Subcutaneous batoclimab in generalized myasthenia gravis: Results from a Phase 2a trial with an open-label extension

OBJECTIVES

To assess the safety, tolerability, and key pharmacodynamic effects of subcutaneous batoclimab, a fully human anti-neonatal Fc receptor monoclonal antibody, in patients with generalized myasthenia gravis and anti-acetylcholine receptor antibodies.

METHODS

A Phase 2a, proof-of-concept, randomized, double-blind, placebo-controlled trial is described. Eligible patients were randomized (1:1:1) to receive once-weekly subcutaneous injections of batoclimab 340 mg, batoclimab 680 mg, or matching placebo for 6 weeks. Subsequently, all patients could enter an open-label extension study where they received batoclimab 340 mg once every 2 weeks for 6 weeks. Primary endpoints were safety, tolerability, and change from baseline in total immunoglobulin G, immunoglobulin G subclasses, and anti-acetylcholine receptor antibodies at 6 weeks post-baseline. Secondary endpoints included changes from baseline to 6 weeks post-baseline for Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, Myasthenia Gravis Composite, and revised 15-item Myasthenia Gravis Quality of Life scores.

RESULTS

Seventeen patients were randomized to batoclimab 680 mg (n = 6), batoclimab 340 mg (n = 5), or placebo (n = 6). Batoclimab was associated with significantly greater reductions in total immunoglobulin G and anti-acetylcholine receptor antibodies from baseline to 6 weeks post-baseline than placebo. Reductions in immunoglobulin G subclasses were generally consistent with total immunoglobulin G. While clinical measures showed directionally favorable improvements over time, the study was not powered to draw conclusions about therapeutic efficacy. No safety issues were identified.

INTERPRETATION

The safety profile, pharmacodynamics, and preliminary clinical benefits observed in this study support further investigation of subcutaneous batoclimab injections as a potential patient-administered therapy for seropositive generalized myasthenia gravis.

A blood biomarker test for brain amyloid impacts the clinical evaluation of cognitive impairment

OBJECTIVE

The objective of this study was to examine clinicians' patient selection and result interpretation of a clinically validated mass spectrometry test measuring amyloid beta and ApoE blood biomarkers combined with patient age (PrecivityAD® blood test) in symptomatic patients evaluated for Alzheimer's disease (AD) or other causes of cognitive decline.

METHODS

The Quality Improvement and Clinical Utility PrecivityAD Clinician Survey (QUIP I, ClinicalTrials.gov Identifier: NCT05477056) was a prospective, single-arm cohort study among 366 patients evaluated by neurologists and other cognitive specialists. Participants underwent blood biomarker testing and received an amyloid probability score (APS), indicating the likelihood of a positive result on an amyloid positron emission tomography (PET) scan. The primary study outcomes were appropriateness of patient selection as well as result interpretation associated with PrecivityAD blood testing.

RESULTS

A 95% (347/366) concordance rate was noted between clinicians' patient selection and the test's intended use criteria. In the final analysis including these 347 patients (median age 75 years, 56% women), prespecified test result categories incorporated 133 (38%) low APS, 162 (47%) high APS, and 52 (15%) intermediate APS patients. Clinicians' pretest and posttest AD diagnosis probability changed from 58% to 23% in low APS patients and 71% to 89% in high APS patients (p < 0.0001). Anti-AD drug therapy decreased by 46% in low APS patients (p < 0.0001) and increased by 57% in high APS patients (p < 0.0001).

INTERPRETATION

These findings demonstrate the clinical utility of the PrecivityAD blood test in clinical care and may have added relevance as new AD therapies are introduced.

The evolution of a neo-XY1Y2 sex chromosome system by autosome-sex chromosome fusion in Dundocoris nodulicarinus Jacobs (Heteroptera: Aradidae: Carventinae)

