Feasibility and effects of cognitive-motor exergames on fall risk factors in typical and atypical Parkinson's inpatients: a randomized controlled pilot study

BACKGROUND

People with Parkinson`s disease (PD) often suffer from both motor and cognitive impairments. Simultaneous motor and cognitive training stimulates neurobiological processes which are important especially for people with PD. The aim of this study is to test the feasibility and effects of simultaneous cognitive-motor training in form of exergames in the setting of inpatient rehabilitation of persons with PD.

METHODS

Forty participants (72.4 ± 9.54 years; Hoehn and Yahr stage 1-4) were randomly assigned to either the intervention group, which trained five times a week in addition to the conventional rehabilitation program, or the control group, which underwent the standard rehabilitation treatment only. Primary outcome was feasibility (measured by adherence rate, attrition rate, occurrence of adverse events, system usability scale (SUS), and NASA TLX score). In addition, various cognitive (Go/No-Go test, reaction time test (RTT), color word interference test (D-KEFS) and Trail Making Test A and B (TMT)) and motor (preferred gait speed, maximum gait speed, dual-task gait speed, Short Physical Performance Battery (SPPB), Timed Up and Go (TUG) and 5 times Sit-to-Stand (5xStS)) tests were conducted before and after the intervention phase in order to determine training effects RESULTS: Adherence rate was 97%, there were just two dropouts due to reasons unrelated to the study and there were no adverse events. The mean NASA TLX value was 56.2 and the mean value of the SUS was 76.7. Significant time-group interaction effects were observed for the 5xStS, the SPPB, the RTT, the Go/No-Go test and the D-KEFS 2.

DISCUSSION

Exergaming, as applied in this study, showed to be feasible, safe and likely effective for the improvement of cognitive and motor functions of PD inpatients. Because of this future randomized controlled trials with a main focus on testing the efficacy of this new intervention are warranted.

TRIAL REGISTRATION

The study has been registered at ClinicalTrials.gov (ID: NCT04872153).

The impact of a coronavirus disease 2019 pandemic-related interruption of regular physical rehabilitation on functional abilities in a patient with two chronic neurological diseases: a case report

Background

Regular outpatient rehabilitation is prescribed for many patients with chronic neurological disorders, such as Parkinson’s disease or multiple sclerosis, to constantly support patients and their proxies in disease management. Due to the coronavirus disease 2019 pandemic, federal institutions and governments worldwide have directed local or nationwide lockdowns. During these times, the provision of regular outpatient rehabilitation service is drastically limited, making it actually impossible for community-dwelling patients with neurological disorders to receive prescribed rehabilitation interventions.

Case presentation

A 67-year-old White Swiss man with two chronic neurological diseases, Parkinson’s disease and multiple sclerosis, underwent a 4-week inpatient rehabilitation in our hospital. The main rehabilitation goals were related to improvements of mobility and a decrease in the risk of falls. The patient gained significant functional improvements that he maintained over the following months, supported by the continuation of physiotherapy in the domestic environment. Due to a coronavirus disease 2019 pandemic-related interruption of the regular ambulatory rehabilitation for several weeks during the first coronavirus disease 2019 wave in Switzerland, the patient’s functional abilities decreased significantly. Thus, the patient was again referred to our hospital for intensive inpatient rehabilitation to regain his physical functioning and mobility capacity. At hospital discharge, the patient improved most of his physical functioning to a prepandemic level.

Conclusions

The interruption of a rehabilitation service due to a pandemic-related lockdown can significantly impact the functional abilities of patients with chronic neurological diseases. This case report supports the claim for continuous access to rehabilitation services for all people with rehabilitation needs.

Psychometric properties of the short form of the Stroke Impact Scale in German-speaking stroke survivors

Background

The short form of the Stroke Impact Scale (SF-SIS) consists of eight questions and provides an overall index of health-related quality of life after stroke. The goal of the study was the evaluation of construct validity, reliability and responsiveness of the SF-SIS for the use in German-speaking stroke patients in rehabilitation.

