Neuraxial analgesia is not associated with an increased risk of post-partum relapses in MS

Background:

Obstetrical analgesia remains a matter of controversy because of the fear of neurotoxicity of local anesthetics on demyelinated fibers or their potential relationship with subsequent relapses.

Objective:

To assess the impact of neuraxial analgesia on the risk of relapse during the first 3 months post-partum, with a focus on women who experienced relapses during pregnancy.

Methods:

We analyzed data of women followed-up prospectively during their pregnancies and at least 3 months post-partum, collected in the Pregnancy in Multiple Sclerosis (PRIMS) and Prevention of Post-Partum Relapses with Progestin and Estradiol in Multiple Sclerosis (POPARTMUS) studies between 1992–1995 and 2005–2012, respectively. The association of neuraxial analgesia with the occurrence of a post-partum relapse was estimated by logistic regression analysis.

Results:

A total of 389 women were included, 215 from PRIMS and 174 from POPARTMUS. In total, 156 women (40%) had neuraxial analgesia. Overall, 24% experienced a relapse during pregnancy and 25% in the 3 months post-partum. Women with a pregnancy relapse were more likely to have a post-partum relapse (odds ratio (OR) = 1.83, p = 0.02), independently of the use of neuraxial analgesia. There was no association between neuraxial analgesia and post-partum relapse (OR = 1.08, p = 0.78).

Conclusion:

Neuraxial analgesia was not associated with an increased risk of post-partum relapses, whatever multiple sclerosis (MS) activity during pregnancy.

Multiple sclerosis in the Faroe Islands. 8. Notifiable diseases

OBJECTIVE

To seek evidence for a possible infectious origin of the type 1 epidemic of multiple sclerosis (MS) in the Faroe Islands. This began in 1943 coincident with their British military occupation throughout World War II.

MATERIALS AND METHODS

Data obtained from the Danish National Health Service were assessed for all notifiable diseases in the Faroe Islands reported from 1900 to 1977.

RESULTS

Among 38 disorders, selective increases were found for acute infectious gastroenteritis (AIGE) and paradysentery, with outbreaks in late 1940 and in 1943 shortly after the introduction and later marked influx, respectively, of British troops. Five other infections showed elevated numbers in 1941 and 1942.

CONCLUSIONS

There is a temporal association of AIGE and paradysentery in the Faroe Islands with the first arrival and later marked augmentation of British forces stationed there during the war. Rises in the incidence of other diseases in 1941-1942 seem more likely a consequence of increased foreign commercial travel by Faroese at that time.

Evaluation of disability, incapacity and environmental status scales in multiple sclerosis

From the Danish Multiple Sclerosis (MS) population a representative sample of 249 patients with a clinically definite diagnosis of MS has been tested by use of the Functional System Scale and Disability Status Scale of Kurtzke and the Incapacity and Environmental Status Scales of the IFMSS. Validity and reliability of the items and the properties of summed scales have been estimated. A statistical evaluation showed that generally the Incapacity and the Environmental Status Scales worked well. Problems encountered with the use of the Incapacity scale are mentioned and on statistical grounds a proposal of an incapacity scale with fewer items is presented.

A randomized study of two interferon- beta treatments in relapsing–remitting multiple sclerosis

Objective: To investigate whether the efficacy of interferon-beta (IFNβ) treatment of relapsing–remitting MS (RR-MS) was influenced by type, dose, and frequency of administration.