Sibling subspecies of Dundocoris nodulicarinus, inhabiting different isolated indigenous evergreen forests in South Africa, have chromosome numbers of 2n(male) = 14XY, 9XY1Y2 and 7XY1Y2. The ancestral chromosome number of Dundocoris is probably 2n(male) = 28XY and several chromosome fusions were involved in the karyotype evolution of these taxa. The XY1Y2 sex chromosome system of the 9XY1Y2 D. nodulicarinus novenus originated by the fusion of a large autosome with the X-chromosome, forming a neo-X with the homologue of the fused autosome forming the neo-Y (=Y1) and the original Y-chromosome, the Y2. While the original X- and Y-chromosomes are heterochromatic and heteropycnotic during prophase I, the autosomal part of the neo-X and the neo-Y stay euchromatic and behave like a normal autosomal pair, forming synapsis and chiasmata. The XY1Y2 sex chromosome system of the 7XY1Y2 D. nodulicarinus septeni probably originated from the 9XY1Y2 karyotype when the homologous chromosomes of a small autosomal pair fused with the original X- and Y-chromosomes, respectively. In both the subspecies with the neo-XY1Y2 systems, the original sex chromosomes still undergo chromatid segregation at anaphase I (= post-reductional). The evolution and behaviour of the karyotypes and sex chromosome systems during the course of meiosis in the subspecies of D. nodulicarinus are described, discussed and illustrated.

Apraxia in corticobasal degeneration

Corticobasal degeneration (CBD) is a degenerative disease that often presents with an asymmetric progressive ideomotor limb apraxia. Some apraxic subjects may fail to perform skilled purposive movements on command because they have lost the memories or representations that specify how these movements should be performed (representational deficit). In contrast, other apraxic subjects may have the movement representations but are unable to utilize the information contained in them to execute skilled purposive movements (production-execution deficit). To learn if the apraxic deficit in CBD is induced by a representational or a production-execution deficit, we tested three nondemented subjects with CBD on tasks requiring production of meaningful or meaningless gestures to command, gesture imitation, gesture discrimination, and novel gesture learning. A fourth subject with incomplete data also is presented. The results suggest that the apraxia associated with CBD is initially induced by a production-execution defect with relative sparing of the movement representations.

Apraxia differs in corticobasal degeneration and left-parietal stroke: A case study

Corticobasal degeneration (CBD) is a progressive disorder characterized by both cortical and basal ganglia dysfunction such as asymmetrical apraxia, and akinetic rigidity, involuntary movements, and cortical sensory loss. Although apraxia is a key finding for the differential diagnosis of CBD, it has not been determined whether the features of apraxia seen in subjects with CBD are similar to those features exhibited by subjects with left-hemisphere damage from stroke. Therefore, for both clinical purposes and in order to better understand the brain mechanisms that lead to apraxia in CBD, we studied praxis in a patient with CBD and compared him to patients who are apraxic from left-parietal strokes. We used three-dimensional movement analyses to compare the features of apraxic movement. This subject with CBD was a dentist whose initial complaint had been that he "forgot" how to use his tools in the mouths of his patients. Analyses were performed on the trajectories made when using a knife to actually slice bread, and when repetitively gesturing slicing made to verbal command. Movements of the left hand, wrist, elbow, and shoulder were digitized in 3-D space. Although the CBD subject was clearly apraxic, the features of his apraxia differed markedly from those of the subjects with lesions in the left parietal lobe. For movements to command, the CBD subject showed joint coordination deficits, but his wrist trajectories were produced in the appropriate spatial plane, were correctly restricted to a single plane, and, like control subjects, were linear in path shape. However, when he was actually manipulating the tool and object, all of these aspects of his trajectories became impaired. In contrast, the deficits of the apraxic subjects with left-parietal damage were most pronounced to verbal command with their movements improving slightly although remaining impaired during actual tool and object manipulation. Unlike patients with parietal strokes, patients with CBD have degeneration in several systems and perhaps deficits in these other areas may account for the differences in praxic behavior.

Apraxia and motor-skill acquisition in Alzheimer's disease are dissociable

Many patients with Alzheimer's disease (AD) are apraxic and the apraxia has been posited to be related to a loss of movement representations. Whereas patients with Alzheimer's disease have been reported to demonstrate normal motor learning on a rotor pursuit skill acquisition task, it is unknown whether AD subjects who are apraxic demonstrate normal skill-learning. We tested subjects with probable AD and normal controls on a rotor pursuit task. We also tested the AD subjects for ideomotor apraxia. Subjects with AD who were apraxic had normal motor learning. In addition, praxis score did not correlate with performance on the skill-acquisition task. The results suggest that ideomotor praxis and motor learning are at least partly dissociable.