Methods

The SF-SIS, the Stroke Impact Scale 2.0 (SIS 2.0), EQ-5D-5L, National Institutes of Health Stroke Scale (NIHSS) and de Morton Mobility Index were assessed in 150 inpatients after stroke, with a second measurement two weeks later for the analyses of responsiveness. In 55 participants, the test–retest-reliability was assessed one week after the first measurement. The study was designed following the recommendations of the COSMIN initiative.

Results

The correlations of the SF-SIS with the SIS 2.0 (ρ = 0.90), as well as the EQ-5D-5L (ρ = 0.79) were high, as expected. There was adequate discriminatory ability of the SF-SIS index between patients who were less and more severely affected by stroke, as assessed by the NIHSS. Exploratory factor analysis indicated a two-factor structure of the SF-SIS explaining 59.9% of the total variance, providing better model fit in the confirmatory factor analysis than the one-factorial structure. Analyses of test–retest-reliability showed an intraclass correlation coefficient of 0.88 (95% CI 0.75–0.94). Hypotheses concerning responsiveness were not confirmed due to lower correlations between the assessments change scores.

Conclusion

Results of this analysis of the SF-SIS’s psychometric properties are matching with the validity analysis of the English original version, confirming the high correlations with the Stroke Impact Scale and the EQ-5D-5L. Examination of structural validity did not confirm the presumed unidimensionality of the scale and found evidence of an underlying two-factor solution with a physical and cognitive domain. Sufficient test–retest reliability and internal consistency were found. In addition, this study provides first results for the responsiveness of the German version.

Trial registration The study was registered at the German Clinical Trials Register. Trial registration number: DRKS00011933, date of registration: 07.04.2017

A generic outcome assessment of mobility capacity in neurorehabilitation: measurement properties of the de Morton Mobility Index

Background

Mobility capacity is a key outcome domain in neurorehabilitation. The de Morton Mobility Index (DEMMI), an established and generic outcome assessment of mobility capacity in older patients, is promising for use in neurorehabilitation. The aim of this study was to examine the measurement properties of the DEMMI in rehabilitation inpatients with neurological conditions.

Methods

Cross-sectional study including a mixed sample of adult inpatients in a neurorehabilitation hospital. Structural validity, unidimensionality and measurement invariance (Rasch analysis), construct validity, internal consistency reliability, and inter-rater reliability of the DEMMI (scale range: 0–100 points) were established. The minimal detectable change, the 95% limits of agreement, and possible floor and ceiling effects were calculated to indicate interpretability.

Results

We analyzed validity (n = 348) and reliability (n = 133) in two samples. In both samples, the majority of participants had a sub-acute stroke or Parkinson’s disease.

Rasch analysis indicated unidimensionality with an overall fit to the model (chi-square = 59.4, P = 0.074). There was no relevant measurement invariance by disease group. Hypotheses-based correlation analyses (DEMMI and other functional outcome assessments) showed sufficient construct validity. Internal consistency reliability (Cronbach’s alpha = 0.94) and inter-rater reliability (intraclass correlation coefficient = 0.94; 95% confidence interval: 0.91–0.95) were sufficient. The minimal detectable change with 90% confidence was 15.0 points and the limits of agreement were 39%. No floor or ceiling effects were observed.

Conclusions

Results indicate sufficient measurement properties of the DEMMI in rehabilitation inpatients with neurological conditions. The DEMMI can be used as a generic outcome assessment of mobility capacity in neurorehabilitation.

Trial registration

German Clinical Trials Register (DRKS00004681). Registered May 6, 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02327-0.

An investigation of the measurement properties of the de Morton Mobility Index for measuring mobility capacity in hospital patients with Parkinson's disease

OBJECTIVE

To examine the measurement properties of the de Morton Mobility Index (DEMMI), a performance-based clinical outcome assessment of mobility capacity, in hospital patients with Parkinson's disease.

DESIGN

Cross-sectional study.

PARTICIPANTS

Hospital patients with Parkinson's disease.