Methods: From June 1996 through October 1997, the authors offered participation to all Danish RR-MS patients who met the following criteria: definite MS, at least two relapses within 2 years, age 18 to 55, and an Expanded Disability Status Scale (EDSS) score of ≤5.5. The study was multicenter, controlled, open-label, randomized, head-to-head comparing IFNβ-1a 22 μg once a week (n = 143) with IFNβ-1b 250 μg every other day (n = 158), both subcutaneously, for 24 months. Patients who declined randomization were offered treatment with IFNβ-1b 250 μg every other day (n = 120). The primary end-points were the annualized relapse rate, the time to first relapse, and neutralizing antibody formation. The secondary endpoint was time to sustained progression

Results: The annual relapse rates were virtually equal in the two arms of the randomized study (IFNβ-1a: 0.70; IFNβ-1b: 0.71); so were the time to first relapse and the time to sustained progression. In the nonrandomized patients (IFNβ-1b), the annual relapse rate was not significantly different, but the time to progression was shorter.

Conclusion: In this study, 250 μg interferon-beta-1b administered every other day did not prove clinically superior to once-a-week administration of 22 μg interferon-beta-1a.

Multiple sclerosis in the Faroe Islands: an epitome

The Faroe Islands are a semi-independent unit of the Kingdom of Denmark and are located in the North Atlantic Ocean between Norway and Iceland. Efforts to identify all cases of multiple sclerosis (MS) since 1900 among Faroese have been continuing for over a quarter century. As of 1998 prevalence was 66 per 100,000, age adjusted to 1960 US population, with a rate of 100 for women and 34 for men. Median survival was at 29 to 34 years with no significant difference by sex. Faroese with overseas residence indicated that at least 2 years of exposure from age 11 on in a high-risk area are required for acquisition of MS. Among native resident Faroese the first instance of symptom onset was in 1943, heralding a type 1 epidemic of 21 cases. This was followed by three successive epidemics of 10, 10, 13 cases, with membership in each epidemic defined by calendar time and age of exposure. Age at exposure for epidemic I was 11 to 45 years; for later epidemics age 11 was the minimum. We believe the source of MS on the Faroes was their occupation by British troops for 5 years in World War II. We think they introduced a widespread, specific, persistent (but unknown) infection, probably asymptomatic, which we call the primary multiple sclerosis affection (PMSA). Only a small proportion of those affected with PMSA will years later show any clinical signs of MS. Models of transmission of PMSA through successive cohorts of Faroese fit the data for epidemics II and III, and predicted the occurrence of epidemic IV. The Faroese provide an ideal location to determine the nature of PMSA, since the disease has remained geographically stable for 50 years without further spread throughout the islands.

Multiple sclerosis in the Faroe Islands. 7. Results of a case control questionnaire with multiple controls

Detailed questionnaires were completed in 1978–79 by 23 of the 28 then known resident Faroese multiple sclerosis (MS) patients and 127 controls. These controls were divided into 69 Group A (patient sibs and other relatives), 37 Group B (matched neighbor controls, their spouses and sibs, plus patient's spouse), and 21 Group C (distant matched controls, spouses, relatives living where MS patients never resided and British troops were not encamped during the war). No differences between cases and controls were found for education, occupation, types of residence, bathing, sanitary or drinking facilities, and nature of house construction or heating. Detailed dietary histories, available for half the subjects, revealed no difference, cases versus controls, for four age periods between age 0 and 30 years, and for 16 specified foodstuffs. Animal exposures showed overall no consistent differences by location or type of animal. There was a tendency to greater exposure to British troops during the war for cases versus Groups A and B, but this did not attain statistical significance. Vaccinations for smallpox, tetanus and diphtheria were less common in the MS; no difference was found for other vaccinations. Except for a relative deficit in the cases for rubella and (insignificantly) for measles, mumps and chicken pox, reported illnesses were equally common among all groups. Operations, hospitalizations and injuries did not differentiate the groups, nor did age at menarche for women. Neurologic symptoms were significantly more common in the cases than in the controls.

Expression of endogenous retroviruses in blood mononuclear cells and brain tissue from multiple sclerosis patients

OBJECTIVES

To compare the expression of endogenous retroviruses in MS patients and controls.

