The Multiple Sclerosis Inventory of Cognition for Adolescents (MUSICADO): A brief screening instrument to assess cognitive dysfunction, fatigue and loss of health-related quality of life in pediatric-onset multiple sclerosis

OBJECTIVE

Screening for cognitive impairment (CI), fatigue and also Health-related quality of life (HRQoL) in patients with pediatric-onset multiple sclerosis (POMS) is of utmost importance in clinical practice. The aim of this study was to establish a new and validated pediatric screening tool "MUSICADO" that is easy to use and time economical.

METHODS

106 patients with POMS aged 12-18 years and 210 healthy controls (HCs) stratified for age and education underwent neuropsychological testing including a screening test "Multiple Sclerosis Inventory of Cognition" for adults and 8 standardized cognitive tests and established scales to assess fatigue and HRQoL.

RESULTS

The phonemic verbal fluency task (RWT "s-words"), the Trail Making Test A (TMT-A), and the Digit Span Forward discriminated significantly between patients and HCs (p = 0.000, respectively) and showed the highest proportion of test failure in patients (24.5%, 17.9%; 15.1%, respectively). Therefore, they were put together to form the cognitive part of the "MUSICADO". After applying a scoring algorithm with balanced weighting of the subtests and age and education correction and a cut-off score for impairment, 35.8% of patients were categorized to be cognitively impaired (specificity: 88.6%). Fatigue was detected in 37.1% of the patients (specificity: 94.0%) and loss of HRQoL in 41.8% (specificity 95.7%) with the screening version, respectively.

CONCLUSION

The MUSICADO is a newly designed brief and easy to use screening test to help to early identify CI, fatigue, and loss of HRQoL in patients with POMS as cut scores are provided for all three items. Further studies will have to show its usability in independent samples of patients with POMS.

Criterion validity and sensitivity to change of the Early Rehabilitation Index (ERI): results from a German multi-center study

Background

Evaluation of functional status is difficult in neurological and neurosurgical early rehabilitation patients. The Early Rehabilitation Index (ERI) was introduced in Germany over 20 years ago, but since then validation studies are lacking. The ERI (range −325 to 0 points) includes highly relevant items including the necessity of intermittent mechanical ventilation or tracheostomy.

Methods

The present paper analyzed data from a German multi-center study, enrolling 754 neurological early rehabilitation patients. Together with ERI, Barthel Index (BI), Glasgow Coma Scale (GCS), Glasgow Outcome Score Extended, Coma Remission Scale (CRS), Functional Ambulation Categories and length of stay were obtained.

Results

ERI showed significant improvements from admission to discharge (p < 0.001). In addition, there were significant correlations of the ERI upon admission and at discharge with BI, CRS and GCS.

Conclusions

Evaluation of our study data suggest that the ERI may be used as a valid assessment instrument for neurological and neurosurgical early rehabilitation patients.

[The MEmbeR Multicenter Study on medical-occupational rehabilitation]

INTRODUCTION

MEmbeR is a prospective multi-center study on medical-occupational rehabilitation in Germany.

METHODS

196 neurological, psychiatric, orthopaedic, and internal medicine patients from 21 rehabilitation centres all across Germany have been enrolled and followed-up for 2 years after discharge. Primary outcome parameter was defined as return to work. Further, the SF-12 and a Mini-ICF-Rating have been used.

RESULTS

Mean age was 34.1 (9.9) years, length of stay 150.0 (223.5) days. Prior to occupational rehabilitation, 69.9% were unable to work, 2 years after discharge only 5.6%. Rate of participants seeking a job was reduced from 19.7% to 3.1%. In summary, 78.1% returned to work. Employed participants were younger (32.8 [9.7] vs. 38.5 [9.4] years, p=0.001) and less disabled (Degree of Disablement [GdB]: 20.0 [31.2] vs. 36.1 [33.7], p<0.05).