Recovery following lateral medullary infarction

Lateral medullary infarction (LMI) has a well-defined clinical syndrome and vascular pathology. The functional outcome and degree of disability of patients with LMI, however, have not been as well investigated. We followed 18 consecutive patients with LMI during inpatient stroke rehabilitation. Thirteen patients were followed after discharge from the hospital over a mean time of 1 year. The degree of disability on admission and discharge from the hospital, and at follow-up was assessed using the motor component of the Functional Independence Measurement (FIM-motor). All patients were discharged home. During inpatient rehabilitation, the functional performance of all patients improved substantially from FIM-motor 50.9 +/- 13.0 (mean +/- SD) on admission to 76.9 +/- 10.5 at discharge. Patients with lower FIM-motor scores on admission had more functional improvement from admission to discharge than those with higher FIM-motor scores on admission. Patients with disease of the posterior inferior cerebellar artery showed significantly less functional improvement than patients with disease of the vertebral artery or no identified vascular pathology in the posterior circulation. In the follow-up group, the FIM-motor scores further improved to 84.6 +/- 8.4, indicating nearly full functional independence. Eighty-five percent were totally independent with ambulation. Five of seven previously working patients returned to work. Patients with LMI have few functional deficits after completion of inpatient rehabilitation, continue to improve functionally after discharge, and often resume their previous activities.

Intracranial angioplasty: experience and complications

PURPOSE

To review our experience with intracranial angioplasty, including the complications we encountered.

METHODS

During a 3-year period, from 1993 to 1996, 10 patients had intracranial percutaneous transluminal angioplasty (PTA). The stenosed vessels included three internal carotid arteries, one middle cerebral artery, one basilar artery, and five vertebral arteries. Stenosis in all patients was 75%, or greater. PTA was technically successful in eight patients; in two patients it could not be performed owing to inability to traverse the stenosed area.

RESULTS

Two patients had successful and uneventful PTA. Five patients had vasospasm, which resolved with local vasodilators in two and with repeat PTA in one. Vasospasm led to stroke in two patients. Compromise of perforating vessels and arterial dissection were associated with stroke in two patients.

CONCLUSION

Intracranial PTA is technically feasible but associated with risks related to vasospasm, arterial trauma, and compromise of perforating vessels.

The influence of center of mass effect on the distribution of spatial attention in the vertical and horizontal dimensions

Normal subjects attend toward the middle of grouped items (center of mass effect). In order to learn if mass effect could influence performance on line bisection tasks and if the spatial orientation of the line (vertical vs. horizontal) could influence center of mass effect, we administered bisection tasks to 16 normal subjects using either lines composed of two unequal segments (one thick and one thin) or unsegmented lines. When the longer segment was to the right, left, up, or down, subjects erred by deviating their bisection toward the longer segment (center of mass effect). Our results demonstrate that the center of mass effect can be seen with bisection tasks and is greater in the vertical than in the horizontal dimension.

Adynamic aphasia: a transcortical motor aphasia with defective semantic strategy formation

Adynamic aphasia is a form of transcortical motor aphasia characterized by sparse but otherwise normal spontaneous speech that may improve when concepts are introduced by external stimuli. Akinesia, impaired concept formation, inertia of concept generation, a defective semantic network, damage or impaired access to the verbal output lexicon, and defective semantic strategy formation have been proposed to account for this disorder. We studied a patient with adynamic aphasia and frontal lobe systems dysfunction due to bilateral striatocapsular infarctions. The patient was not akinetic but did demonstrate inertia of concept generation that could be overcome with prompting. However, prompting did not improve the number of concepts generated. He demonstrated a generally intact verbal lexicon and semantic network and normal lexical priming. However, his ability to sort closely related items into different classes without prior cuing regarding the nature of the classes was defective. Although his verbal memory was normal, he appeared to use a serial rather than a semantic strategy to recall items. Finally, despite normal lexical priming, he was impaired on a letter fluency task. These results most clearly demonstrate a defect in semantic strategy formation but indicate an additional and possibly related deficit in concept formation and a partial deficit in lexical strategy formation. All of these deficits appear to reflect impairment in the hierarchical organization of knowledge specific to the task at hand. This appears to be a key component of executive functions supported by frontal lobe systems.

Diencephalic temporal order amnesia

OBJECTIVE

Amnesia for temporal relations may occur without amnesia for content memories. The aim was to determine whether a patient with mild memory loss due to a thalamic lesion had amnesia for temporal relations, and whether the amnesia was specific for particular material.

METHODS

A male patient had an isolated right dorsomedial thalamic infarct and resolving amnesia. He was tested on tasks relating to content (what) and temporal (when) memories for both verbal and non-verbal material, three and seven months after his infarct.

RESULTS

Three months after his infarct, the man had amnesia for temporal, but not content memories using non-verbal stimuli, and normal performance using verbal stimuli. Seven months after his infarct, he had a normal performance using verbal and non-verbal stimuli.