MATERIAL AND METHODS

Peripheral blood mononuclear cells were obtained from 22 MS patients, a corresponding number of matched healthy donors and five patients with other central nervous system disease. Also brain specimens from MS patients and controls were obtained. Transcripts of various endogenous retroviruses in these samples were detected by RNA-PCR.

RESULTS

Several endogenous retroviral sequences were transcribed in peripheral blood mononuclear cells and brain tissue from MS patients as well as controls. A composite transcript of an endogenous retrovirus and a zinc finger sequence was more frequently found in healthy donors than in MS patients.

CONCLUSION

Some endogenous retroviruses are normally transcribed in white blood cells and brain tissue. The significance of those findings, which concerned the composite transcripts of the zinc finger sequence and its associated endogenous retrovirus is uncertain.

Possible association between multiple sclerosis and the human T cell leukemia virus (HTLV)-related endogenous element, HRES-1

In the present study we searched for an association between the human endogenous retroviral element HRES-1 and multiple sclerosis (MS). Fragments of this endogenous retrovirus were amplified for subsequent examination by single strand conformational analysis. We did not find HRES-1 markers exclusively linked with MS and only the two already known polymorphisms, which define three alleles of HRES-1, were detected. However, we found a significant difference in the distribution of these alleles between a group of 87 MS patients and a control group of 158 healthy individuals (P = 0.014). There were no differences in the distribution of the HRES-1 allelic forms between MS patients with a relapsing-remitting course and patients with chronic progressive MS. Our results provide evidence of an association between HRES-1 and MS. Possible explanations for this are discussed.

Three allelic forms of the human endogenous retrovirus, ERV3, and their frequencies in multiple sclerosis patients and healthy individuals

A possible association between the endogenous retrovirus, ERV3, and multiple sclerosis (MS) was examined. Samples of DNA from 74 MS patients and 159 healthy blood donors were subjected to enzymatic amplification followed by single strand conformational analysis to detect polymorphisms in the long terminal repeats of ERV3. Using this approach we detected six single base pair variations and a drop-out of a nucleotide. The linkage pattern of these base pair variations enabled us to define three allelic forms of ERV3. Polymorphisms exclusively present in the group of patients were not found and the distribution of the three allelic forms did not differ significantly between the group of controls and the MS group. Neither was there a significant difference in the distribution of the three alleles between MS patients with the progressive form and patients with relapsing/remitting MS. Our results are not in support of an association between ERV3 and MS.

Expression of endogenous retroviruses in blood mononuclear cells and brain tissue from multiple sclerosis patients

The aim of the present study was to examine whether there is an abnormal expression of certain endogenous retroviruses in MS patients. For this purpose samples of peripheral blood mononuclear cells were obtained from 22 MS patients, a corresponding number of age and sex-matched healthy donors and five patients with other diseases affecting the central nervous system. In addition, brain specimens of macroscopic normal white and gray matter from four MS patients and a similar number of controls were included in the study. Using an enzymatic amplification technique, we found expression of the endogenous retroviral sequences, HRES-1, HERV-K10 and ERV3 in most samples of peripheral blood mononuclear cells from MS patients and controls without obvious differences between these two groups. In contrast, composite transcripts of ERV3 and a zinc finger sequence were more frequently detected in healthy donors than in MS patients. At present, the possible significance of this is uncertain. The retroviral element 4-1 was not transcribed or only transcribed at a very low level in peripheral blood cells of controls and MS patients. Transcripts of various endogenous retroviruses were also detected in the brain samples, but a different pattern was not apparent in the MS group as compared with controls. Aspects concerning a possible association between endogenous retroviruses and autoimmunity are considered.

