.8).

Factors that mediate treatment outcome of sexually abused preschool children: six- and 12-month follow-up

OBJECTIVE

The role of familial, demographic, developmental, and treatment-mediating factors on treatment outcome of sexually abused preschool children was evaluated 6 and 12 months after treatment.

METHOD

Forty-three sexually abused preschool children and their parents who were evaluated shortly after disclosure of sexual abuse and then were provided with one of two treatment interventions were reevaluated at the completion of treatment and 6 and 12 months after treatment. Parents completed the Child Behavior Checklist, the Child Sexual Behavior Inventory, and the Weekly Behavior Report to measure a variety of emotional and behavioral symptoms in children. Parents also completed the Beck Depression Inventory, the Family Adaptability and Cohesion Evaluation Scales-III, the Parent Emotional Reaction Questionnaire, the Parental Support Questionnaire, and the Maternal Social Support Index. Children completed the Battelle Developmental Inventory and the Peabody Picture Vocabulary Test at pretreatment to assess developmental levels.

RESULTS

Correlational and stepwise multiple regression analyses were conducted to analyze the role of the hypothesized mediating variables in predicting scores on outcome measures across the two treatment groups. While the Parent Emotional Reaction Questionnaire was the strongest familial predictor of treatment outcome at posttreatment, parental support became a stronger predictor of outcome at the 6- and 12-month follow-up points. Treatment group was the strongest overall predictor of outcome at posttreatment and at 12-month follow-up. Demographic and developmental factors did not strongly predict outcome.

CONCLUSIONS

Findings indicate the strong impact of parental support on treatment outcome in sexually abused preschool children over the course of a 12-month follow-up and emphasize the importance of including parental interventions in treating sexually abused preschool children. They also support the superior effectiveness of cognitive-behavioral therapy over supportive counseling for this population.

Glycated albumin stimulates fibronectin and collagen IV production by glomerular endothelial cells under normoglycemic conditions

Albumin modified by Amadori glucose adducts, formed in increased amounts in diabetes, stimulates the synthesis of matrix by renal glomerular mesangial cells and has been causally linked to the pathogenesis of diabetic nephropathy. However, the effect of glycated albumin on the biology of glomerular endothelial cells, which elaborate a basement membrane that undergoes thickening in diabetes, has not been investigated. We used well-characterized rat glomerular endothelial cells to examine the influence of glycated albumin on the synthesis of extracellular matrix proteins by these cells in culture. Concentrations of glycated albumin that are present in clinical specimens stimulate fibronectin and collagen IV production by glomerular endothelial cells, and this effect is operative under normoglycemic conditions. These results support the hypothesis that increased glycated albumin contributes to glomerular basement membrane thickening in diabetes.

Epoetin alfa: focus on maintaining a higher, stable, Hct. Case study of the anemic patient

Clinical evidence indicates that maintaining a stable hematocrit (Hct) higher in the target range of 30% to 36% can lead to improvement in overall patient outcomes. On the basis of these data, a recent analysis by the Dialysis Outcomes Quality Initiative Anemia Work Group has recommended a target Hct of 33% to 36% (hemoglobin 11 g/dl to 12 g/dl). Maintaining a stable Hct higher in the target range provides nurses and other dialysis clinicians with two benefits: improved patient care and decreased time and costs for patient management. This article focuses on the data supporting such a policy. Clinical practices from two prominent dialysis centers are presented as models of good anemia management.

A treatment study for sexually abused preschool children: outcome during a one-year follow-up

OBJECTIVE

Treatment outcome in sexually abused preschool children was evaluated 6 and 12 months after treatment.

METHOD

Forty-three sexually abused preschool children and their parents were evaluated 6 and 12 months after completion of either Cognitive-Behavioral Therapy for Sexually Abused Preschoolers (CBT-SAP) or nondirective supportive therapy (NST). Parents completed the Child Behavior Checklist, Child Sexual Behavior inventory, and Weekly Behavior Report to measure a variety of symptoms in their children.

RESULTS

Repeated-measures analyses indicated that there were significant group by time interactions on several outcome measures from the beginning of the study to the end of the 12-month follow-up period, with the CBT-SAP group exhibiting significantly more improvement over time than the NST group. Clinical findings also indicated the superior effectiveness of CBT-SAP over NST in reducing sexually inappropriate behavior.