MAIN OUTCOME MEASURE(S)

Structural validity and unidimensionality (Rasch analysis), construct validity, internal consistency reliability, and inter-rater reliability of the de Morton Mobility Index (scale range: 0-100 points) were established. The minimal detectable change, the 95% limits of agreement and possible floor and ceiling effects were calculated to indicate interpretability.

RESULTS

We analysed validity (n = 100; mean age: 70 years; 71% male) and reliability (n = 47; mean age: 71 years; 68% male) in two samples. The mean Hoehn and Yahr stage was 3.2 and the mean disease duration was 12 years in both samples. Rasch analysis indicated unidimensionality with an overall fit to the model (chi-square = 21.49, P = 0.122). Seventy-three percent of hypotheses on construct validity were confirmed. Internal consistency reliability (Cronbach's alpha = 0.91) and inter-rater reliability (intraclass correlation coefficient = 0.88; 95% confidence interval: 0.80 to 0.93) were sufficient. The minimal detectable change with 90% confidence was 17.5 points and the limits of agreement were 31%. No floor or ceiling effects were observed. The mean administration time was 6.6 minutes.

CONCLUSION

This study provides evidence of unidimensionality, sufficient internal consistency reliability, inter-rater reliability, construct validity, and feasibility of the de Morton Mobility Index in hospital patients with Parkinson's disease.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00004681). Registered May 6, 2013.

Die Effekte des Lee Silverman Voice Treatment (LSVT)-BIG Trainings auf die motorische Funktionsfähigkeit von Menschen mit M. Parkinson – eine systematische Übersichtsarbeit

Hintergrund Interventionen zur Verbesserung der motorischen Funktionsfähigkeit sind wichtige Aspekte der Rehabilitation von Menschen mit Morbus Parkinson. Das Lee Silverman Voice Treatment BIG (LSVT-BIG) ist ein in der klinischen Praxis verbreitetes bewegungstherapeutisches Therapiekonzept bei M. Parkinson, dessen Wirksamkeit auf die motorische Funktionsfähigkeit unklar ist.

Ziel Dieser systematische Review fasst die Studien zur Wirksamkeit des LSVT-BIG auf die motorische Funktionsfähigkeit im Vergleich zu anderen bewegungstherapeutischen Interventionen zusammen.

Methode Die elektronischen Datenbanken MEDLINE, CINAHL und Cochrane Library wurden für den Publikationszeitraum 2005 bis 2017 nach randomisierten kontrollierten Studien (RCT) durchsucht, die das LSVT-BIG bei leicht bis schwer betroffenen Menschen mit idiopathischem M. Parkinson (Hoehn u. Yahr Stadium I–IV) mit anderen bewegungstherapeutischen Interventionen verglichen. Die Bewertung der methodischen Qualität der eingeschlossenen Studien erfolgte anhand der PEDro-Skala. Die eingeschlossenen Studien wurden narrativ zusammengefasst.

Ergebnisse Eingeschlossen wurden 3 RCT mit moderater methodischer Qualität (PEDro-Skala: 5 – 6/10 Punkten). Zwei Studien zeigten keine Vorteile des standardisierten LSVT-BIG-Trainings gegenüber einer anderen bewegungstherapeutischen Intervention bei annähernd vergleichbaren Trainingsdosierungen. In einer Studie, die das LSVT-BIG mit anderen bewegungstherapeutischen Interventionen in anderen Trainingsdosierungen untersuchte, erwies sich das LSVT-BIG als überlegen.

Schlussfolgerungen Aufgrund der geringen Studienzahl ist die Bewertung der Wirksamkeit des LSVT-BIG auf die motorische Funktionsfähigkeit nur bedingt möglich. Für eine mögliche Dose-Response-Beziehung zwischen körperlichem Training – darunter LSVT-BIG – und motorischer Funktionsfähigkeit sind mehr qualitativ hochwertige Studien notwendig.

Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children

The present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent-child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study's limitations, and future directions for research are further discussed.

Reliability and validity of the de Morton Mobility Index in individuals with sub-acute stroke

PURPOSE

To establish the validity and reliability of the de Morton Mobility Index (DEMMI) in patients with sub-acute stroke.