Multiple sclerosis in the Faroe Islands: transmission across four epidemics

As of 1991 we had ascertained 42 native resident Faroese plus 12 non-resident "migrant" Faroese with clinical onset of MS in this century. The resident series comprised four successive epidemics beginning in 1943 and then at 13-year intervals thereafter, a separation of very high statistical significance (p < 0.00001). We concluded that the first epidemic in the Faroes resulted from the introduction of a specific but unknown infection which we call the "primary MS affection" (PMSA) by occupying British troops during World War II. Clinical neurologic MS (CNMS) is then the rare late sequel of infection with PMSA. The first epidemic defined age of susceptibility to PMSA as age 11 to 45 at onset of exposure. Models of transmission used for the first three epidemics included the need for two years of exposure before PMSA acquisition and limitation of transmissibility of PMSA to age 13 to 26. With these conditions successive cohorts of susceptible Faroese were defined to account for the second and third epidemics, and they also predicted the occurrence of the fourth epidemic. Further consideration of these models suggests transmissibility is even more limited, perhaps to age 20 to 26 or so.

Effects of neuropsychological treatment in patients with multiple sclerosis

The chronic and progressive nature of multiple sclerosis (MS) often excludes patients from neuropsychological treatment. At the Multiple Sclerosis Rehabilitation Hospital, Haslev, 40 patients with mild to moderate cognitive and behavioral impairment associated with MS were randomized to either specific cognitive treatment (20 pts) by direct training, compensatory strategies and neuropsychotherapy, or to non-specific, deliberately diffuse mental stimulation (20 pts). Treatment was for a mean of 46 days. The effects of treatment were evaluated by neuropsychological tests before treatment, immediately after treatment (short-term effects) and 6 months later (long-term effects). After short-term treatment, effects on cognitive measures were not convincing, but on the Beck Depression Inventory (BDI) the specific cognitive treatment group reported significantly less depression. After 6 months only this group showed an effect, since the visuo-spatial memory was improved. However, the depression ratings (BDI) were almost maintained from the short-term level. Interestingly, the non-specific treatment group rated themselves as significantly more depressed. Conclusively, it is worth while to offer specific neuropsychological treatment to MS patients with cognitive and behavioral dysfunction.

Multiple sclerosis in the Faroe Islands. 5. The occurrence of the fourth epidemic as validation of transmission

Based on 32 cases with clinical onset 1943-73, we previously described the occurrence of clinical neurologic multiple sclerosis (CNMS) on the Faroe Islands as constituting three consecutive epidemics, with 20, 9, and 3 cases respectively. As of 1991 there were seven additional cases of CNMS with clinical onset 1984-1989 constituting the fourth epidemic, as well as three more members of epidemic III. We have proposed that CNMS is the rare late result of infection with PMSA (the primary multiple sclerosis affection), a state requiring some two years of exposure from age 11+ for acquisition by Faroese, and that PMSA was first transmitted during World War II by affected but asymptomatic British troops to Faroese residents; part of this (F1) cohort of affected asymptomatic Faroese transmitted PMSA to the next (F2) cohort comprising Faroese reaching age 11 in the interval when that F1 subset was present, and the F2 cohort similarly transmitted PMSA to the third (F3) cohort. Cases of CNMS defining epidemic I-III were members of the respective F1-F3 cohorts. The existence of epidemic IV within the F4 cohort of Faroese may be taken as validation of our transmission models and of our theses as to the nature of multiple sclerosis.

Multiple sclerosis in the Faroe Islands. VI. Studies of HLA markers

Occurrence of clinical neurologic multiple sclerosis (CNMS) among resident Faroese began between 1943 and 1973 and comprised three epidemics. The occupation by British forces for 5 years during World War II was interpreted to have been of major importance for the occurrence of these epidemics and led us to believe that CNMS is the rare, late result of a single, widespread, systemic and specific infectious disease which we have labelled the primary MS affection (PMSA). In this study we describe the occurrence of genetic markers of the HLA system in 16 Faroese MS patients, 25 of their siblings, 30 unrelated healthy neighbors and spouses to MS patients, 18 healthy controls from areas where no MS cases have been detected, and 80 unrelated normal Faroese. These studies show no significant deviations of HLA class I antigens, whereas the class II antigens do deviate: 50% of the Faroese MS patients carry the HLA-DR2 (DQ1/DRB 15) antigen, compared to a frequency of 15-20% among the control groups. Also the group of siblings of MS patients showed an increased frequency of DR4 (72%) compared to normal frequency among MS patients and other normal controls (43-47%). However, if DR15-positive individuals were excluded, this difference was further reduced. If PMSA was widespread within this group, DR4 or some closely associated genetic marker may confer protection against PMSA developing into CNMS. The occurrence of CNMS in these epidemics seems therefore associated to HLA class II-linked genetic factors similar to those found in studies of other caucasians with MS. This observation seems important in understanding the pathogenesis of this disease.