CONCLUSIONS

Findings support the superior efficacy of CBT-SAP over NST in maintaining symptom reduction in the year after treatment completion. The importance of using cognitive-behavioral interventions for sexually inappropriate behaviors and including nonoffending parents in the treatment of sexually abused preschool children is discussed.

Loss of RB and MTS1/CDKN2 (p16) expression in human sarcomas

The product of the MTS1/CDKN2 gene (p16) and the retinoblastoma protein (pRB) inhibit cell cycle progression at the late G1 checkpoint. The absence of functional p16 or pRB has been identified in a variety of human tumors but has not been well studied in mesenchymal neoplasia. Using an immunohistochemical approach, the authors identified abnormal expression of either p16 or RB in 16 and 14 of 59 sarcomas, respectively, for an overall abnormality rate of 51%. Specific rates of abnormality varied by histological subtype, with leiomyosarcomas most commonly affected by loss of either tumor-suppressor gene product. There was no significant correlation between p16 or RB expression and overall grade, mitotic grade, or tumor progression for sarcomas. In contrast, no fibromatoses and other spindle cell neoplasms of low malignant potential displayed abnormal p16 expression, and only 4 of 23 cases showed loss of pRB expression. These data show that aberrant expression of p16/pRB is one of the most common molecular derangements in sarcomagenesis.

Serum angiotensin-converting enzyme in multiple sclerosis

OBJECTIVE

To determine the extent and significance of serum angiotensin-converting enzyme (ACE) elevation in multiple sclerosis (MS) and the correlation between serum ACE activity and clinical and magnetic resonance imaging (MRI) indicators of disease activity.

DESIGN

A retrospective cross-sectional study of 45 consecutive patients with clinically definite MS and a longitudinal study of 30 additional patients with clinically definite MS involved in a long-term study of neurologic function and MRI in MS.

SETTING

Comprehensive MS center of a tertiary care university hospital.

SUBJECTS

A total of 75 patients with clinically definite MS and 31 healthy controls.

METHODS

Serum ACE activity was measured using a spectrophotometric assay and correlated with clinical indicators of disease activity and with total cerebral MS lesion volume measured by MRI.

RESULTS

An elevated ACE activity was found in 17 (23%) of 75 patients with MS as compared with 2 (6%) of 31 healthy controls. Changes in serum ACE activity correlated with changes in total plaque volume on MRI.

CONCLUSIONS

Serum ACE activity may be an indicator of disease activity in longitudinal analysis. Also, elevated ACE activity in a patient with otherwise typical MS need not raise suspicions of alternative diagnoses.

Lymphocyte-specific inducible expression of potassium channel beta subunits

Many studies have shown that voltage-gated potassium (Kv) channel activity is essential for T-lymphocyte proliferation. The IL-2-inducible neuroimmune gene, I2rf5 is the mouse homologue of the rat Kv beta 2 subunit. In this study we show that in addition to constitutive expression in adult murine brain, expression of Kv channel subunits beta 1.1 and beta 2.1 is inducible in a cloned T-helper cell line stimulated with IL-2 and in normal murine splenocytes stimulated with Con A or LPS. This expression pattern appears to be lymphocyte specific, because stimulated fibroblasts and vascular smooth muscle cells do not express Kv beta channel subunit mRNA. These observations suggest that Kv beta subunit expression is tissue specific and inducible in stimulated lymphocytes. Because Kv beta subunits modulate K+ channel activity, the inducible and variable expression of these subunits in lymphocytes may represent an additional regulatory mechanism for lymphocyte proliferation.

Relationship of the antispasticity effect of tizanidine to plasma concentration in patients with multiple sclerosis

BACKGROUND

Spasticity is a serious problem in multiple sclerosis (MS) and many patients do not achieve a satisfactory response to currently available oral antispasticity drugs. Tizanidine hydrochloride, an alpha 2-noradrenergic agonist, has been shown to have an antispasticity effect in single center trials of patients with MS.

OBJECTIVE

To compare plasma concentrations of tizanidine with objective measures of muscle tone in patients with MS with moderate to severe spasticity.

