Improving diagnostic procedure and treatment in patients with non-epileptic seizures (NES)

The purpose of this study was to examine the incidence of patients with NES vs. NES and concomitant epilepsy in an epilepsy centre and to present a diagnostic algorithm. We collected and reviewed the data of 322 patients consecutively referred to the adult ward of our epilepsy centre in 1 year. The results of our study reveal that 44 (14%) of all patients referred had NES. Of these, nine proved to have concomitant epilepsy. Of 44 patients with NES, 20 were treated with AED on admission. In 14 cases this unnecessary antiepileptic drug treatment was stopped. In six remaining patients with NES and concomitant epilepsy, the total number of AEDs could be reduced until discharge. The maximum duration of AED treatment among patients with NES only, had been longer than 360 months (median 72 months). Much has been written about whether the diagnosis of psychogenic non-epileptic events is overused. According to our experience however, the fact that many patients with so-called 'pharmacoresistant epilepsy', suspected NES or other diagnoses are referred to a centre of excellence much too late, proves to be the key problem in diagnosis and treatment of NES. We conclude that early admission of so-called 'pharmacoresistant epilepsy' to an epilepsy centre, establishing a standard work-up and clarifying the medical terminology will improve diagnosis and lead to adequate therapy of NES as well as prevent unnecessary drug treatment.

Quitting cigarette smoking produces minimal loss of chronic tolerance to nicotine

RATIONALE

Long-term exposure to nicotine is associated with chronic tolerance to its acute effects, adaptation that may lead to tobacco dependence. The time course for loss of this tolerance after cessation of exposure is not known in humans but could relate to risk of smoking relapse.

OBJECTIVES

We examined changes in responses to nicotine as a function of days, weeks, or years of smoking cessation in formerly dependent smokers to determine at what point sensitivity to nicotine is reinstated (i.e., loss of tolerance).

METHODS

Acute subjective, cardiovascular, performance, and reinforcing (self-administration) effects of nicotine nasal spray (0-20 microg/kg) were assessed prospectively in men and women smokers before and then day-by-day (study 1) or 3 weeks (study 2) after stopping smoking. A smoking resumption period (study 1) and a group of non-quitting smokers (study 2) were included to control for the passage of time. These effects were also compared cross-sectionally between those who had quit for 1-4 years and those who had for 6-19 years in a separate sample of long-time ex-smokers to determine whether lengthier abstinence causes greater loss of tolerance (study 3).

RESULTS

No clear loss of tolerance was observed on any measure in studies 1 or 2, suggesting that chronic tolerance is fully maintained for at least weeks after quitting smoking. Sensitivity to nicotine's effects was also not different as a function of years quit in study 3.

CONCLUSIONS

Chronic tolerance to nicotine is not lost within several weeks of quitting smoking and may not change even after years of abstinence from tobacco use.

Threshold doses for nicotine discrimination in smokers and non-smokers

RATIONALE

Tobacco use during initial experimentation often involves modest nicotine exposure, escalating to larger doses and more frequent exposure with the onset of tobacco dependence. Threshold doses for nicotine discrimination therefore may differ between naive and experienced tobacco users.

OBJECTIVES

We determined the lowest (threshold) dose of nasal spray nicotine that smokers and non-smokers could reliably discriminate from placebo spray.

METHODS

Male and female smokers (n=18) and non-smokers (n=17) were initially trained to discriminate 20 microg/kg from placebo before proceeding to threshold determination sessions, which involved discrimination of progressively lower doses below 20 microg/kg ("descending order" subgroup) or higher doses above 1 microg/kg ("ascending order" subgroup). Threshold was determined by the lowest dose reliably discriminated from placebo (correct on > or =80% of testing trials) and by failure to discriminate the next lowest dose.

RESULTS

Threshold doses for nicotine discrimination were low and not different between smokers and non-smokers (median thresholds of 3 versus 2 microg/kg and approximate blood levels of 2.6 versus 1.6 ng/ml, respectively). Thresholds were similar between descending and ascending order subgroups. Several subjective responses differentiated threshold dose from the dose just below threshold, particularly in non-smokers.

CONCLUSIONS

Threshold doses for nasal spray nicotine discrimination in humans are low, well below the typical nicotine delivery of most cigarette brands, and may not change after long-term smoking exposure.

