Comparative effectiveness and cost-effectiveness of natalizumab and fingolimod in rapidly evolving severe relapsing-remitting multiple sclerosis in the United Kingdom

AIM

To evaluate the real-world comparative effectiveness and the cost-effectiveness, from a UK National Health Service perspective, of natalizumab versus fingolimod in patients with rapidly evolving severe relapsing-remitting multiple sclerosis (RES-RRMS).

METHODS

Real-world data from the MSBase Registry were obtained for patients with RES-RRMS who were previously either naive to disease-modifying therapies or had been treated with interferon-based therapies, glatiramer acetate, dimethyl fumarate, or teriflunomide (collectively known as BRACETD). Matched cohorts were selected by 3-way multinomial propensity score matching, and the annualized relapse rate (ARR) and 6-month-confirmed disability worsening (CDW6M) and improvement (CDI6M) were compared between treatment groups. Comparative effectiveness results were used in a cost-effectiveness model comparing natalizumab and fingolimod, using an established Markov structure over a lifetime horizon with health states based on the Expanded Disability Status Scale. Additional model data sources included the UK MS Survey 2015, published literature, and publicly available sources.

RESULTS

In the comparative effectiveness analysis, we found a significantly lower ARR for patients starting natalizumab compared with fingolimod (rate ratio [RR] = 0.65; 95% confidence interval [CI], 0.57-0.73) or BRACETD (RR = 0.46; 95% CI, 0.42-0.53). Similarly, CDI6M was higher for patients starting natalizumab compared with fingolimod (hazard ratio [HR] = 1.25; 95% CI, 1.01-1.55) and BRACETD (HR = 1.46; 95% CI, 1.16-1.85). In patients starting fingolimod, we found a lower ARR (RR = 0.72; 95% CI, 0.65-0.80) compared with starting BRACETD, but no difference in CDI6M (HR = 1.17; 95% CI, 0.91-1.50). Differences in CDW6M were not found between the treatment groups. In the base-case cost-effectiveness analysis, natalizumab dominated fingolimod (0.302 higher quality-adjusted life-years [QALYs] and £17,141 lower predicted lifetime costs). Similar cost-effectiveness results were observed across sensitivity analyses.

CONCLUSIONS

This MSBase Registry analysis suggests that natalizumab improves clinical outcomes when compared with fingolimod, which translates to higher QALYs and lower costs in UK patients with RES-RRMS.

Effect of aging on clinical features and metabolic complications of women with polycystic ovary syndrome

PURPOSE

To assess the distribution of clinical features and metabolic abnormalities of polycystic ovary syndrome (PCOS) women according to their age.

METHODS

Retrospective study on 602 women (mean age 23.9 ± 6.2 years), diagnosed according to International PCOS Network Guidelines criteria as having PCOS in a University-based Hospital. Anthropometric features, hormonal and metabolic parameters were measured and compared between the different age groups (group A ≤ 20 years; group B 21-30 years; group C > 30 years).

RESULTS

Patients in group A were more often hyperandrogenic, while in group C hypertension, dyslipidemia, obesity, impaired fasting glucose, and insulin resistance (IR) were more prevalent. After adjusting for BMI, age correlated positively with sex hormone-binding globulin (SHBG), IR, total- and LDL-cholesterol, and negatively with DHEAS, insulin, and free androgen index (FAI). SHBG was significantly associated with IR and atherogenic dyslipidemia, while FAI levels were linked to hypertension, independently of other factors considered. Furthermore, the regression analysis showed a stronger relationship between BMI and metabolic outcomes, regardless of age.

CONCLUSION

Polycystic ovarian syndrome (PCOS) phenotype changes with age. Clinical and biochemical hyperandrogenism are a major concern in young PCOS women, while metabolic burden tends to increase with aging. Some of the cardiovascular risk factors are dependent on FAI and SHBG levels, whereas BMI confirms its key role in the genesis of most of the metabolic sequelae in PCOS, independently of age.

Anti-inflammatory disease-modifying treatment and disability progression in primary progressive multiple sclerosis: a cohort study

BACKGROUND AND PURPOSE

Treatment options in primary progressive multiple sclerosis (PPMS) are scarce and, with the exception of ocrelizumab, anti-inflammatory agents have failed to show efficacy in ameliorating disability progression. The aim of this study was to investigate a potential effect of anti-inflammatory disease-modifying treatment on disability outcomes in PPMS.

METHODS

Using MSBase, a large, international, observational database, we identified patients with PPMS who were either never treated or treated with a disease-modifying agent. Propensity score matching was used to select subpopulations with similar baseline characteristics. Expanded Disability Status Scale (EDSS) outcomes were compared with an intention-to-treat and an as-treated approach in paired, pairwise-censored analyses.

RESULTS

Of the 1284 included patients, 533 were matched (treated, n = 195; untreated n = 338). Median on-study pairwise-censored follow-up was 3.4 years (quartiles 1.2-5.5). No difference in the hazard of experiencing 3-month confirmed EDSS progression events was observed between the groups [hazard ratio (HR), 1.0; 95% confidence interval (CI), 0.6-1.7, P = 0.87]. We did not find significant differences in the hazards of confirmed EDSS improvement (HR, 1.0; 95% CI, 0.6-1.6, P = 0.91) or reaching a confirmed EDSS step ≥7 (HR, 1.1; 95% CI, 0.7-1.6, P = 0.69).

CONCLUSION

Our pooled analysis of disease-modifying agents suggests that these therapies have no substantial effect on short- to medium-term disability outcomes in PPMS.