SETTING

Ten centers, all tertiary referral centers for the specialized treatment of patients with MS, in the United States and Canada.

DESIGN

A randomized, double-blind, placebo-controlled, dose-response study of tizanidine hydrochloride (8 or 16 mg).

PATIENTS

One hundred forty-two patients with spastic MS who were not taking any interfering medication, such as an antispasticity drug or other alpha-noradrenergic agonist, entered the trial.

RESULTS

Tizanidine treatment reduced muscle tone significantly, as shown by improved Ashworth scores and increased knee swing amplitude recorded by the pendulum test, both of which correlated significantly with plasma concentration. Placebo had no significant effect on muscle tone. Dizziness, drowsiness, dry mouth, and fatigue were reported most often in the group treated with tizanidine at peak plasma concentration.

CONCLUSIONS

Tizanidine reduces spasticity in MS, and both therapeutic effects and side effects are related to the plasma drug levels.

Factors that mediate treatment outcome of sexually abused preschool children

OBJECTIVE

The role of demographic, developmental, and familial mediating factors on treatment outcome of sexually abused preschool children was evaluated.

METHOD

Sixty-seven sexually abused preschool children and their parents were evaluated shortly after disclosure of sexual abuse and then were provided with one of two treatment interventions. At the completion of treatment, the parents and their children were reevaluated. Parents completed the Child Behavior Checklist, the Child Sexual Behavior Inventory, and the Weekly Behavior Report to measure a variety of emotional and behavioral symptoms in children. Parents also completed the Beck Depression Inventory, the Family Adaptability and Cohesion Evaluation Scale-III, the Parent Emotional Reaction Questionnaire, the Parental Support Questionnaire, and the Maternal Social Support Index. Children completed the Preschool Symptom Self-Report to assess self-reported affective symptoms and the Battelle Developmental Inventory and the Peabody Picture Vocabulary Test to assess developmental level.

RESULTS

Correlational analyses were conducted to analyze the relationships between the hypothesized mediating variables and the outcome measures at posttreatment across the two treatment groups. Multiple regression analyses were also performed. Both parental depression and parental emotional distress correlated significantly with several of the child outcome measures. Battelle scores were significantly negatively correlated with several outcome measures. Multiple regression analyses demonstrated that the Parent Emotional Reaction Questionnaire remained a highly significant predictor of treatment outcome.

CONCLUSIONS

The findings indicate a strong correlation between parental emotional distress related to the abuse and treatment outcome in sexually abused preschool children, independent of the type of treatment provided. The findings indicate the importance of addressing parental distress related to the abuse in providing effective treatment to sexually abused preschool children.

Evolution of renal function abnormalities in the db/db mouse that parallels the development of human diabetic nephropathy

The db/db mutant mouse is a rodent model of genetic diabetes that develops renal glomerular lesions with striking mesangial matrix accumulation by the age of 16 weeks, after 8-10 weeks of sustained hyperglycemia. However, abnormalities in renal function that antedate or accompany the appearance of these pathologic changes, which resemble those found in human diabetes, have not been delineated. We therefore examined renal function in young db/ db mice and their nondiabetic db/m littermates from the age of 8 through 15 weeks. Serum creatinine and blood urea nitrogen concentrations at the onset of diabetes in db/db mice did not differ significantly from mean concentrations in db/m controls. An elevated creatinine clearance, due in large part to increased body weight, and increased urinary albumin excretion were observed in db/db compared with db/m mice soon after establishment of sustained hyperglycemia. A relative reduction in creatinine clearance was demonstrable in db/db mice at the age of 15 weeks, coincident with the appearance of overt compromise in renal function manifested by frank increases in the serum creatinine and blood urea nitrogen. The findings indicate that the well-documented glomerular pathology in db/db mice is accompanied by definable alterations in renal function, which are similar in chronology and nature to those found in human diabetes.

Subcutaneous sumatriptan for the treatment of migraine: humanistic, economic, and clinical consequences

OBJECTIVES

This study examined the humanistic, economic, and clinical consequences of using subcutaneous sumatriptan for 6 months for the acute treatment of migraine in 126 patients enrolled in a group-model health maintenance organization.