Localized in vivo proton spectroscopy in the brain of patients with multiple sclerosis

Localized proton spectroscopy was performed in 15 patients with acute or chronic multiple sclerosis (MS). Some of the patients were investigated serially, being given a total of 22 spectroscopic investigations. Resonances corresponding to free lipids were observed in six plaques. This was distinctly seen in two plaques at Days 70 and 85 after the occurrence of the plaques. A lesser content of lipids in plaques was observed as early as Day 10 and as late as nearly 1 year after occurrence. The relative concentration of N-acetyl asparate (NAA) was significantly lower in patients than in controls, and the relative concentration of choline (Cho) was significantly higher in patients than in controls. These differences were most pronounced in older plaques. MR spectroscopic demonstration of lipids in a MS plaque probably reflects disintegration of myelin, and a decreased NAA/Cho ratio may be related either to gliosis or to axonal degeneration, which sometimes occurs in longstanding MS.

Serum sex hormone and gonadotropin concentrations in premenopausal women with multiple sclerosis

Dysfunctions within the hypothalamic-pituitary-gonadal axis occur frequently among women with multiple sclerosis (MS) and may induce menstrual disturbances and subsequent infertility. We have measured serum concentrations of prolactin. gonadotropins and sex hormone binding globulin (SHBG) as well as free and bound oestrogen and androgen levels in 14 women of fertile age with MS. These women all displayed regular cycles without having experienced fertility problems. As controls 14 normal women with regular periods and ideal body weight of 91% (range 80-101) were included. Serum from both groups was sampled during the early follicular phase. The MS-patients had significantly (P less than 0.05) higher concentrations of prolactin, LH, FSH, total and free testosterone (P less than 0.01) and a significantly lower serum concentration of oestrone sulphate (P less than 0.01). The abnormal hormone concentrations were not related to clinical status of the disease. We propose that the increased androgen levels are of ovarian origin as adrenal androgens were normal. The reason for the slight increase of prolactin and the marked increase of gonadotropins in women with MS is speculative. As oestradiol levels, however, were within normal range, we assume that a peripheral resistance to gonadotropins combined with an abnormal central regulation causes the increased pituitary secretion.

Long-term prognosis and quality of life after reversible cerebral ischemic attacks

The long-term prognosis and quality of life of 201 patients admitted to hospital with reversible ischemic attacks (RIA) were estimated in a prospective study. The median follow-up time was 58 months. Further RIAs were reported by 91 patients (45%) and 48 (24%) suffered a stroke. The risk of stroke was markedly higher in the first 6 months after RIA, after which the annual stroke rate was rather constant with an average of 4.8%, about 8 times higher than expected. The average annual mortality rate for the RIA patients was 5.9%, which is significantly higher than expected. Cardiovascular deaths accounted for more than half of all deaths, stroke for one fourth. Life-table analysis of subgroups disclosed a much more favorable prognosis for women under 60 years. High systolic blood pressure, diabetes, and previous myocardial infarction were identified as risk factors. The occurrence of RIA had significantly influenced the quality of life and occupational status for the majority of the patients, even for those who did not suffer a subsequent stroke. Decreased working capacity, general asthenia and fatigue and impaired memory were the most common complaints. We conclude that RIA may be a more serious vascular event than generally believed. Apart from carrying a substantial risk of stroke and death, even a single RIA can cause permanent psychological dysfunction influencing the quality of life.