CONCLUSION

The multicenter cohort study MEmbeR provides further knowledge about the outcome of medical-occupational rehabilitation in Germany.

Enhanced kinase-activity in sv40-transformed cells may be compensated by enhanced phosphatase-activity in revertants as reflected by phosphorylation of p53

Transformation of rat cells with SV40 large T antigen results in activation of protein kinases and hyperphosphorylation of the tumor suppressor protein p53. In searching for cellular targets involved in SV40-mediated transformation, flat revertants of SV40-transformed rat cells had been isolated carrying a presumptive defect in a cellular gene (Bauer et al: J Virol 61: 1821, 1987). In this investigation, we asked whether the phosphorylation state of p53 might be affected in the revertants. Two-dimensional phosphopeptide analyses revealed indeed a characteristic reduction of phosphorylation of p53 compared to the parental transformed cells. However, when we employed the phosphatase inhibitor okadaic acid in vivo hyperphosphorylation of p53 resumed indicating that the kinases involved in phosphorylation of p53 were fully active but counterbalanced by enhanced phosphatase activity. Indeed, the phosphate turnover of p53 in vivo and phosphatase activity towards p53 in vitro was higher in the revertants than in the parental transformants. These findings demonstrate that the transformation state of a cell correlates with the phosphorylation state of p53 which in turn can be regulated in different ways, enhanced kinase activity in transformed cells may be counteracted by enhanced phosphatase activity in revertant cells.

Effect of levodopa in combination with physiotherapy on functional motor recovery after stroke: a prospective, randomised, double-blind study

BACKGROUND

Functional disability is generally caused by hemiplegia after stroke. Physiotherapy used to be the only way of improving motor function in such patients. However, administration of amphetamines in addition to exercise improves motor recovery in animals, probably by increasing the concentration of norepinephrine in the central nervous system. Our aim was to ascertain whether levodopa could enhance the efficacy of physiotherapy after hemiplegia.

METHODS

We did a prospective, randomised, placebo-controlled, double-blind study in which we enrolled 53 primary stroke patients. For the first 3 weeks patients received single doses of levodopa 100 mg or placebo daily in combination with physiotherapy. For the second 3 weeks patients had only physiotherapy. We quantitatively assessed motor function every week with Rivermead motor assessment (RMA).

FINDINGS

Six patients were excluded from analyses because of non-neurological complications. Motor recovery was significantly improved after 3 weeks of drug intervention in those on levodopa (RMA improved by 6.4 points) compared with placebo (4.1), and the result was independent of initial degree of impairment (p<0.004). The advantage of the levodopa group was maintained at study endpoint 3 weeks after levodopa was stopped. At the end of the study the total RMA score gain for the levodopa group was 8.2 points compared with 5.7 in the placebo group (p=0.020).

INTERPRETATION

A single dose of levodopa is well tolerated and, when given in combination with physiotherapy, enhances motor recovery in patients with hemiplegia. In view of its minimal side-effects, levodopa will be a possible add- on during stroke rehabilitation.

Mutations in the gene encoding epsilon-sarcoglycan cause myoclonus-dystonia syndrome

The dystonias are a common clinically and genetically heterogeneous group of movement disorders. More than ten loci for inherited forms of dystonia have been mapped, but only three mutated genes have been identified so far. These are DYT1, encoding torsin A and mutant in the early-onset generalized form, GCH1 (formerly known as DYT5), encoding GTP-cyclohydrolase I and mutant in dominant dopa-responsive dystonia, and TH, encoding tyrosine hydroxylase and mutant in the recessive form of the disease. Myoclonus-dystonia syndrome (MDS; DYT11) is an autosomal dominant disorder characterized by bilateral, alcohol-sensitive myoclonic jerks involving mainly the arms and axial muscles. Dystonia, usually torticollis and/or writer's cramp, occurs in most but not all affected patients and may occasionally be the only symptom of the disease. In addition, patients often show prominent psychiatric abnormalities, including panic attacks and obsessive-compulsive behavior. In most MDS families, the disease is linked to a locus on chromosome 7q21 (refs. 11-13). Using a positional cloning approach, we have identified five different heterozygous loss-of-function mutations in the gene for epsilon-sarcoglycan (SGCE), which we mapped to a refined critical region of about 3.2 Mb. SGCE is expressed in all brain regions examined. Pedigree analysis shows a marked difference in penetrance depending on the parental origin of the disease allele. This is indicative of a maternal imprinting mechanism, which has been demonstrated in the mouse epsilon-sarcoglycan gene.