ELIME assay vs Real-Time PCR and conventional culture method for an effective detection of Salmonella in fresh leafy green vegetables

The detection of Salmonella according to EC regulation is still primarily based on traditional microbiological culture methods that may take several days to be completed. The purpose of this work is to demonstrate the applicability of an Enzyme-Linked-Immuno-Magnetic-Electrochemical (ELIME) assay, recently developed by our research group for the detection of salmonella in irrigation water, in fresh (raw and ready-to-eat) leafy green vegetables by comparison with Real-Time PCR (RTi-PCR) and ISO culture methods. Since vegetables represent a more complex matrix than irrigation water, preliminary experiments were carried out on two leafy green vegetables that resulted negative for salmonella by the ISO method. 25g of these samples were experimentally inoculated with 1-10 CFU of S. Napoli or S. Thompson and pre-enriched for 20h in two different broths. At this time aliquots were taken, concentrated at different levels by centrifugation, and analyzed by ELIME and RTi-PCR. Once selected the best culture medium for salmonella growth, and the optimal concentration factor suitable to reduce the sample matrix effect, enhancing the out-put signal, several raw and ready-to-eat leafy green vegetables were artificially inoculated and pre-enriched. Aliquots were then taken at different incubation times and analyzed with both techniques. Results obtained showed that 20 and 8h of pre-enrichment were required to allow the target salmonella (1-10 CFU/25g) to multiply until reaching a detectable concentration by ELIME and RTi-PCR assays, respectively. A confirmation with the ISO culture method was carried out. Based on the available literature, this is the first report of the application of an ELISA based method for the detection of Salmonella in vegetables.

Development and evaluation of an ELIME assay to reveal the presence of Salmonella in irrigation water: Comparison with Real-Time PCR and the Standard Culture Method

A reliable, low-cost and easy-to-use ELIME (Enzyme-Linked-Immuno-Magnetic-Electrochemical) assay for detection of Salmonella enterica in irrigation water is presented. Magnetic beads (MBs), coupled to a strip of eight-magnetized screen-printed electrodes localized at the bottom of eight wells (8-well/SPE strip), effectively supported a sandwich immunological chain. Enzymatic by-product is quickly measured by chronoamperometry, using a portable instrument. With the goal of developing a method able to detect a wide range of Salmonella serotypes, including S. Napoli and S. Thompson strains responsible for various community alerts, different kinds of MBs, antibodies and blocking agents were tested. The final system employs MBs coated with a broad reactivity monoclonal antibody anti-salmonella and blocked with dry milk. For a simple and rapid assay these two steps were performed in a preliminary phase, while the two sequential incubations for the immuno-recognition events were merged in a single step of 1h. In parallel a Real-Time PCR (RTi-PCR) method, based on a specific locked nucleic acid (LNA) fluorescent probe and an internal amplification control (IAC), was carried out. The selectivity of the ELIME and RTi-PCR assays was proved by inclusivity and exclusivity tests performed analyzing different Salmonella serotypes and non-target microorganisms, most commonly isolated from environmental sources. Furthermore, both methods were applied to experimentally and not experimentally contaminated irrigation water samples. Results confirmed by the ISO culture method, demonstrated the effectiveness of ELIME and RTi-PCR assays to detect a low number of salmonella cells (1-10 CFU/L) reducing drastically the long analysis time usually required to reveal this pathogen.

Implementation of the ‘Sapere Migliora’ information aid for newly diagnosed people with multiple sclerosis in routine clinical practice: a late-phase controlled trial

Background:

The SIMS-Trial showed that the ‘Sapere Migliora’ information aid (IA) for newly diagnosed people with multiple sclerosis (PwMS) effectively improved patient knowledge and satisfaction with care.

Objectives:

The objectives of this paper are to assess the effectiveness of the IA in clinical practice and to compare the whole IA with the take-home booklet/website component alone.

Methods:

After updating the IA and replacing the CD with a website, a prospective, open-label non-randomised controlled trial compared the whole IA (group A, five SIMS-Trial centres) to take-home (group B, 16 centres). One month after the intervention, participants completed the MS Knowledge Questionnaire (MSKQ), care satisfaction questionnaire (COSM-R) (primary study outcomes), Hospital and Anxiety Depression Scale, and ad hoc questionnaire appraising the IA.

Results:

We enrolled 159 newly diagnosed PwMS (May 2012–March 2013). Drop-outs were four of 77 (5%, group A) and 11/82 (13%, group B). Primary endpoint (highest tertile both for MSKQ and COSM-R section 2 scores) was achieved by 38/77 (49%) group A and 33/82 (40%) group B ( p = 0.25). Attainment of secondary outcomes was also similar between groups.

Conclusions:

This study shows that the entire IA is not superior to the booklet/website alone, and that both are comparable in efficacy to the intervention arm of the SIMS-Trial.

Trial registration number:

ISRCTN78940214.

Anetoderma: evidence of the relationship with autoimmune disease and a possible role of macrophages in the etiopathogenesis

Anetoderma is a benign condition characterized by round or oval macular lesions with focal loss of dermal elastic tissue resulting in localized areas of flaccid or herniated saclike skin. Often, the anetoderma is associated with immuno-mediated pathogenetic mechanism. In this article, we describe the association between anetoderma and autoimmune diseases, by underlining the role and the action of macrophages as a possible etiopathogenesis.

An information aid for newly diagnosed multiple sclerosis patients improves disease knowledge and satisfaction with care

Background: Patients report information deficits in the period surrounding diagnosis of multiple sclerosis (MS). We assessed the effectiveness of an add-on information aid for newly diagnosed MS patients.

Methods: We randomly assigned 120 newly diagnosed MS patients from five Italian centres to diagnosis disclosure (current practice at the centre) or current practice plus information aid (ISRCTN81072971). The information aid consisted of a personal interview with a physician using a navigable compact disc and a take-home booklet. The primary composite endpoint was score in the highest tertile of MS knowledge and satisfaction with care questionnaires. Other endpoints were safety; treatment adherence; extra contacts/consultations; switching of care centre; and changes in Hospital Anxiety and Depression Scale and Control Preference Scale scores.