The Vfl1 Protein in Chlamydomonas localizes in a rotationally asymmetric pattern at the distal ends of the basal bodies

In the unicellular alga Chlamydomonas, two anterior flagella are positioned with 180 degrees rotational symmetry, such that the flagella beat with the effective strokes in opposite directions (Hoops, H.J., and G.B. Witman. 1983. J. Cell Biol. 97:902-908). The vfl1 mutation results in variable numbers and positioning of flagella and basal bodies (Adams, G.M.W., R.L. Wright, and J.W. Jarvik. 1985. J. Cell Biol. 100:955-964). Using a tagged allele, we cloned the VFL1 gene that encodes a protein of 128 kD with five leucine-rich repeat sequences near the NH(2) terminus and a large alpha-helical-coiled coil domain at the COOH terminus. An epitope-tagged gene construct rescued the mutant phenotype and expressed a tagged protein (Vfl1p) that copurified with basal body flagellar apparatuses. Immunofluorescence experiments showed that Vfl1p localized with basal bodies and probasal bodies. Immunogold labeling localized Vfl1p inside the lumen of the basal body at the distal end. Distribution of gold particles was rotationally asymmetric, with most particles located near the doublet microtubules that face the opposite basal body. The mutant phenotype, together with the localization results, suggest that Vfl1p plays a role in establishing the correct rotational orientation of basal bodies. Vfl1p is the first reported molecular marker of the rotational asymmetry inherent to basal bodies.

Dissociation of nicotine tolerance from tobacco dependence in humans

Chronic functional tolerance to nicotine generally is believed to be associated with processes responsible for tobacco dependence. The dose-related effects of nicotine (0-20 microg/kg by nasal spray) on subjective, cardiovascular, and performance responses were compared among four groups varying in current or past dependence: dependent smokers (21 cigarettes per day for 20 years; n = 45), nondependent smokers (three cigarettes per day for 14 years; n = 12), former dependent smokers (mean of 7 years quit after smoking 25 cigarettes per day for 19 years; n = 17), and life-long nonsmokers (n = 19). Chronic tolerance was determined by a shift to the right, or flattening, of the dose-response curve relative to the curve for nonsmokers. Responses were corrected for plasma nicotine concentration to rule out dispositional tolerance. Chronic tolerance was observed for most subjective responses, but little or none for cardiovascular and performance effects. Tolerance was substantial and virtually identical between dependent and nondependent smokers, whereas tolerance of former smokers was intermediate between nonsmokers and dependent smokers. Identical chronic tolerance between dependent and nondependent smokers indicates that tolerance is not a linear function of smoking exposure and does not require presence of dependence. Thus, the wide variability in daily smoking rate among smokers cannot be attributed to differences in tolerance and must involve other processes of adaptation to nicotine. The modest reversal of tolerance in long-time former smokers suggests that such tolerance reversal is either limited or extremely slow after extended abstinence, despite loss of dependence. These results suggest there is no close link between nicotine tolerance and dependence and question the utility of tolerance as one of the criteria for defining dependence.

Comparative pharmacokinetics, safety, and tolerability after subcutaneous administration of recombinant human erythropoietin formulated with different stabilizers

This report summarizes the results of two double-blind, single-center, randomized studies that used a two-period crossover design. The objective of these two studies was to compare the safety, tolerability, pharmacokinetics, and pain score at the subcutaneous (sc) injection site of a phosphate-buffered recombinant human erythropoietin (EPREX, epoetin alfa, r-HuEPO) formulated with a new stabilizer (glycine and Polysorbate 80) with the commercially available EPREX formulations, which uses human serum albumin (HSA) as the stabilizer. Twenty-four healthy male volunteers were enrolled in each of the two studies. In the first study, subjects received a single 150 IU/kg sc dose of r-HuEPO using the 2000 IU/mL (2K) phosphate-buffered formulation with or without the new stabilizer (12 subjects/group). In the second study, subjects received a single 750 IU/kg sc dose of r-HuEPO using the 40 000 IU/mL (40K) phosphate-buffered formulation with or without the new stabilizer (12 subjects/group). In each study, r-HuEPO was administered over two separate dosing periods, each separated with a 28-day washout period. There were no significant differences in AUC and C(max) for either strength of r-HuEPO formulated with or without the new stabilizer, indicating that the absorption and disposition characteristics of the two formulations were similar after sc administration. Both r-HuEPO strengths with and without the new stabilizer were safe and well tolerated; the safety and tolerability profiles of both formulations for each r-HuEPO concentration were comparable. There were no statistically significant differences in pain score for either strength of r-HuEPO with and without the new stabilizer. It was concluded that the two phosphate-buffered r-HuEPO concentrations formulated with and without the new stabilizer are pharmacokinetically equivalent.