METHODS

This cross-sectional study was performed in a neurological rehabilitation hospital. We assessed unidimensionality, construct validity, internal consistency reliability, inter-rater reliability, minimal detectable change and possible floor and ceiling effects of the DEMMI in adult patients with sub-acute stroke.

RESULTS

The study included a total sample of 121 patients with sub-acute stroke. We analysed validity (n = 109) and reliability (n = 51) in two sub-samples. Rasch analysis indicated unidimensionality with an overall fit to the model (chi-square = 12.37, p = 0.577). All hypotheses on construct validity were confirmed. Internal consistency reliability (Cronbach's alpha = 0.94) and inter-rater reliability (intraclass correlation coefficient = 0.95; 95% confidence interval: 0.92-0.97) were excellent. The minimal detectable change with 90% confidence was 13 points. No floor or ceiling effects were evident.

CONCLUSIONS

These results indicate unidimensionality, sufficient internal consistency reliability, inter-rater reliability, and construct validity of the DEMMI in patients with a sub-acute stroke. Advantages of the DEMMI in clinical application are the short administration time, no need for special equipment and interval level data. The de Morton Mobility Index, therefore, may be a useful performance-based bedside test to measure mobility in individuals with a sub-acute stroke across the whole mobility spectrum. Implications for Rehabilitation The de Morton Mobility Index (DEMMI) is an unidimensional measurement instrument of mobility in individuals with sub-acute stroke. The DEMMI has excellent internal consistency and inter-rater reliability, and sufficient construct validity. The minimal detectable change of the DEMMI with 90% confidence in stroke rehabilitation is 13 points. The lack of any floor or ceiling effects on hospital admission indicates applicability across the whole mobility spectrum of patients with sub-acute stroke.

Effects of additional, dynamic supported standing practice on functional recovery in patients with sub-acute stroke: a randomized pilot and feasibility trial

OBJECTIVE

To evaluate the feasibility and preliminary effectiveness of additional dynamic versus static passive standing performed by patients with sub-acute stroke supervised by trained helpers.

DESIGN

Assessor blinded, randomized pilot and feasibility trial.

SETTING

Neurological rehabilitation centre.

PARTICIPANTS

Non-ambulatory participants in the sub-acute phase after stroke.

INTERVENTION

Usual care plus additional standing training, consisting of either dynamic standing practice in a modified standing frame (intervention group, n=14) or static standing practice in a conventional standing frame (control group, n=14) for 5 weeks.

MAIN MEASURES

Feasibility was assessed through occurrence of adverse events, patient satisfaction and operability of the technical device handled by trained helpers. Preliminary effectiveness was assessed with the Berg Balance Scale (primary outcome) and other measures of physical functioning.

RESULTS

Trained helpers were capable to apply the intervention, and no adverse events occurred. Both groups were comparable at baseline. Within-group changes tended to be higher for the intervention group, but did not reach a significant level except for the Functional Ambulation Categories. Specifically, median pre-post improvements in the Berg Balance Scale tended to be higher in the dynamic (20, inter quartile range (IQR): 2-33 points) than in the static standing group (4.5, IQR: 0-16 points; U=62; P=0.052; effect size=0.478).

CONCLUSIONS

In severely affected individuals after stroke, dynamic supported standing practice can be performed safely by trained helpers. In a larger-scale phase III study, a total of 116 patients would be needed to prove the preliminary effectiveness found in this study.

The impact of rollator loading on gait and fall risk in neurorehabilitation - a pilot study

PURPOSE

Rollator loading is an application used clinically sometimes to improve functional integrity and security of the patients' gait. As empirical evidence supporting this intervention is equivocal, the purpose of this study was to examine the effects of rollator loading on several gait parameters and fall risk.

METHODS

An explicatory experiment with a follow-up cohort study of falls was conducted. In the experimental part of the study, participants (n = 25) were evaluated three times by means of different gait and fall risk assessments, whereby each trial was carried out with different rollator loading (0, 4.5 and 9 kg, respectively). Participants were blinded towards the applied load. In addition, the odds ratio of falls with respect to rollator loading in all-day rehabilitation life was determined.