CONCLUSIONS

Patients with thalamic lesions may have a material specific amnesia for temporal relations in the absence of amnesia for content.

Emotional facial imagery, perception, and expression in Parkinson's disease

Patients with Parkinson's disease (PD) may be impaired at expressing emotional faces and perceiving emotional facial affect. We tested the hypothesis that patients with PD may be impaired at imaging emotional faces. We first compared 12 patients with PD and 30 control subjects on perceptual and imagery tasks. Patients were significantly impaired on a task of emotional facial imagery but not on a control task of object imagery. Patients were also impaired on a task of perceiving emotional faces. Subsequently, we found that PD patients were impaired relative to controls on making emotional faces. Performance on both the perceptual and motor tasks of facial expression significantly correlated with performance on the emotional facial imagery task. We suggest that the basal ganglia, together with the right hemisphere, are part of a neural network subserving emotional facial tasks.

Neglect of radial and vertical space: importance of the retinotopic reference frame

Neglect from bilateral brain injury can disrupt responses along space defined by the vertical and radial axes. The spatial reference frames for vertical and radial neglect remain largely undefined, however. The viewer centred system, for example, consists of retinocentric and cephalocentric/corporacentric frames. In the present study, different viewer centred reference frames were dissociated in a patient with combined far radial superior vertical neglect through performance of radial line bisections above and below eye level. To separate reference frames for vertical space, bisections were performed while the patient was lying sideways. Results suggest that this patient's neglect respected a retinotopic viewer centred reference frame.

Impaired perception of facial identity and facial affect in Huntington's disease

We tested five patients with Huntington's disease on tasks of facial discrimination and facial affect discrimination and matching. Four patients were impaired on a task or tasks of face discrimination, and all patients were impaired on at least one task of facial affect discrimination. We suggest that these findings reflect the role of the basal ganglia or its connections in visual processing.

Right-left confusion in Gerstmann's syndrome: a model of body centered spatial orientation

Gerstmann's syndrome encompasses the tetrad of finger agnosia, agraphia, acalculia and right-left confusion and is associated with lesions of the dominant angular gyrus. The localizing value of this syndrome has been questioned because multiple mechanisms can account for each of the components of the syndrome. We present the case of a man who developed Gerstmann's syndrome following a focal infarct of the left angular gyrus. The patient's right-left confusion could not be accounted for by either an aphasia or a degraded body schema. A series of experiments that investigated the patient's spatial mapping system by progressively restricting the degrees of freedom for spatial rotation revealed an isolated defect in deriving the relative position of an object along the horizontal axis. Defective horizontal mapping can account for the other components of Gerstmann's syndrome because they all share a common dependency on relative horizontal positioning.

Anosognosia for hemiplegia: an electrophysiologic investigation of the feed-forward hypothesis

The cause of anosognosia for hemiplegia (AHP) remains unclear. Weakness is detected when there is a mismatch between the expectancy of movement and the sensory perception of movement. The feed-forward hypothesis of AHP posits that there is a failure of detection because there is a loss of motor intention and expectancy of movement. We tested motor intention by measuring the activation of proximal muscles (pectoralis majoris) while subjects squeezed a dynamometer with each hand. We tested a group of normal controls, a group of patients with hemiparesis, a patient with neglect, a patient with resolved AHP, and a patient with persistent AHP. The patient with AHP did not contract either of his pectoralis muscles when asked to squeeze with his contralesional, paretic hand, yet he contracted both of them when squeezing the dynamometer with his ipsilesional hand. Normal controls, hemiparetic controls, and the patient with hemispatial neglect contracted both pectorales when asked to squeeze with each hand. The pattern of activation seen in the patients with persistent AHP and resolved AHP demonstrates a loss of motor intention and lends support to the feed-forward hypothesis of AHP.

Screening cerebrovascular patients for silent myocardial ischemia with stress testing and ambulatory left ventricular function monitor

Patients with symptomatic cerebrovascular disease suffer a high mortality from myocardial ischemia, which may occur during rest or following the conclusion of exercise. In a pilot study, we screened 11 patients with transient cerebral ischemic attack or stroke for silent myocardial ischemia using bicycle ergometer stress testing with electrocardiographic (EKG) monitoring and ambulatory left ventricular function monitoring (VEST). Three of 11 patients had nondiagnostic exercise EKGs due to failure to achieve their target heart rates during exercise but had positive VEST tests during and after exercise. One patient was falsely positive. VEST may be useful in combination with stress EKG for the detection of silent myocardial ischemia in cerebrovascular patients, but further assessment of the sensitivity and specificity in this patient population needs to be accomplished.