Results: At 1 month, 30/60 intervention and 8/60 control patients achieved the primary endpoint (odds ratio [OR] 6.5, 95% CI 2.6—16.0; p < 0.001; number needed to treat [NNT] 3). Figures at 6 months were 26/60 intervention and 11/60 control patients (OR 3.4, 95% CI 1.5—7.8; p = 0.04; NNT 4). There were no adverse events. No significant treatment effects were seen on secondary outcomes.

Conclusion: The information aid was safe and significantly associated with attainment of the primary outcome at 1 and 6 months.

The Multiple Sclerosis Knowledge Questionnaire: a self-administered instrument for recently diagnosed patients

There are few studies on patient knowledge in multiple sclerosis (MS), and only two published questionnaires. The objective of this article was to develop and validate the MS Knowledge Questionnaire (MSKQ), a self-assessed instrument for newly diagnosed MS patients. Thirty multiple-choice statements, conceived to test MS knowledge, were produced by a multidisciplinary panel and pre-tested on three MS patients, resulting in an intermediate 26-item version. This was tested on 54 MS patients for internal consistency, content and construct validity (validation sample I). The final (25-item) MSKQ was a primary outcome measure in the SIMS-Trial on an information aid to newly diagnosed MS patients. Postal responses of SIMS-Trial participants to the MSKQ a month after intervention (validation sample II) were analysed. Median MSKQ scores in validation samples I and II were, respectively, 18 (range 9-23) and 17 (range 3-24). Acceptability, internal consistency (Kuder-Richardson-20 formula 0.76) and content validity were good. Educational attainment and receiving the information aid were the main independent predictors of MS knowledge. Other predictors were female sex (positive association) and disease duration (negative association). In conclusion, the MSKQ has good clinimetric properties and is sensitive to an educational intervention. We propose the MSKQ as a brief instrument for clinical practice and research.

Responsiveness of patient reported outcome measures in multiple sclerosis relapses: the REMS study

OBJECTIVES

To assess the responsiveness of the three most used patient reported multiple sclerosis (MS) specific questionnaires: the Functional Assessment of MS (FAMS), the MS Impact Scale (MSIS-29) and the 54 item MS Quality of Life (MSQOL-54).

DESIGN

Prospective multicentre longitudinal study on 104 MS patients treated with intravenous steroids for clinical exacerbation.

METHODS

Patient reported data, Expanded Disability Status Scale (EDSS) score and clinical information were collected at admission and 8 weeks later. "Internal" (distribution based) responsiveness was assessed by standardised response means (SRM). "External" (anchor based) responsiveness was assessed by receiver operating characteristic (ROC) curves in relation to corresponding changes in a pre-specified reference measure (anchor). The pre-specified anchor was patients' self-reported recovery assessed on a 5 point Likert scale.

RESULTS

SRM was 0.39 for FAMS, 0.58 for MSIS-29 physical scale, 0.45 for MSIS-29 psychological scale, 0.71 for MSQOL-54 physical health composite and 0.57 for MSQOL-54 mental health composite. Seventy-three patients (70%) reported they had improved; physicians agreed substantially with patient assessments (kappa statistic 0.70, 95% CI 0.54 to 0.85). Areas under ROC curves differed significantly from 0.50 only for the MSIS-29 and MSQOL-54 scales where areas ranged from 0.65 (95% CI 0.53 to 0.76) for the MSIS-29 psychological scale to 0.70 (95% CI 0.58 to 0.81) for the MSQOL-54 mental health composite. Areas under ROC curves assessed using a physician based anchor were similar to the patient based areas.

CONCLUSIONS

The responsiveness of the MS specific instruments was less than ideal. The MSIS-29 and MSQOL-54 were significantly more responsive, using both distribution based and anchor based approaches, than FAMS, and should be preferred in longitudinal studies.

Ethical questions in the treatment of subjects with dementia. Part I. Respecting autonomy: awareness, competence and behavioural disorders

The document deals with some ethical issues raised by the treatment of demented people. In particular the conceptual and empirical aspects of the assessment of awareness and competence of these patients are analysed, as well as the dilemmas related to the treatment of behavioral disorders.

Communicating the diagnosis of multiple sclerosis - a qualitative study

Studies on communicating the diagnosis of multiple sclerosis (MS) are few, and all reveal communication and information deficits. We explored the personal experience of diagnosis communication of people with MS and health professionals, using a qualitative methodology. Data were obtained from two sets of focus group meetings (FGM) with people with MS (total 23; 16 females; age range: 23-70) and one FGMs with health professionals (four neurologists, three psychologists, two nurses). The methods of framework analysis were applied to meeting transcripts to identify key topics and categories. The experience of communicating/receiving an MS diagnosis was highly varied; all patients reported the moment as powerfully evocative and unforgettable. Very poor levels of support and information were sometimes given. Although diagnosis communication had improved in more recent experience, all felt it should be further improved with appropriate setting (privacy, no interruptions, sufficient time), information tailored to the individual, and continuity of care. Such improvements imply a more meaningful patientneurologist relationship, and also structural and organisational changes. Multiple Sclerosis 2007; 13: 763-769. http://msj.sagepub.com

Amantadine for fatigue in multiple sclerosis

BACKGROUND

Fatigue is one of the most common and disabling symptoms of people with Multiple Sclerosis (MS). The effective management of fatigue has an important impact on the patient's functioning, abilities, and quality of life. Although a number of strategies have been devised for reducing fatigue, treatment recommendations are based on a limited amount of scientific evidence. Many textbooks report amantadine as a first-choice drug for MS-related fatigue because of published randomised controlled trials (RCTs) showing some benefit.