RESULTS

No changes in spatio-temporal gait parameters and fall risk in relation to a particular load could be identified by clinical measures in the tested sample. A separate sub-group analysis (Parkinson's disease, hemiparesis and ataxia) showed only little impact of the load in each case. Rollator loading had no impact on the odds ratio of inpatient fall risk.

CONCLUSION

On the basis of our findings, weighting of rollators can neither be discouraged nor recommended. Implications for Rehabilitation Unless more research is has been conducted on this topic, rollator loading can neither be recommended nor discouraged in individuals suffering from neurologic diseases. There is more research needed to examine the impact on ambulation in distinct conditions such as severe ataxia and fear of falling.

Serological survey of exposure to Erysipelothrix rhusiopathiae in poultry in New Zealand

AIMS

To estimate the seroprevalence of antibodies to Erysipelothrix rhusiopathiae in chickens in New Zealand, and to estimate the effect of housing type, geographical location and age on seroprevalence.

METHODS

A cross-sectional serological survey of a convenience sample of 545 broiler, breeder, and layer chickens in 55 flocks was conducted in 2010-2011. Birds were aged 5-83 weeks; housing types were free-range, shed, caged, and unknown; and flocks were located in the Auckland, Manawatu, North Canterbury, Otago, Taranaki, Waikato, and Wairarapa regions of New Zealand. An ELISA was used to measure antibodies to E. rhusiopathiae. Samples with an optical density reading ≥ 1.50 were considered to be positive. Logistic regression analysis was used to model the effect of housing type, geographical location and flock age on the prevalence of samples positive for antibodies to E. rhusiopathiae.

RESULTS

The overall prevalence of samples with antibodies to E. rhusiopathiae was 39.8 (95% CI=35.68-44.06)% for the 545 samples, and 46/55 (84%) farms that were tested had at least one positive sample. Mean seroprevalence for types of housing was 44.2 (95% CI=37.79-50.70)% for free-range (n=240 birds), 23.7 (95% CI=17.83-30.38)% for shed (n=190), 73 (95% CI=56-86)% for caged (n=37) and 50 (95% CI=38-62)% for unknown (n=78). The disease was present in all seven geographical locations from which samples were obtained for this study. Seroprevalence increased with increasing age of birds (p<0.001); for birds ≤ 12 weeks of age it was 2 (95% CI=0.3-8)% (n=91), 13-24 weeks 29.1 (95% CI=23.34-35.46)% (n=230), 25-36 weeks 47 (95% CI=32-64)% (n=40), 37-48 weeks 75 (95% CI=51-91)% (n=20), >48 weeks 63.8 (95% CI=54.78-72.12)% (n=127). Neither housing type nor geographical location had a significant effect on the likelihood of samples being positive for antibodies to E. rhusiopathiae.

CONCLUSIONS

The results of this study suggest the prevalence of erysipelas under New Zealand field conditions may be higher than expected and that the disease is significantly associated with increasing age. Housing type and geographical location appear to be unrelated to seroprevalence.

CLINICAL RELEVANCE

Further study of the epidemiology of E. rhusiopathiae in chickens in New Zealand should be considered in order to minimise the extent of birds' exposure to the organism. These findings will assist in the design of further studies.

Probabilistic cost-effectiveness analysis of cascade screening for familial hypercholesterolaemia using alternative diagnostic and identification strategies

OBJECTIVE

To estimate the probabilistic cost-effectiveness of cascade screening methods in familial hypercholesterolaemia (FH) from the UK NHS perspective.

DESIGN

Economic evaluation (cost utility analysis) comparing four cascade screening strategies for FH: Using low-density lipoprotein (LDL) cholesterol measurements to diagnose affected relatives (cholesterol method); cascading only in patients with a causative mutation identified and using DNA tests to diagnose relatives (DNA method); DNA testing combined with LDL-cholesterol testing in families with no mutation identified, only in patients with clinically defined 'definite' FH (DNA+DFH method); DNA testing combined with LDL-cholesterol testing in no-mutation families of both 'definite' and 'probable' FH patients (DNA+DFH+PFH). A probabilistic model was constructed to estimate the treatment benefit from statins, with all diagnosed individuals receiving high-intensity statin treatment.