Preliminary report of a phase I study of combined fractionated stereotactic radiosurgery and conventional external beam radiation therapy for unfavorable gliomas

PURPOSE

To determine the tolerance and toxicities of fractionated stereotactic radiosurgery (FSRS) given in combination with conventional external beam radiation therapy (CEBRT).

METHODS AND MATERIALS

From March 1995 to September 1998, 14 patients with previously unirradiated and unfavorable glioma (malignant glioma, n = 8; unfavorable low-grade glioma, n = 5; and recurrent glioma, n = 1) were stratified into 3 groups according to tumor volume (TV) to determine the initial FSRS dose schedule: Group A (n = 3): TV </= 5 cc (7 Gy x 2 pre- and post-CEBRT]; Group B (n = 6): 5 cc < TV </= 15 cc [7 Gy x 2 pre- and 7 Gy x 1 post-CEBRT]; and Group C (n = 5): 15 cc < TV </= 30 cc (7 Gy x 1 pre- and post-CEBRT). All patients received CEBRT to 59.4 Gy at 1.8 Gy/fraction. Dose escalation was planned, if toxicity was acceptable.

RESULTS

All patients were able to complete CEBRT without interruption or experiencing disease progression. Unacceptable toxicity has been limited to patients in groups B (grade 4, n = 2/6) and C (grade 4, n = 2/5). Eight patients required reoperation, with 3 (38%) having necrosis without evidence of tumor. Eleven patients (79%) have had objective partial (>/=50% reduction, n = 2) or minor (>20% reduction, n = 9) imaging response. Follow-up ranged from 9 to 51 months (median 15 months), with 7 patients alive at 22-51 months.

CONCLUSIONS

Imaging response and the ability of these patients with unfavorable intracranial gliomas to complete therapy without interruption or experiencing disease progression is very encouraging. Excessive toxicity of combined FSRS and CEBRT as evaluated thus far in this study was seen for patients with group B/C lesions. Evaluation of this novel treatment strategy with dose modification is ongoing.

Comparison of two commercially available near-infrared spectroscopy instruments for cerebral oximetry. Technical note

Two near-infrared spectroscopy (NIRS) devices were compared with regard to their responses to changes in cerebral hemoglobin oxygenation induced by hypoxia and hypercapnia in five healthy volunteers. Sensors belonging to each NIRS device were placed on opposite sides of the volunteer's forehead. The INVOS-3100A device, approved by the United States Food and Drug Administration, records the percentage of oxyhemoglobin (HbO2) saturation and the investigational NIRO500 device records absolute changes in HbO2, deoxyhemoglobin, and total hemoglobin in micromolar concentrations referenced to an arbitrary baseline. The volunteers breathed separate mixtures of 7% CO2 in O2 and 10% O2 for 5 minutes in random order. Arterial blood pressure, end-tidal CO2 (ETCO2), arterial O2 saturation, and electrocardiographic data were continuously monitored. Hypercapnia increased (p < 0.01) ETCO2 from 42+/-2 to 56+/-3 mm Hg (mean +/- standard deviation), resulting in a 7.3+/-0.2% increase (p < 0.005) in cerebral HbO2 saturation detected by the INVOS3100A device and an 11.6+/-3 microM increase (p < 0.0008) in HbO2 detected by the NIRO500. Hypoxia decreased (p < 0.01) arterial HbO2 saturation from 98+/-1 to 87+/-3%, causing a 5.1+/-1.2% decrease (p < 0.01) in the percentage of HbO2 saturation detected by the INVOS3100A device and a 9.7+/-6.3 microM decrease in HbO2 detected by the NIRO500. The responses of the NIRO500 and the INVOS3100A instruments to changes in cerebral oxygenation resulting from hypercapnia and hypoxia were generally similar; however, responses tended to be greater when recorded by the NIRO500 device, perhaps because, unlike the INVOS3100A device, the NIRO500 does not correct for skin and bone contamination.