OBJECTIVES

To determine the effectiveness and safety of amantadine in treating fatigue in people with MS.

SEARCH STRATEGY

We searched The Cochrane MS Group Trials Register (July 2006), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2006), MEDLINE (January 1966 to July 2006), EMBASE (January 1974 to July 2006), bibliographies of relevant articles and handsearched relevant journals. We also contacted drug companies and researchers in the field.

SELECTION CRITERIA

Randomised, placebo or other drugs-controlled, double-blind trials of amantadine in MS people with fatigue.

DATA COLLECTION AND ANALYSIS

Three reviewers selected studies for inclusion in the review and they extracted the data reported in the original articles. We requested missing and unclear data by correspondence with the trial's principal investigator. A meta-analysis was not performed due to the inadequacy of available data and heterogeneity of outcome measures.

MAIN RESULTS

Out of 13 pertinent publications, 5 trials met the criteria for inclusion in this review: one study was a parallel arms study, and 4 were crossover trials. The number of randomised participants ranged between 10 and 115, and a total of 272 MS patients were studied. Overall the quality of the studies considered was poor and all trials were open to bias. All studies reported small and inconsistent improvements in fatigue, whereas the clinical relevance of these findings and the impact on patient's functioning and health related quality of life remained undetermined. The number of participants reporting side effects during amantadine therapy ranged from 10% to 57%.

AUTHORS' CONCLUSIONS

The efficacy of amantadine in reducing fatigue in people with MS is poorly documented, as well as its tolerability. It is advisable to: (1) improve knowledge on the underlying mechanisms of MS-related fatigue; (2) achieve anagreement on accurate, reliable and responsive outcome measures of fatigue; (3) perform good quality RCTs.

Serum PSA levels are not affected by the menstrual cycle or the menopause, but are increased in subjects with polycystic ovary syndrome

BACKGROUND/AIMS

Prostatic specific antigen (PSA) is the most specific prostatic tumor marker in man. Recently, PSA has been detected in a variety of tissues and fluids in women, and its determination suggested as a marker of hyperandrogenism. However, precise information about the physiology of PSA in females is not available. The goal of this study was to assess serum concentrations of PSA in healthy pre-menopausal women (healthy pre-menopausal group), menopausal women (menopause group) and patients with polycystic ovary syndrome (PCOS group).

METHODS

PSA, androgens, LH, FSH, 17-beta-estradiol (E2), progesterone (Pg) were assessed in 40 post-menopausal women, 35 fertile controls and 35 women with PCOS.

RESULTS

No significant difference in PSA concentrations could be demonstrated in different phases of the menstrual cycle in healthy pre-menopausal group and between pre- and post-menopausal groups. No correlations could be demonstrated between serum PSA levels and the following parameters: age, body mass index (BMI), LH, FSH, E2, testosterone (T), DHEAS, and SHBG, both in pre- and post-menopausal women. Significantly higher PSA levels (median=14 pg/ml) were found in the PCOS group compared to both pre-menopausal (median=5 pg/ml) and menopausal (median= 5 pg/ml) groups (p< 0.05).

CONCLUSIONS

only minor fluctuations of serum PSA concentrations are observed in healthy pre- and post-menopausal women, while serum level is higher in PCOS, and therefore PSA can be considered a suitable marker of female hyperandrogenism.

What do Italians at high risk of stroke know about ischaemic stroke? A survey among a group of subjects undergoing neuro-sonographic examination

The objective was to assess the knowledge about ischaemic stroke among selected groups of persons at high risk for stroke. Outpatients referred to 3 hospital ultrasound departments in the Marche Region (Italy) were asked to answer a questionnaire. Data were collected on: (1) demographic characteristics; (2) risk profile determined using Coppola et al.'s scoring system; (3) knowledge about symptoms, risk factors, part of the body injured and best referral option for stroke. Of the 352 respondents, around 52% were unable to report even one warning symptom of stroke, while 58.4% of participants at increased risk did not know any risk factors. Only 64.5% identified the brain as the part of the body injured by stroke. Only 59.4% considered the Emergency Department as the best referral option in the event of stroke. This study confirms poor knowledge about stroke in our study population, particularly in subjects with increased stroke risk.

[Headache as "sentinel" symptom in personnel involved in the preparation and administration of antineoplastic drugs]

The increased prevalence of neoplastic diseases observed over the last years has resulted for in more frequent operations of preparation and administration of antiblastic drugs performed by the medical personnel. In this study, we examined a group of subjects involved in the preparation of ACNU, Methotrexate, Novantrone, Vincristine, Cyclophosphamide, Carboplatinum, Mythoxantrone, in order to elucidate whether headache may represent an early symptom of exposure to these products. At the same time, we measured the degree of pollution in the air surrounding the vertical laminar flow aspiration cabinet used for drug preparation. The 66.6% of the 12 subjects studied, 9 females and 3 males, complained of headache. However, the environmental detection using high performance liquid chromatography coupled with triple quadrupole mass spectrometry (HPLC/MS/MS) gave negative results with respect to a possible environmental damage. These findings suggest that headache is the onset symptom of the toxic effect of antiblastic chemiotherapics in the medical personnel involved in drug preparation and administration.

Late diagnosis in severe and mild intellectual disability in adulthood

BACKGROUND

The diagnosis of intellectual disability (ID) is highly dependent on a comprehensive personal and family medical history, a complete physical examination and a careful developmental assessment of the patient. Our study intended to: (1) classify the aetiology of mild and severe ID in an adult population of 140 Italian subjects; (2) evaluate the frequency of associated medical conditions; (3) evaluate the age of diagnosis in both groups; and (4) underline the importance of aetiological diagnosis for adult ID patients also.