POPULATION

A cohort of 1000 people suspected of having FH aged 50 years for index cases and 30 years for relatives, followed for a lifetime.

MAIN OUTCOMES

Costs, quality-adjusted life-years (QALY) and incremental cost-effectiveness ratios (ICER).

RESULTS

The DNA+DFH+PFH method was the most cost-effective cascade screening strategy. The ICER was estimated at £3666/QALY. Using this strategy, of the tested relatives 30.6% will be true positives, 6.3% false positives, 61.9% true negatives and 1.1% false negatives. Probabilistic sensitivity analysis showed that this approach is 100% cost-effective using the conventional benchmark for cost-effective treatments in the NHS of between £20,000 and £30,000 per QALY gained.

CONCLUSION

Cascade testing of relatives of patients with DFH and PFH is cost-effective when using a combination of DNA testing for known family mutations and LDL-cholesterol levels in the remaining families. The approach is more cost-effective than current primary prevention screening strategies.

Family tracing to identify patients with familial hypercholesterolaemia: the second audit of the Department of Health Familial Hypercholesterolaemia Cascade Testing Project

BACKGROUND

Family tracing is a method recognized to find new patients with familial hypercholesterolaemia (FH). We have implemented family tracing led by FH Nurses and have determined acceptability to patients, feasibility and costs.

METHODS

Nurses were located at five National Health Service (NHS) Trusts; they identified FH patients and offered them family tracing. Responses and test results were recorded on a database and summarized on a family pedigree.

RESULTS

The majority ( approximately 70%) of index cases participated; the proportion was lower when patients had been discharged from the clinics and in metropolitan areas. On average, 34% (range 13-50%) of relatives lived outside the catchment area of the clinics and could not attend the nurse-led FH clinics. Of the previously untested relatives, 76% who lived in the catchment area of the clinic came forward to be tested. One-third of the relatives who came forward for testing were children <or=16 y of age. The proportion of relatives diagnosed as likely to have FH was lower than would be predicted (30% vs. 50%). This was mainly due to the uncertainty of a diagnosis based on lipid measurements. The average cost to identify and test one relative was approximately pound 500 but was higher in the metropolitan areas.

CONCLUSION

Cascade testing for FH in the UK is feasible, acceptable and likely to be cost-effective if it is a routine aspect of clinical care. However, national implementation would require an integrated infrastructure, so that all individuals have access to testing, and specialist services for the management of young people.

Serum leptin levels, hepatic leptin receptor transcription, and clinical predictors of non-alcoholic steatohepatitis in obese bariatric surgery patients

BACKGROUND

Non-alcoholic steatohepatitis (NASH) is a major cause of liver disease in morbidly obese patients. Clinical predictors of NASH remain elusive, as do molecular mechanisms of pathogenesis.

METHODS

A series of 35 morbidly obese patients undergoing bariatric surgery had a liver biopsy performed for standard histologic analysis. In addition, RNA was obtained from liver tissue and analyzed for leptin receptor gene expression. Regression analysis was used to correlate clinical variables, including serum leptin levels and hepatic leptin receptor gene expression, with the presence of histologically confirmed NASH.

RESULTS

Of the 35 subjects enrolled, 29% had steatosis only, 60% had NASH, and 11% had normal liver histology. Among the clinical variables studied, only diabetes mellitus was an independent predictor of NASH. There was a trend toward lower levels of mRNA encoding the long form of the leptin receptor in hepatic tissue from patients with NASH compared to those with steatosis only.

CONCLUSIONS

Diabetes mellitus is associated with an increased risk of NASH in obese patients. Downregulation of hepatic leptin receptor may play a role in the pathogenesis of NASH.

Cascade screening for familial hypercholesterolaemia: implications of a pilot study for national screening programmes

OBJECTIVES

To determine what proportion of cases of heterozygous familial hypercholesterolaemia would be identified by cascade screening conducted by a specialist hospital clinic, and by how much this would increase the prevalence of diagnosed cases.

