The natural history of primary lateral sclerosis

OBJECTIVE

To define the syndrome of primary lateral sclerosis (PLS) and disorders that contain features of both ALS and PLS, to determine the time beyond which PLS is less likely to become ALS clinically, and to determine the outcome of people with PLS and those who develop lower motor neuron (LMN) signs.

METHODS

The authors reviewed the records of all 39 patients initially diagnosed with PLS in 1984 to 2004. Diagnostic subgroups were defined based on clinical features. The authors used Kaplan-Meier methods to estimate the time to diagnosis, linear regression analyses to assess function, and a Cox proportional hazard model to assess survival in subgroups.

RESULTS

Of the 39 patients, 29 had only upper motor neuron (UMN) signs on initial evaluation. Thirteen of the 29 were later classified as having UMN-dominant ALS (UMN-D) because they acquired evidence of denervation by EMG (3.17 years) or examination (3.67 years). Sixteen of the 29 patients, classified as clinically pure PLS, retained only UMN signs and a normal EMG (mean follow-up 8.7 years). Ten patients who met criteria for ALS at the initial visit were used as controls. The UMN-dominant ALS group had lower functional scores (p = 0.033) than the PLS group, and similar scores to those with ALS. Survival was longer in both the PLS group (p = 0.027) and the UMN-D group (p = 0.067) than the ALS group.

CONCLUSIONS

Clinically pure PLS can be defined by isolated UMN signs 4 years after symptom onset, and is a syndrome of slow progression with high levels of function. Prior to the fourth year, the diagnosis of PLS cannot be made with certainty because many patients develop LMN signs. UMN-dominant ALS, defined by predominantly UMN disease with minor LMN signs, has disability similar to ALS, but slower progression.

Employee assistance: a business and community hospital partnership

Employers are now providing a variety of healthcare services to combat health problems that affect productivity. These employee assistance programs are designed to improve work performance by providing an approach to the prevention, diagnosis, and treatment of such illnesses as alcoholism, drug dependence, mental illness and family, martial, financial, and legal difficulties common to all worksites. This article examines the concept, incentives, structure, obstacles, marketing, and cost containment factors that are part of the development of this new partnership between businesses and community hospitals.

Planning and developing a prehospital mobile intensive care system in an urban setting

A suggested model for the development of an urban based prehospital emergency care system is described. Factors considered in the planning and development include: 1) demand for services, projected and actual; 2) analysis of costs; 3) design and maintenance of the delivery system; and 4) establishment of the evaluation mechanisms. Over one year's experience and 1,144 mobile intensive care unit (MICU) calls in a densely populated urban setting with over 500,000 persons are reported. During the peak 8-hour period, predetermined dispatch categories were employed to activate one MICU operating in conjunction with three conventional ambulances. This partial conversion imparted MICU capability to the entire system at an 11 per cent increase in the ambulance budget. MICU calls averaged 4.5 per 8-hour peak shift and took 45 minutes each.

Pregnancy in the unwed White South African

A sociological and obstetric analysis of 130 unwed Afrikaans- and English-speaking mothers showed that 78% of English-speaking and 61% of Afrikaans-speaking mothers preferred to keep their babies. More than 80% of women in both language groups did not use contraceptives. There were no statistically significant differences between the unwed mothers and a married control group as regards antenatal anaemia, toxaemia of pregnancy, antepartum haemorrhage and breech presentation. Labour lasted longer than 18 hours in 8.6% of English-speaking unwed mothers but in none of the Afrikaans group. English-speaking mothers who gave up their babies for adoption had a higher incidence of prolonged labour, toxaemia, forceps delivery and premature birth.