METHODS

Patients received open-label sumatriptan (6 mg) for the treatment of migraines that occurred during a 6-month period. For each migraine, patients recorded migraine pain severity (none, mild, moderate, or severe) before treatment and 2 hours posttreatment and the time until onset of patient-defined meaningful relief. Patients also completed both the Short Form-36 Health Survey and Migraine-specific Quality of Life (QOL) Questionnaire at screening (to cover the period prior to initiation of treatment) and after 3 and 6 months of treatment. Patients' medical records were reviewed to obtain information on the frequency of migraine-related pharmacy use, general outpatient services, and urgent care services during the treatment period and the 12 months prior to initiation of treatment.

RESULTS

By 2 hours after the dose, 71% of patients had moderate or severe pain reduced to mild or none, and 86% of patients achieved meaningful relief. At 3 months and 6 months, sumatriptan was associated with improvements relative to pre-sumatriptan baselines in Short Form-36 Health Survey and Migraine-specific QOL Questionnaire scores (P < .002). Sumatriptan was also associated with significant reductions in the average number of migraine-related general outpatient and urgent care services (P < .001).

CONCLUSIONS

The use of sumatriptan for 6 months was associated with improvements in health-related quality of life, reductions in health care resource use, and a high percentage of treatment successes.

Prevention of decline in renal function in the diabetic db/db mouse

We recently reported that when diabetic db/db mice, which develop glomerular pathology resembling that in human diabetes mellitus, are treated with monoclonal antibodies (A717) that neutralize the effects of excess glycated albumin, there is an amelioration of mesangial expansion, renal overexpression of mRNAs encoding for the extracellular matrix proteins collagen IV and fibronectin and proteinuria. These findings suggested that A717 might also retard the development of compromised renal function in this animal model. To examine this possibility, serum creatinine and blood urea nitrogen (BUN) were measured in diabetic db/db mice and their non-diabetic db/m littermates before and after an 8-week course of treatment with A717 or irrelevant murine immunoglobulin (MIg). Early in the course of diabetes, BUN and serum creatinine concentrations did not significantly differ from those in the db/m littermates, but were significantly increased after 10 weeks of sustained hyperglycaemia. Treatment of db/db mice with A717 prevented the rise in creatinine and attenuated the elevation in BUN. A717 also prevented the decrease in creatinine clearance observed in diabetic compared with non-diabetic animals (2.2 +/- 0.8 vs 4.1 +/- 0.3 vs 5.0 +/- 1.1 ml/h in db/db vs db/db-A717 vs db/m, respectively). MIg did not alter the change in renal function with time in db/db mice. Taken together with our previous results, the present findings indicate that the diabetic db/db mouse develops changes in renal function and structure that parallel the course of human diabetic nephropathy in nature and chronology and demonstrate, for the first time, that therapy directed against increased glycated albumin can prevent the decline in renal function in this rodent model of genetic diabetes.

Newer versus older treatments for relapsing-remitting multiple sclerosis

Multiple sclerosis (MS) is a chronic disease with an unpredictable clinical course and several distinct clinical patterns. Recent developments in immunology, molecular biology and genetics have improved our understanding of the pathophysiology of MS. Further, advances in trial methodology, including the availability of magnetic resonance imaging (MRI) as a surrogate outcome measure, have led to the identification of several new therapeutic options for relapsing-remitting (RR) MS. These therapies include corticosteroids, recombinant interferon-beta-1b (rIFN beta-1b), recombinant interferon-beta-1a (rIFN beta-1a) and copolymer-1 (Cop-1). Corticosteroids have been shown to accelerate the recovery from acute exacerbations, but there are still conflicting data on their effect on outcome and long term course. rIFN beta-1b, rIFN beta-1a and Cop-1 all effectively alter the natural history of RR-MS. These 3 agents all decrease the relapse rate by approximately one-third, but differ in their adverse effect profiles and administration regimens. Further trials are required to define the optimal treatment of RR-MS.