Meningiomas are not significantly associated with breast cancer

We studied 283 meningiomas seen at the University of Kansas, Kansas City, from 1948 through 1984, identifying all additional nonmeningeal malignancies and primary brain tumors in these patients and calculating the expected number of additional tumors by the use of a person-year method from age and sex-matched cancer incidence data. We determined expected numbers of total neoplasms in our meningioma population as well as the expected numbers in each major organ system for the sexes independently and together. We then calculated standard morbidity ratios and 95% confidence intervals for each tumor type. The number of breast cancers did not reach statistical significance. We found a significantly increased number of second primary brain tumors in women (standard morbidity ratio, 8.0; 95% confidence interval, 2.2 to 20.4) and an increased number of thyroid cancers in both sexes (standard morbidity ratio, 7.5; 95% confidence interval, 1.5 to 21.9).

The role of the caudate in nonmotor behaviors in Huntington's disease

Neuropsychologic data suggest an important role for the caudate nucleus (CN) in behavioral impairments in Huntington's disease (HD). These include abnormalities in executive function, egocentric visuospatial representations, communication, and retrieval of declarative memories, changes in personality, and psychiatric disturbances. Animal paradigms of CN lesions support a role for the CN in some of these behaviors. Current theories of basal ganglia function add explanatory value to the role of the CN in these behaviors. A disconnection of the caudate from limbic structures, including the amygdala may account for many nonmotor behaviors observed in HD.

Matrix vesicle biogenesis in vitro by rachitic and normal rat chondrocytes

Calcifying matrix vesicles (MVs) are released from chondrocytes and osteoblasts in monolayer culture. In the present studies, we tested the ability of rachitic versus normal rat growth plate chondrocytes in micromass or monolayer primary cultures to produce MVs. Unlike earlier reports of in vitro MV biogenesis by chicken chondrocytes in which most MVs were released into the medium, we found that most of the released rat matrix vesicles were entrapped in a newly formed cartilaginous matrix enveloping the cells. These matrix-associated MVs could be isolated by mild collagenase treatment and concentrated by differential centrifugation. Vesicle production slowed in the older 2- to 4-week-old cultures and, unlike vesicle release from cultured chicken chondrocytes, active vesicle production did not show a second burst of activity at 3 to 4 weeks. Alkaline phosphatase (ALP) activity diminished with time in culture in cells and matrix vesicles, suggesting a decrease in differentiative expression. Protein profiles on SDS polyacrylamide gels of native matrix vesicles and culture-derived MVs from rachitic and normal cells were quite similar and showed a typical simplified protein pattern as compared to chondrocyte plasma membrane proteins. There were distinctive proteins migrating at 130, 80 to 95, 66, 43, 20, and 14 kd. Culture-derived MVs showed vigorous in vitro calcifying activity that was ALP related. We conclude that 1) rachitic chondrocytes are essentially normal in their matrix vesicle production; 2) matrix entrapment of MVs is a characteristic of rat chondrocyte cultures; and 3) culture-produced MVs are similar to native MVs in protein profile and calcifiability, and thus can be studied as a model for normal MV composition and calcification.

Female patients with meningioma of the sphenoid ridge and additional primary neoplasms of the breast and genital tract

Of 283 meningioma patients seen at the University of Kansas from 1948 to 1984, eight women acquired two primary extraneural cancers in addition to their meningiomas. Of these eight patients, six (75%) had sphenoid ridge meningiomas compared with 15% of meningioma patients overall (P less than 0.001). Seven (87.5%) had at least one breast or genital cancer (P less than 0.001). Of the six with sphenoid ridge meningiomas, five (83.3%) had both of their additional tumors in these two organ systems, and the sixth had one such tumor. It is proposed that this grouping of sphenoid ridge meningioma, breast cancer, and genital cancer represents a unique constellation of neoplasms in women.