Twin studies in multiple sclerosis

The classical method of evaluating whether genetic factors are involved in the etiology of a given disease and to what extent is the twin method. However, methodological problems are great, and it is possible only in a few countries to apply this method to multiple sclerosis (MS) research. To draw genetical conclusions it is of fundamental importance that the material should be an unselected, unbiased material derived from a twin population. Another fundamental point is the diagnosis of twin zygosity. In MS research the twin method has been applied by several authors, but a Mendelian mode of inheritance has not been shown to exist. However, an association of MS to the genetic HLA system has been demonstrated, and this suggests that genetical factors are of some importance in the development of MS. Methodological problems are discussed and the most important twin studies in MS, including the Danish twin study.

A study of some immunological variables in twins, discordant for multiple sclerosis

11 twin pairs, discordant for multiple sclerosis (MS), were studied: 5 were monozygotic, 6 dizygotic. The mixed leukocyte reaction (MLR) with cells from unrelated patients with MS, the natural killer cell (NK) activity, OKT 4/OKT 8 ratio, and monocyte numbers were studied. The impaired MLR seen in some patients with MS was even more pronounced in the healthy twin, irrespective of the zygosity of the twins. A reduced NK activity and a high OKT 4/OKT 8 ratio is seen in the diseased twin compared to the healthy one, more strongly indicated at monozygosity. The significance of genetics, early environment, and disease is discussed.

Immune complexes and the complement factors C4 and C3 in cerebrospinal fluid and serum from patients with chronic progressive multiple sclerosis

Immune complexes (IC) have been found in both serum and cerebrospinal fluid (CSF) in multiple sclerosis (MS). The complement system is known to play a major role as a mediator of inflammation in immune complex disease. Therefore, we have investigated paired samples of serum and CSF from 32 patients with progressive MS for IC, the levels of the complement factors C4 and C3, and presence of their activation products (AP). IC was found in serum from 17 of the 32 MS patients (53%) and in CSF from 9 of 31 MS patients (29%). No correlation was found between the occurrence of IC in serum and in CSF. The levels of C3 in serum and CSF from the MS patients did not differ from the levels in a control group, whereas the levels of C4 in MS-serum were elevated and the C4 levels in MS-CSF reduced. A low level of CSF-C4 correlated significantly to the occurrence of CSF-IC. AP of C4 and C3 in serum were seen in 11 of the 32 patients (34%), appearing significantly more frequently among patients with circulating IC. No C4- or C3AP could be identified in CSF.

Acetylsalicylic acid in the prevention of stroke in patients with reversible cerebral ischemic attacks. A Danish cooperative study

Two hundred and three patients, 148 males and 55 females, who during the last month before admission had experienced at least one reversible cerebral ischemic attack of less than 72 hours duration, were randomly assigned to treatment with either acetylsalicylic acid (ASA) 1000 mg daily (101 patients) or placebo (102 patients). The average follow-up period was 25 months. The two treatment groups were comparable with respect to age, sex, associated diseases, risk factors, number and duration of cerebral ischemic attacks. No statistically significant differences were found between the treatment groups as to the primary end point: stroke or death (ASA group 20.8%, placebo group 16.7%). Occurrence of transient ischemic attacks during the treatment period was not reduced by ASA treatment, whereas there was a trend suggesting fewer myocardial infarctions in the ASA group (5.9%) than in the placebo group (13.7%). The difference, however, was not statistically significant (p = 0.10). We were thus unable to demonstrate any favorable influence of ASA 1000 mg daily in patients with reversible ischemic attacks. This study does not, of course, prove that ASA treatment is ineffective in stroke prevention.