[Familial myoclonus-dystonia syndrome associated with panic attacks]

We report a case of autosomal dominantly inherited dystonia and panic attacks to discuss successful treatment of a common serotonergic pathology with medication. The objective analysis of the movement disorder was done by Optotrak. First we demonstrate a reduction of the myoclonus by L-5-hydroxytryptophan, which inhibits after 11 months. After changing the medication to Nefadozone, the myoclonus and the frequency of panic attacks were reduced.

Protein phosphatase 2A is required for the initiation of chromosomal DNA replication

Protein phosphatase 2A (PP2A) is an abundant, multifunctional serine/threonine-specific phosphatase that stimulates simian virus 40 DNA replication. The question as to whether chromosomal DNA replication also depends on PP2A was addressed by using a cell-free replication system derived from Xenopus laevis eggs. Immunodepletion of PP2A from Xenopus egg extract resulted in strong inhibition of DNA replication. PP2A was required for the initiation of replication but not for the elongation of previously engaged replication forks. Therefore, the initiation of chromosomal DNA replication depends not only on phosphorylation by protein kinases but also on dephosphorylation by PP2A.

Activation of Raf kinase by phorbol ester does not correlate with enhanced phosphorylation or transactivation activity of tumor suppressor protein p53

The tumor suppressor protein p53 appears to be regulated by various means including phosphorylation. We investigated a possible influence of the raf kinase on phosphorylation and transactivation of p53. The phosphorylation pattern of p53 was analysed in normal or v-raf-transformed rat cells or in insect cells which were co-infected with recombinant baculoviruses encoding p53, protein kinase C and c-Raf. The presence of activated v-raf kinase or treatment of cells with PMA, which resulted in activation of both v-raf and c-Raf kinases, did not reveal any additional phosphorylation sites in p53 nor did any of the known sites show enhanced phosphorylation, neither in rat nor in baculovirus-infected insect cells. Instead, PMA treatment led to reduced phosphorylation of p53. This latter effect was similar in normal and v-raf-transformed cells suggesting that it is mediated by a PKC-dependent but raf-independent mechanism. Okadaic acid treatment compensated this reduced phosphorylation of p53 suggesting that it was due to activation of phosphatase(s). The transactivation activity of p53 was assayed under the same conditions, using an mdm2-promoter luciferase reporter gene construct. In this case, we obtained conflicting results: in normal rat cells both PMA and okadaic acid had a stimulatory effect which was additive. In the v-raf transformed cells, on the other hand, PMA alone reduced, whereas okadaic acid alone enhanced transcriptional activation and application of both drugs resulted in a slight net increase in transactivation. Thus, PMA seemed to have separable effects on phosphorylation and transactivation activity of p53. Our data suggest i) that neither Raf-l kinase nor PKC phosphorylate p53 directly in vivo, ii) that the reduced phosphorylation observed upon PMA treatment is independent of Raf, and perhaps mediated by indirect activation of phosphatases, iii) that the effects of PMA on p53-dependent transcription are not mediated by changes in the phosphorylation state of p53 itself.