T cell-induced expression of membrane IgG by 70Z/3 B cells

To study T cell regulation of B cell isotype differentiation, we determined the capacity of clonal T cell populations (hybridomas derived by fusing BW5147 with Con A-activated Peyer's patch (PP) and spleen T cells) to induce "downstream" isotype expression by the pre-B cell lymphoma 70Z/3. In initial studies, we found that 70Z/3 B cells cultured in the presence of LPS (1 microgram/ml) expressed membrane IgM (mIgM) but not membrane IgG (mIgG). In contrast, 70Z/3 B cells cultured with HAJ-3 T cells, a PP-derived T cell hybridoma (as well as other similarly derived PP and spleen hybridomas), or with HAJ-3 T cells plus LPS do express mIgG. Such expression occurred in spite of mitomycin C-induced blockage of cell proliferation, and is observed in 70Z/3 B cell subclones cultured with HAJ-3 T cells. For these reasons, it is not due to selective expansion of a small pre-switched mIgG-bearing 70Z/3 B cell subpopulation. In other studies it was shown that 70Z/3 B cells expressing mIgG after induction by HAJ-3 T cells continue to express mIgM and do not secrete IgG. Finally, exposure of 70Z/3 B cells to the macrophage factor IL 1 and the T cell factors IL 2, BSF-pl, and BCGF-II present in EL-4 cell supernatants did not result in mIgG expression. On the basis of these studies, we conclude that a clonal B cell population expressing mIgM can be induced by T cells to co-express mIgG. Because the B cells do not express mIgG unless exposed to T cells, this represents a T cell-induced isotype switch.

T cell-induced expression of membrane IgG by 70Z/3 B cells

To study T cell regulation of B cell isotype differentiation, we determined the capacity of clonal T cell populations (hybridomas derived by fusing BW5147 with Con A-activated Peyer's patch (PP) and spleen T cells) to induce "downstream" isotype expression by the pre-B cell lymphoma 70Z/3. In initial studies, we found that 70Z/3 B cells cultured in the presence of LPS (1 microgram/ml) expressed membrane IgM (mIgM) but not membrane IgG (mIgG). In contrast, 70Z/3 B cells cultured with HAJ-3 T cells, a PP-derived T cell hybridoma (as well as other similarly derived PP and spleen hybridomas), or with HAJ-3 T cells plus LPS do express mIgG. Such expression occurred in spite of mitomycin C-induced blockage of cell proliferation, and is observed in 70Z/3 B cell subclones cultured with HAJ-3 T cells. For these reasons, it is not due to selective expansion of a small pre-switched mIgG-bearing 70Z/3 B cell subpopulation. In other studies it was shown that 70Z/3 B cells expressing mIgG after induction by HAJ-3 T cells continue to express mIgM and do not secrete IgG. Finally, exposure of 70Z/3 B cells to the macrophage factor IL 1 and the T cell factors IL 2, BSF-pl, and BCGF-II present in EL-4 cell supernatants did not result in mIgG expression. On the basis of these studies, we conclude that a clonal B cell population expressing mIgM can be induced by T cells to co-express mIgG. Because the B cells do not express mIgG unless exposed to T cells, this represents a T cell-induced isotype switch.

Esophageal cryptococcosis in a patient with the hyperimmunoglobulin E-recurrent infection (Job's) syndrome

Patients with the hyperimmunoglobulin E-recurrent infection (Job's) syndrome, which is characterized by an elevated immunoglobulin E level, recurrent staphylococcal infections, and an abnormality of neutrophil chemotaxis, have been reported to have visceral Candida infections in addition to their more frequent pyogenic infections. We report a patient with Job's syndrome who presented with massive hematemesis secondary to esophageal cryptococcosis. A thorough evaluation for an occult neoplasm or extraesophageal cryptococcosis was negative. The patient received a 6-wk course of amphotericin B (970 mg) and 5-fluorocytosine with complete radiographic and endoscopic resolution of the lesion. He is doing well 18 mo after therapy. The patient was not anergic, and his response to T-cell mitogens, helper-to-suppressor T-cell ratio, total number of T cells, and immunoglobulin-producing capability were all normal. This case is unusual in that it is the first documentation of a cryptococcoma of the esophagus and underscores the importance of culturing abnormal specimens for unsuspected pathogens in unusual clinical circumstances.

The neglected alliance: the inpatient unit as a consultant to referring therapists

During two years of work on an inpatient psychiatry unit in a general hospital, the authors became impressed with how often patient-therapist difficulties preceded the need to hospitalize a patient. Difficulties in the therapeutic relationship sometimes precipitated the hospitalization; other times they were complicating factors. Unresolved difficulties in this relationship had to be addressed during hospitalization if inpatient treatment was to be successful. The authors present several typical cases that demonstrate different kinds of difficulties in the patient-therapist relationship and the use of consultation by an inpatient staff in resolving them. They conclude that an inpatient unit with sufficient staff should serve as a consultant to the referring therapist in almost every case.