Prognostic value of in vitro measurements of platelet aggregability and fibrinolytic activity in patients with reversible cerebral ischemic attacks

Platelet aggregability and fibrinolytic activity were studied repeatedly in 83 patients with reversible cerebral ischemic attacks over a median follow-up period of 26 months. Platelet hyperaggregability, defined as in vitro secondary aggregation obtained by adenosine diphosphate concentration less than or equal to 1 mumol/l, was demonstrated in 36.1% or the patients examined 5-8 days after the attack, but only in 6% of age- and sex-matched blood donors (p less than 0.001). Fibrinolytic activity was reduced in 57.8% of the patients, as compared with 20.5% of the controls. At the time of follow-up only 8% of the survivors showed platelet hyperaggregability, whereas the fibrinolytic activity was still reduced in 44.4%. Over the observation period 21.7% of the patients had a stroke or died. No significant correlation was found between abnormalities of platelet aggregability or of fibrinolytic activity, when observed 5-8 days after the ischemic episode, and the subsequent risk of stroke or death. It is concluded that in patients with recent cerebral ischemic attacks the demonstration of platelet hyperaggregability or reduced fibrinolytic activity appears to be without prognostic significance.

Circulating immune complexes and complement in the course of multiple sclerosis

To evaluate the reactions of the humoral immune response in the course of multiple sclerosis (MS), 21 patients were examined approximately 10 times at regular intervals for 1 year. The study included concomitant investigations of the total neurological deficit (TND) and laboratory analyses of the complement profile, detection of circulating immune complexes (CIC) and heterophilic antibodies (HPA). CIC were found in 58.7% of the investigations, often with simultaneous activation of C4 and C3. The mean values of the complement levels of the MS patients, however, did not differ from the values in a normal population. The consecutive investigations demonstrated a negative regression of TND on C4 from one month previously, a concomitant negative regression of TND on C3 and a positive regression of CIC from one month subsequently on TND. No significant relation between the clinical type of the disease and the occurrence of CIC was demonstrated, but the occurrence of attacks seemed to correlate with development of HPA.

Long-term prognosis after transient ischemic attacks

A retrospective follow-up study of 243 patients with transient ischemic attacks (TIA) is reported. The long-term mortality of the patients was higher than that of the corresponding general population. It is demonstrated that the excess mortality over the whole period of observation, irrespective of the age and sex of the patients, can be characterized by a single figure expressing the slope of the curve obtained by semilogarithmic plotting of the ratios of observed to expected survival against time. The use of this numerical expression--in the present series -0.04--will thus facilitate comparisons of the survival of TIA patients drawn from different populations. Unfavourable prognostic factors were: carotid TIA, associated extracerebral disease, and a history of hypertension. Fatal strokes, being four times as frequent as expected according to published incidence figures, accounted for 20% of the deaths, heart disease 38%. Stroke deaths tended to occur earlier than cardiac deaths. The results support the concept that most TIAs, like strokes, are incidents in the progressive course of a generalized vascular disease. The finding of a constant excess mortality over the years following a TIA makes it difficult to recommend a discontinuation of prophylactic therapy at any particular time.

A double-blind trial with baclofen (Lioresal) and diazepam in spasticity due to multiple sclerosis

In 17 in-patients suffering from spasticity due to multiple sclerosis, the effect and tolerability periods were 4 weeks each. As to efficacy, the variables: spasticity, clonus, flexor spasms, gait and bladder function were evaluated clinically. No significant difference was found between the two drugs. As far as side-effects are concerned, sedation was specifically inquired about. Apart from that, spontaneoulsy reported side-effects were recorded. Sedation was more often seen during treatment with diazepam, while the side-effects during baclofen treatment were more varied. The total number and severity of side-effects were equal in the two treatment groups. A preference for one of the two treatment periods was stated by the investigator before the code was broken. A significant difference (p less than 0.001) in favor of Lioresal was found. This is discussed in the light of the fact that no significant difference was found for the individual symptoms or side-effects.