Improvement of motor fluctuations in patients with Parkinson's disease following treatment with high doses of pergolide and cessation of levodopa

The combination of levodopa and a dopamine agonist in the treatment of patients with Parkinson's disease often reduces the severity of motor fluctuations. In patients with very severe motor fluctuations, monotherapy with continuous subcutaneous infusions of the dopamine agonist apomorphine may result in a marked reduction of hyperkinesia and on-off phenomena. We report 3 patients with Parkinson's disease and motor fluctuations who received high doses of pergolide without levodopa resulting in a reduction of motor fluctuations. All patients received doses of pergolide exceeding the maximum recommended dose. One patient also required additional therapy with amantadine. These data show that in some patients oral treatment with high doses of a dopamine agonist may improve the severity of motor fluctuations and achieve a good control of parkinsonian signs without concomitant levodopa treatment.

UV irradiation leads to transient changes in phosphorylation and stability of tumor suppressor protein p53

Tumor suppressor protein p53 is thought to play a crucial role in maintaining the integrity of the genome. DNA damage caused by genotoxic drugs, UV or gamma-irradiation leads to accumulation of p53 and activation of its DNA binding and transcriptional activities and subsequently to cell cycle arrest or apoptosis. We investigated whether the apparent activation of p53 might be due to post-translational modification. The rat fibroblast cell lines REF52, 208F, and rat1 were irradiated with W-A and the synthesis, stability and phosphorylation state of p53 were investigated by pulse chase experiments, SDS-PAGE and two-dimensional phosphopeptide mapping. The three cell lines exhibited different sensitivities and biological responses to UV irradiation, REF52 cells responded with a growth arrest whereas 208F and rat1 cells underwent apoptosis. The fate of p53 was similar in all cases. Both the stability of p53 and its phosphorylation increased instantaneously but transiently. However, the amount of p53 that accumulated after UV treatment was much higher in 208F and rat1 than in REF52 cells. Interestingly, p53 that was synthesized early after irradiation was stable for more than 14 h whereas molecules synthesized 8 or more hours post irradiation were increasingly susceptible to degradation. Moreover, between 14 and 20 h after treatment, the rate of synthesis of p53 decreased to a level lower than in untreated cells suggesting negative feed back control. The expression of different p53-responsive genes, waf1/cip1, Gadd45, and bax was investigated by protein analyses. Surprisingly, p21(waf1) was expressed only in REF52 cells but not in the others. Furthermore, UV irradiation led only to a moderate increase of p21(waf1) expression. Expression of Gadd45 and box was detectable in both cell types but its expression did not change significantly upon UV treatment. Our results suggest i) that both cell types share a common pathway which upon UV irradiation results in enhanced stability and phosphorylation of p53 and ii) that the decision whether a cell undergoes a growth arrest or apoptosis may be determined independent of p53 by the cellular environment i.e. the expression patterns of genes that mediate the response.

Motor recovery following capsular stroke. Role of descending pathways from multiple motor areas

The functional anatomy of motor recovery was studied by assessing motor function quantitatively in 23 patients following capsular or striatocapsular stroke. While selective basal ganglia lesions (caudate and/or putamen exclusively) did not affect voluntary movements of the extremities, lesions of the anterior (plus caudate/putamen) or posterior limb of the internal capsule led to an initially severe motor impairment followed by excellent recovery, hand function included. In contrast, lesions of the posterior limb of the internal capsule in combination with damage to lateral thalamus compromised motor outcome. In experimental tracing of the topography of the internal capsule in macaque monkeys, we found axons of primary motor cortex passing through the middle third of the posterior limb of the internal capsule. Axons of premotor cortex (dorsolateral and post-arcuate area 6) passed through the capsular genu, and those of supplementary motor area (mesial area 6) through the anterior limb. Small capsular lesion can therefore disrupt the output of functionally and anatomically distinct motor areas selectively. The clinically similar motor deficits with a similar course of functional restitution following disruption of these different descending motor pathways indicate a parallel operation of cortical motor areas. They may have the further capability of substituting each other functionally in the process of recovery from hemiparesis.