METHODS

The study involved 140 consecutive adult Italian ID inpatients and outpatients neurologically investigated at the Neurological Institute C. Mondino of Pavia Service for Mental Retardation. A total of 80 patients had mild ID (MID group) (39 females, 41 males), mean age 34 years (range 19-61 years), mean IQ = 64 (range 51-75), and 60 had severe ID (SID group) (32 females, 28 males), mean age 30 years (range 19-69 years). They underwent a complete diagnostic work-up that comprised prenatal, perinatal and postnatal history, physical examinations, laboratory investigations, genetic survey and neuroradiological investigations to determine the aetiology of ID and to evaluate the presence of associated medical conditions.

RESULTS

ID aetiology was classified as prenatal in 34% of the MID and 28% of the SID group. Perinatal and postnatal events were found in 6% of the MID and in 5% of the SID group. Associated medical conditions were found in 97 patients (47% MID and 26% SID). A genetic diagnosis was possible in 6% of patients above 20 years of age and in 5% of patients above 40 years. A diagnosis of cerebral dysgenesis was possible in 5% of patients above 20 years and 4% of patients above 40 years.

CONCLUSIONS

A long interval between the diagnosis of ID and the aetiological definition can be observed in a significant percentage (24%) of our population, leading to unfortunate consequences of late diagnosis: late onset of a specific therapeutic program, genetic counselling that is frequently no more useful, and ineffective prenatal diagnosis, leading to the birth of other affected subjects (for familiar ID).

Italian version of the Chicago multiscale depression inventory: translation, adaptation and testing in people with multiple sclerosis

Depression is the commonest psychiatric disturbance in people with multiple sclerosis (MS), with prevalence higher than in the general population and other chronic diseases. However, accurate assessment of depressive symptoms can be biased by somatic symptoms which are part of both MS and depression. We translated and adapted into Italian the Chicago multiscale depression inventory (CMDI) and assessed its acceptability, internal consistency and test-retest reliability in 213 MS outpatients and 213 individually matched healthy controls. The questionnaire was also tested in 32 people with major depression. Acceptability, internal consistency, and test-retest reliability were good overall. We found greater odds for depressive symptoms in people with MS than healthy controls, with highest odds ratio for somatic symptoms (vegetative subscale). The Italian CMDI is characterized by good acceptability, internal consistency, and test-retest reliability. These findings support the use of the CMDI in Italian subjects with MS to screen for and follow depressive symptoms.

General practitioners facing dementia: are they fully prepared?

We assessed knowledge about Alzheimer's disease (AD) in a sample of Italian general practitioners (GPs). We first carried out a propedeutic study to verify the ability of an Italian version of the University of Alabama at Birmingham's AD Knowledge Test for Health Professionals to distinguish between 20 AD specialists and 20 non-specialists and to gain reference values. We then administered the test, together with a short questionnaire, to 139 GPs attending an educational programme in November 2000. The cut-off score for discriminating specialists from non-specialists was >/=9. Among the 95 GPs who performed the AD Knowledge Test (68.3% response rate), 21% had a total score >/=9. Our findings suggest that particular focus should be given to dementia in continuing medical education (CME) programmes for GPs.

Why physicians need to look more closely at the use of complementary and alternative medicine by multiple sclerosis patients

With the aim of contributing to the knowledge of attitudes, patterns and motivations for the use of complementary and alternative medicine (CAM) for multiple sclerosis (MS), 109 MS outpatients, or their close relative in cases of mental status impairment, were interviewed using a semi-structured questionnaire. The main results are: (i). 35.7% used at least one CAM at least once; (ii). homeopathy and diets were the most common; (iii). 39.4% showed a positive attitude towards CAM; (iv). a perceived benefit was recorded in 61.5% of cases; (v). the referral source was a physician in only 12.8% of cases; (vi). caring neurologist was not consulted in 82% and generalist was not consulted in 67% of cases; (vii). of 61 CAM interventions, 21 were expected to be disease-modifying and 40 symptomatic; (viii). CAM negatively influenced compliance with conventional medical management in very few cases (2/39); (ix). a higher expanded disability status scale (EDSS) was observed in CAM users; and (x). in those who used CAM during last 3 years (21.1%), the approximate mean cost per year per person was 483 euro. In Italy, the use of CAM in MS is widespread but costly. This study has provided further baseline data on which to assess trends in CAM use and has highlighted issues for patients and conventional doctors about the use of CAM to deal with health problems. More research into the implications of concurrent use of CAM with conventional medicine on public health care is required.

Reliability of the nitroglycerin provocative test in the diagnosis of neurovascular headaches

Nitroglycerin administration provokes spontaneous-like migraine attacks in migraine and cluster headache (CH) patients. Nitroglycerin-induced migraine-like headache has been used as an experimental model of migraine. In this paper, we evaluate the possibility of using the nitroglycerin provocative test (NPT) as a supportive measure in the diagnosis of primary neurovascular headaches by assessing its reliability on a large population and adopting strict criteria for rating the response as positive or negative. Our population consisted of 197 migraineurs, 42 subjects suffering from cluster headache and 53 healthy controls. In migraine without aura, the test sensitivity was 82.1%, specificity 96.2% and accuracy 85.5%, while in subjects suffering from migraine with aura, the reliability of the NPT was less satisfactory (sensitivity 13.6%, specificity 96.2% and accuracy 72%). In CH patients tested during the active phase of the disease the sensitivity was 80.6%, specificity 100% and accuracy 92.9%. NPT is an easy, low-cost and reliable method for supporting the diagnosis of migraine without aura and cluster headache.

[Prevalence of primary headache related to work activity in a group of hospital workers undergoing periodic visits (D. Lgs. 626/94 s.s.m. ed i.)]