A model intervention for elder abuse and dementia

This article describes a 2-year collaborative project in Cleveland, OH, that improved the reporting and management of potential and suspected elder abuse situations involving persons with dementia. Educational curricula for cross-training, screening tools, and referral protocols were developed and tested for staff and volunteers in adult protective services and dementia care. A handbook for caregivers of persons with dementia was produced that enables caregivers to self-identify elder abuse risk and seek appropriate interventions to prevent abuse. Project organization, implementation, and evaluation are discussed along with strategies for replication in other communities.

A review of controlled clinical trials examining the effects of antimalarial compounds and gold compounds on radiographic progression in rheumatoid arthritis

At least 8 randomized controlled clinical trials have examined the effects of chloroquine or hydroxychloroquine on radiographic progression in rheumatoid arthritis (RA). At least 12 randomized controlled trials have examined the effects of either intramuscular or oral gold on radiographic progression. A review of these studies shows that hydroxychloroquine and chloroquine have minimal, if any, inhibitory effects on radiographically documented progression of bone erosions and joint destruction when used to treat RA. Intramuscular gold (with most of the data from studies of sodium aurothiomalate) appears to be better than placebo, about equal to intramuscular methotrexate (MTX), but probably not as effective as cyclophosphamide or azathioprine in its effects on radiographic progression. Auranofin appears to be better than placebo, comparable to or perhaps moderately less effective than intramuscular gold, comparable to lower dose oral MTX (7.5 mg/week), and not as effective as higher dose oral MTX (7.5-15 mg/wk) in inhibiting radiographic progression in RA. The inhibitory effects of gold compounds on proinflammatory cytokine synthesis (especially interleukin 1) offer a plausible mechanism for their inhibitory effects on bone erosion and joint destruction in RA.

Body dissatisfaction and dieting in young children

OBJECTIVE

To develop a broader understanding of young children's knowledge and beliefs about dieting and body dissatisfaction.

METHOD

Sixty-two third through sixth-grade boys and girls completed audiotaped interviews and questionnaires regarding eating behavior, attitudes toward dieting, and body dissatisfaction.

RESULTS

Fifty percent of all children wanted to weigh less and 16% reported attempting weight loss. Children were well informed about dieting and were most likely to believe that dieting meant changing food choices and exercising as opposed to restricting intake. Their primary source of information was the family. Seventy-seven percent of children mentioned hearing about dieting from a family member, usually a parent.

DISCUSSION

Young children are knowledgeable about dieting and the concept of dieting does not necessarily mean caloric restriction to them. These data suggest that the family can play a powerful role in countering the development of eating concerns and body dissatisfaction in children.

Sequences throughout the basic beta-1,3-glucanase mRNA coding region are targets for homology dependent post-transcriptional gene silencing

In the transgenic tobacco line T17, plants homozygous for the gn1 transgene display developmentally regulated post-transcriptional silencing of basic beta-1,3-glucanase genes. Previously, it has been shown that silencing involves a markedly increased turnover of silencing-target glucanase mRNAs. Using a two-component viral reporter system facilitated a comparison, in a quantitat- ive manner, of the relative silencing efficiencies of various sequences derived from the gn1 transgene. The results show that target sites for the silencing mechanism are present throughout the coding region of the gn1 mRNA. Similar-sized coding region sequences along the entire gn1 mRNA display a similar susceptibility to the silencing mechanism. The susceptibility to silencing increases as the coding region elements increase in size. Relative to internal sequences, the 5' and 3' terminal regions of the gn1 mRNA are inefficient targets for the silencing machinery. Importantly, sequences of the gn1 transgene that are not part of the mature gn1 mRNA are not recognized by the silencing machinery when expressed in chimeric viral RNAs. These results show that the glucanase silencing mechanism in T17 plants is primarily directed against gn1 mRNA-internal sequences and that terminal sequences of the gn1 mRNA are relatively unaffected by the silencing mechanism.

A new class of selective and potent inhibitors of neuronal nitric oxide synthase

The synthesis and SAR of a series of 6-(4-(substituted)phenyl)-2-aminopyridines as inhibitors of nitric oxide synthase are described. Compound 3a from this series shows potent and selective inhibition of the human nNOS isoform, with pharmacokinetics sufficient to provide in vivo inhibition of nNOS activity.