Glycated albumin promotes a generalized vasculopathy in the db/db mouse

Increased protein glycation has been mechanistically linked to accelerated vascular pathobiology in diabetes. Because glycated albumin induces biosynthetic abnormalities in cultured aortic endothelial cells that resemble those associated with macrovascular disease, we sought evidence that increased glycated albumin is operative in the genesis of diabetic vasculopathy in vivo. Plasma concentrations of fibronectin, a sensitive marker of endothelial cell damage, were increased two-fold in diabetic db/db mice compared with their nondiabetic db/m littermates. Treatment with monoclonal antibodies specifically reactive with albumin modified by Amadori glucose adducts normalized fibronectin in diabetic animals despite persistent hyperglycemia. These findings suggest that increased glycated albumin causally contributes to diabetic vasculopathy, and that blocking this influence ameliorates vascular damage.

A treatment outcome study for sexually abused preschool children: initial findings

OBJECTIVE

Treatment outcome for sexually abused preschool-age children and their parents was assessed, comparing the effectiveness of a cognitive-behavioral intervention to nondirective supportive treatment.

METHOD

Sixty-seven sexually abused preschool children and their parents were randomly assigned to either (1) cognitive-behavioral therapy adapted for sexually abused preschool children (CBT-SAP) or (2) nondirective supportive therapy (NST). Treatment consisted of 12 individual sessions for both the child and parent, monitored for integrity with the therapeutic model through intensive training and supervision, use of treatment manuals, and rating of audiotaped sessions. Parents completed the Child Behavior Checklist, the Child Sexual Behavior Inventory, and the Weekly Behavior Report to measure a variety of emotional and behavioral symptoms.

RESULTS

Within-group comparison of pretreatment and posttreatment outcome measures demonstrated that while the NST group did not change significantly with regard to symptomatology, the CBT-SAP group had highly significant symptomatic improvement on most outcome measures. Repeated-measures analyses of variance demonstrated group x time interactions on some variables as well. Clinical findings also supported the effectiveness of the CBT-SAP intervention over NST.

CONCLUSIONS

Findings provide strong preliminary evidence for the effectiveness of a specific cognitive-behavioral treatment model for sexually abused preschool children and their parents.

Multiple sclerosis lesions: relationship between MR enhancement pattern and magnetization transfer effect

PURPOSE

To investigate the relationship between the enhancement pattern of a multiple sclerosis lesion and its magnetization transfer effect.

METHODS

Fifty-four lesions were chosen from 29 patients with multiple sclerosis on the basis of enhancement pattern on contrast-enhanced T1-weighted MR images. They included 14 homogeneously enhancing lesions, 26 nonenhancing lesions, and 14 ring-enhancing lesions. Magnetization transfer ratios of the homogeneously enhancing lesions, nonenhancing lesions, and central portion of the ring-enhancing lesions were measured. Means were calculated and compared.

RESULTS

The magnetization transfer ratios for homogeneously enhancing lesions were higher (mean, 32.2%; SD, 3.4%) than those for nonenhancing lesions (mean 29.4%; SD, 4.3%) and for the central portion of ring-enhancing lesions (mean, 24.5%; SD, 4.0%). Significant differences were found between the ring-enhancing lesions and the homogeneously enhancing lesions and between the ring-enhancing lesions and the nonenhancing lesions.

CONCLUSION

We found a relationship between decreased magnetization transfer ratios and those enhancement patterns in which myelin is known to be decreased histopathologically. Thus, use of the magnetization transfer technique may increase the specificity of MR imaging in assessing the extent of residual myelination in multiple sclerosis lesions.

Autonomic nervous system disorders and reflex sympathetic dystrophy in lightning and electrical injuries

Both lightning and electrical injuries can cause autonomic nervous system (ANS) symptoms and signs (Table 1). Published descriptions of ANS involvement occurring with lightning and electrical injuries are rare. The most often reported neurologic complications of lightning injuries involve the central nervous system. ANS abnormalities have been documented with lightning, although the descriptions are scant. There is a lack of complete clinical information or ANS testing data in these cases. This is usually a result of the transient nature of ANS complications. In electrical injuries, ANS involvement is less well described than for lightning. Electrical injuries can be associated with peripheral nerve damage. As a result of peripheral nerve damage, reflex sympathetic dystrophy (RSD) may occur in patients with electrical injuries. Various treatment strategies for RSD associated with electrical injuries are found in single case reports. This article summarizes ANS involvement, predominantly in lightning injuries, and describes RSD and its treatment, predominantly in electrical injuries.