Since headache is one of the most frequent complaints in clinical practice, its burden in terms of the both social cost and individual sufference is considerable. Headache is a frequent cause of absence from work and decreased productivity; it is therefore clear that investigating its possible relationship with working conditions represents a topic of increasing interest for the scientific community. This study was aimed at identifying specific occupational factors able to modify the prevalence of headache in a population of hospital workers undergoing periodic examinations. It was indeed suspected that the hospital environment could be per se a predisposing factor for headache onset, due to the considerable impact of stress on such working environment. The results obtained suggest that specific occupational conditions such as shift work and P.C. use may play an important role in headache development even in the presence of a wide number of professional risk factors.

Nitric oxide pathway and response to nitroglycerin in cluster headache patients: plasma nitrite and citrulline levels

Nitric oxide (NO) may participate in the mechanisms underlying vascular headaches, such as migraine and cluster headache (CH), by triggering neurogenic inflammation and activation of fibres conveying nociceptive inputs to the trigeminal ganglion. Similarly to migraine, the administration of the NO donor glyceryltrinitrate (GTN) to CH patients is a known model of inducing spontaneous-like attacks. We carried out a GTN test (0.9 mg, sublingually) in 18 patients with episodic CH in active phase and 12 controls. The plasma levels of NO metabolite nitrites (NO2-), after conversion of nitrates to NO2-, were measured spectrophotometrically at baseline, at the maximum intensity of the induced response (or 45 min after GTN in controls), and 120 min after GTN administration. The basal plasma levels of L-citrulline were also assayed in patients and controls using high-performance liquid chromatography. Basal NO2- levels, similar in GTN-responsive patients and controls (48.3 +/- 10.6 and 44.6 +/- 9.5 micromol/l, respectively) were found to be increased significantly at pain peak in patients (76.1 +/- 10.2 micromol/l) and after 45 min in controls (78.2 +/- 9.6 micromol/l) (P < 0.01 vs. respective baseline values), but not after 120 min, without differences between groups. L-citrulline levels in basal conditions showed no differences between groups (patients 64.8 +/- 11.7, controls 67.3 +/- 10.8 micromol/l). These data do not support the presence of a basal hyperactivity of the L-arginine-NO pathway in CH patients. Increased NO production may be of importance in the mechanisms leading to CH attacks, but other factors are likely to render CH patients hyperresponsive to NO, and ultimately to cause the occurrence of pain and associated features.

Relatives' attitudes towards informing patients about the diagnosis of Alzheimer's disease

OBJECTIVES

To evaluate relatives' attitudes towards informing patients with Alzheimer's disease (AD) about their diagnosis.

SETTING

A university hospital in Italy.

METHODS

The closest relatives of each of 71 subjects diagnosed for the first time as having AD were interviewed, using a semistructured questionnaire. Spontaneous requests by relatives not to communicate issues concerning the diagnosis were also recorded.

RESULTS

Forty three (60.6%) relatives spontaneously requested that patients not be fully informed. After being interviewed, nobody thought that the patient should be given all the information. Justifications were related to the fear of the onset or worsening of depressive symptoms in the patient.

CONCLUSIONS

In Italy relatives' opposition to informing AD patients appears to be common. Knowledge of the relatives' attitudes may be useful for clinicians but disclosure of diagnosis should be based on the clinical evaluation of the patient and on a prudent evaluation of the relationship between the patient and her/his relative caregiver.

Amantadine for fatigue in multiple sclerosis

BACKGROUND

Fatigue is one of the most common and disabling symptoms of people with Multiple Sclerosis (MS). The effective management of fatigue has an important impact on the patient's functioning, abilities, and quality of life. Although a number of strategies have been devised for reducing fatigue, treatment recommendations are based on a limited amount of scientific evidence. Many textbooks report amantadine as a first-choice drug for MS-related fatigue because of published randomised controlled trials (RCTs) showing some benefit. We performed a systematic review in order to gather existing evidence, and contribute to the topic.

OBJECTIVES

To determine the effectiveness and safety of amantadine in reducing fatigue in people with MS.

SEARCH STRATEGY

RCTs of amantadine were identified using MEDLINE, EMBASE, bibliographies of relevant articles, personal communications, manual searches of relevant journals, and information from drug companies.

SELECTION CRITERIA

Randomised, placebo or other drugs-controlled, double-blind trials of amantadine in MS people with fatigue.

DATA COLLECTION AND ANALYSIS

Three reviewers selected studies for inclusion in the review and they extracted the data reported in the original articles. Missing and unclear data were requested by correspondence with the trial's principal investigator. A meta-analysis was not performed due to the inadequacy of available data, heterogeneity of outcome measures.

MAIN RESULTS

Out of twelve pertinent publications, four trials met the criteria for inclusion in this review: one study was a parallel arms study, and 3 were crossover trials. The number of randomised participants ranged between 10 and 115, and a total of 236 MS patients had been studied. Overall the quality of the studies considered was poor and all trials were open to bias. All studies reported small and inconstant improvements in fatigue, whereas the clinical relevance of these findings and the impact on patient's functioning and health related quality of life remains undetermined. The number of participants reporting side effects during amantadine therapy ranged from 10% to 57%, without significant differences between treatment and placebo. The side effects reported were generally mild, and discontinuation of the drug due to side effects occurred in less than 10% of the patients.

REVIEWER'S CONCLUSIONS

Amantadine treatment is overall well tolerated, however its efficacy in reducing fatigue in people with MS is poorly documented and there is insufficient evidence to make recommendations to guide prescribing. It is advisable to (a) improve knowledge on the underlying mechanisms of MS-related fatigue; (b) achieve an agreement on accurate, reliable and responsive outcome measures of fatigue; (c) perform good quality RCTs.

Outcome after treatment of papillary thyroid microcarcinoma

Patients with thyroid microcarcinoma (TMC) have favourable long-term prognoses. However, recurrences in the neck and distant metastases have been reported. The authors investigated independent factors associated with recurrence in an effort to define therapeutic guidelines. In this study they report the results of a retrospective review of patients followed at one Institution. 120 patients ( 96 females and 24 males; mean age 45.2 years) with a papillary thyroid microcarcinoma (PTC) < or =1 cm in greatest dimension were analyzed. All of them were followed for 5 to 15 years. 106 of them were managed aggressively (total thyroidectomy), the remainder treated with lobectomy alone. Radioiodine therapy was performed in 62/106 patients submitted to total thyroidectomy. Despite the different treatment and the presence of neck node metastases at the time of the diagnosis in 26 of the reported 120 patients (22%) and local invasion beyond the thyroid capsule in 20 (17%), only 1.7% of patients had neck nodal local recurrence. No patient died or developed distant metastases. In this preliminary study the authors conclude that the outcome of PMC is generally favourable, even in presence of lymph-node metastases and local invasion, independently of the primary treatment.

A rare association between malignant mediastinal seminoma and other malignant neoplasms

Primary malignant mediastinal seminomas (PMMS) are rare tumors accounting for 1-6% of all mediastinal tumors. PMMS mostly affect young men, arising from primordial germ cells that abnormally migrate from the ectoderm of the yolk sac to the gonadal region. They are clinically and biologically distinct from primary testicular tumors and seem to have a worse prognosis. Due to the rarity of the disease, the choice of treatment is a matter of debate. Literature data do not show any association between this kind of tumor and malignant Schwannoma or thyroid carcinoma. In this report we describe the case of a patient affected by PMMS and 12 yr later by a malignant brachial plexus Schwannoma and papillary thyroid carcinoma (PTC). Since both mediastinal seminoma and Schwannoma were treated with surgery followed by local radiotherapy, we were not able to ascertain if either PTC or Schwannoma had been induced by radiotherapy or represented a casual neoplastic association.

Information and competency for consent to pharmacologic clinical trials in Alzheimer disease: an empirical analysis in patients and family caregivers

This study was undertaken to evaluate (1) what information normal and Alzheimer disease (AD) participants are able to manage; (2) the correlation between the degree of competency and age, education and dementia scores, and the ability of dementia scores to predict incompetence; and (3) the capacity to retain consent-related information. To fulfil these aims, a four-point competency rating scale (1 = incompetent, 2 = marginally competent, 3 = sufficiently competent, and 4 = completely competent) was used in 70 patients (Mini-Mental State Examination [MMSE] score >9; Global Deterioration Scale score <6) and in 40 cognitively normal caregivers. Patients were divided into two subgroups (competency ratings 1 and 2 versus 3 and 4) to calculate positive and negative predictive values of MMSE and Alzheimer Disease Assessment Scale-cognitive (ADAScog) for absent/marginal competence. Main results were as follows: (1) 32.9% of AD patients were "incompetent" (no caregivers), 37.1% were "marginally competent" (20% caregivers), 18.6% were "sufficiently competent" (50% caregivers), and 11.4% were "completely competent" (30% caregiverss). (2) Competency ratings and age did not correlate in AD, whereas a negative correlation was significant in caregivers; competency ratings positively correlated to education in caregivers. (3) ADAScog and MMSE were the tests most significantly correlated to competency; MMSE score below 18 had a positive predictive value of 95% and a negative predictive value of 63.3%. The fact that 95% of patients with MMSE scores below 18 are incompetent or marginally competent points to an urgent need for ethical procedures capable of creating a balance between difficulties in obtaining valid consent and a patient's right to benefit from advances in clinical research.

Aminopyridines for symptomatic treatment in multiple sclerosis

BACKGROUND

Because of their ability to increase nerve conduction in demyelinated nerve fibers, potassium channel blockers 4-aminopyridine (AP) and 3,4-diaminopyridine (DAP) have been proposed as a symptomatic therapy for people with multiple sclerosis (MS).

OBJECTIVES

To determine the efficacy and safety of aminopyridines in improving neurological deficits in people with MS.

SEARCH STRATEGY

Computerised general (MEDLINE, EMBASE) and specialised databases (Cochrane MS Group's trials register, CCTR). Hand search of bibliographic references from retrieved studies and recent MS symposia reports. Contact with principal investigators of known studies.

SELECTION CRITERIA

Trials were included if they fulfilled all following criteria: randomised controlled trials (RCTs); adults with MS, out of exacerbation; AP or DAP treatment versus placebo; clinical endpoints.

DATA COLLECTION AND ANALYSIS

We identified 26 potentially pertinent studies. Three reviewers independently extracted data and assessed trial quality from the 16 studies available as full papers.

MAIN RESULTS

Five studies (six publications) and 144 participants were considered in this review. Two more abstracts are awaiting assessment. All five studies were single-centre, double-blind, crossover trials. Four studies assessed the efficacy of AP versus placebo, one compared DAP with active placebo. The duration of treatment ranged from hours to three months. The median quality score of the studies was 3 (range 2-5). The heterogeneity of outcome assessment and the absence of information on individual study periods, allowed quantitative pooling of results for few categorical variables. Of the 144 treated patients, there were six major side effects: one acute encephalopathy, three episodes of confusion, and two seizures. Manual muscle testing was assessed in three studies (54 patients), with 29 patients (54%) improving in at least one muscular district during study treatment versus four patients (7%) during placebo (odds ratio [OR] 14.5, 95% confidence interval [CI] 4.7-43.7). Ambulation was assessed in three studies (54 patients): 9 patients (17%) improved during study treatment versus none during placebo (p<0.001). An improvement in EDSS score was found in 13 of the 144 participants during study treatment (9%) versus none during placebo (p<0.001). No improvement in neuropsychological tests was found in the two trials that evaluated cognitive function. Finally, 47 of 136 people with MS (35%) felt improved when receiving the study drug, against 7(5%) on placebo (OR 9.7, 95% CI 4.3-22.0).

REVIEWER'S CONCLUSIONS

Based on currently available information, no unbiased statement can be made about the safety or efficacy of aminopyridines for treating MS symptoms. Furthermore, we could not obtain any data on three unpublished RCTs involving more than 300 participants. We conclude that publication bias remains a pervasive problem in this area, and that until the results of these unpublished studies are available to the scientific community, no confident estimate of effectiveness of aminopyridines in the management of MS symptoms is possible.

Hippocampus and parahippocampal gyrus linear measurements based on magnetic resonance in Alzheimer's disease

MRI-based linear measurements of the hippocampus and parahippocampal gyrus complex (HPC) discriminated 39 subjects with probable Alzheimer's disease, from 15 patients with other dementias and 33 miscellaneous controls without evidence of dementia. The best discriminating parameter was the left height of the HPC at the level of the mammillary bodies, with a sensitivity of 79.49% and a specificity of 68.75%. The diagnostic value of these results is discussed considering the volumetric data found in the current literature.

Migraine with aura and reproductive life events: a case control study

The course of migraine without aura (MO) is greatly influenced by the events of female reproductive life. Much less is known about migraine with aura (MA). The aim of this study was to evaluate the relationship between MA and the milestones of reproductive life. A retrospective case control study was carried out on 100 women affected by migraine with typical aura (cases) and 200 age-matched women with MO (controls). Premenstrual syndrome was found to be much more common among the patients with MA (odds ratio (OR) 6.0; confidence interval (CI) 3.1-11.6). Menstrually triggered migraine was more frequently encountered among MO than among MA patients (MA 15.0%; MO 53.5%; OR 0.1; CI 0.1-0.3). In both forms of migraine, pregnancy had a favourable effect; however, a lower percentage of MA (43.6%) than MO patients (76.8%; OR 0.2; CI 0.1-0.5) showed improvement or remission. The use of oral contraceptives worsened migraine in MA more frequently than in MO patients (MA 56.4%; MO 25.3%; OR 3.8; CI 1.6-9.3). The course of MA seems to be influenced by female reproductive life events, but in a different way with respect to MO.

Thyroid and lipid metabolism

Thyroid hormones influence all major metabolic pathways. Their most obvious and well-known action is an increase in basal energy expenditure obtained acting on protein, carbohydrate and lipid metabolism. With specific regard to lipid metabolism, thyroid hormones affect synthesis, mobilization and degradation of lipids, although degradation is influenced more than synthesis. The main and best-known effects on lipid metabolism include: (a) enhanced utilization of lipid substrates; (b) increase in the synthesis and mobilization of triglycerides stored in adipose tissue; (c) increase in the concentration of non-esterified fatty acids (NEFA); and (d) increase of lipoprotein-lipase activity. While severe hypothyroidism is usually associated with an increased serum concentration of total cholesterol and atherogenic lipoproteins, the occurrence of acute myocardial infarction (AMI) in hypothyroid patients is not frequent. However, hypothyroid patients appear to have an increased incidence of residual myocardial ischemia following AMI. Even in subclinical hypothyroidism, which is characterized by raised serum TSH levels with normal serum thyroid hormone concentrations, mild hyperlipidemia is present and may contribute to an increased risk of atherogenesis. Prudent substitution therapy with L-thyroxine is indicated in patients with both overt and subclinical hypothyroidism, with or without angina, to counteract the cardiovascular risk resulting from hyper-dyslipidemia.

Topographical disorientation consequent to amnesia of spatial location in a patient with right parahippocampal damage

We describe a patient who selectively lost the ability to orient himself in the environment after a stroke involving the right parahippocampal gyrus. The neuropsychological assessment showed a specific pattern of impairment of topographical memory; the patient recognised and recalled environmental landmarks but was unable to recall their spatial location. This study provides evidence that different forms of topographical disorientation may be related to distinct mechanisms of cognitive dysfunction. Furthermore, neuroimaging data suggest that a lesion of the right parahippocampal gyrus is critically related to pure topographical disorientation.

Absence of HHV-6 and HHV-7 in cerebrospinal fluid in relapsing-remitting multiple sclerosis

OBJECTIVE

To contribute to clarifying the controversy on the association between Human Herpesviruses 6 and 7 (HHV-6, HHV-7) and multiple sclerosis (MS) studying patients with relapsing-remitting MS (RRMS) with or without evidence of disease activity (clinically or radiologically evaluated).

MATERIAL AND METHODS

In 25 RRMS patients, 7 suspected MS patients and 9 patients with other neurological diseases, the following parameters were analysed: i) antibody titers (IgM and IgG) against HHV-6 by indirect immunofluorescence both in serum and cerebrospinal fluid (CSF) samples; ii) PCR-detection of HHV-6 DNA and HHV-7 DNA in CSF and HHV-6 DNA in peripheral blood mononuclear cells (PBMCs). MS patients in remission underwent a gadolinium-enhanced magnetic resonance imaging in proximity of sample collections.

RESULTS

No viral DNA was found in any CSF sample, HHV-6 DNA frequency in PBMCs of MS patients and controls was not statistically different. Antibody titers against HHV-6 were comparable to those of the general population. Some 30.4% of MS patients were seronegative to HHV6.

CONCLUSION

Our data suggest that there is no relationship between HHV-6 or HHV-7 and MS.