SETTING

Hospital clinic serving a population of 605,900 in Oxfordshire, UK.

METHODS

A specialist nurse obtained details of living first-degree relatives from 227 adult patients with heterozygous familial hypercholesterolaemia currently or previously attending Oxford lipid clinic after excluding 79 adults without relatives living in Oxfordshire and 48 children. Index cases were asked to invite relatives resident in Oxfordshire for testing.

RESULTS

A total of 227 index cases had 1075 first-degree relatives, including 442 adults and 117 children aged < 18 years resident in Oxfordshire. We excluded 171 previously screened adults and 46 for other reasons. Among 225 eligible adult relatives, 28 responders (12%) planned to consult their general practitioner and 52 (23%) attended the clinic for testing. Parents of 113 children (97%) wanted them tested. The positive diagnostic rate was 29% (15/52) in adults and 32% (36/113) in children. Screening increased prevalence by 14.4%, from 0.58/1000 (95% confidence intervals [CI] 0.52-0.65) to 0.67/1000 (95% CI 0.60-0.73), representing 33.5% of predicted cases.

CONCLUSIONS

Cascade screening conducted by a specialist hospital clinic within its population catchment area did not substantially increase the prevalence of diagnosed familial hypercholesterolaemia. To maximize response rates, clinic staff need to approach relatives directly. Validated age, sex and country-specific diagnostic criteria should be defined, possibly with access to DNA-based tests, to help resolve diagnostic uncertainty.

Alterations in peripheral blood lymphocyte cytokine expression in obesity

Obesity is characterized by alterations in immune and inflammatory function. In order to evaluate the potential role of cytokine expression by peripheral blood mononuclear cells (PBMC) in obesity-associated inflammation, we studied serum protein levels and mRNA levels in PBMC of interleukin (IL)-6, IL-1beta, tumour necrosis factor (TNF)-alpha and IL-1Ra in nine lean and 10 obese subjects. Serum IL-1beta was undetectable, IL-1Ra serum levels were elevated, serum levels of TNF-alpha were decreased and serum levels of IL-6 were similar in obese subjects compared to lean subjects, while transcript levels of IL-6, IL-1beta and TNF-alpha, but not IL-1Ra, were decreased in PBMC from obese subjects. PBMC from obese subjects did, however, up-regulate cytokine expression in response to leptin. Thus, obesity-associated changes in IL-1Ra serum levels and IL-6 mRNA levels were not correlated with changes in cognate mRNA and serum levels, respectively, while TNF-alpha serum levels and PBMC mRNA levels were both decreased in obese patients. While immune alterations in obesity are manifest in peripheral blood lymphocytes, the general lack of correlation between altered serum levels and altered PBMC gene expression suggests that PBMC may not be the source of aberrant serum cytokine levels in obesity.

Topical issues in unrelated donor haematopoietic stem cell transplants: a report from a workshop convened by the Anthony Nolan Trust in London - 2005

Over more than three decades, The Anthony Nolan Trust (ANT) has provided an unrelated donor (UD) for over 4000 children and adults lacking a suitable family member donor, and has remained at the forefront of developments in haematopoietic stem cell transplantation (HSCT) and bone marrow register management. These three decades have seen major changes in clinical practice of UD-HSCT, including new indications, increased use of alternative haematopoietic cell sources, significant improvement of the outcome as a result of better support care, less-toxic conditioning regimens, and better donor selection, and expansion to older patients with higher comorbidities. In order to foster our goal of improving UD-HSCT availability and outcome in a progressively more complex clinical scenario, a new initiative from ANT was launched in 2005 to convene an experts workshop to address the topical issues in this field. Four consecutive panels addressed factors influencing donor selection and transplant outcome, the use of cord blood, regulatory and accreditation issues, and future developments in this field. This report summarizes the discussions held in this workshop, which will likely develop into a periodic event where transplant clinicians, scientists and registry members will meet to share their experience and vision in the field of UD-HSCT.

Frontier medicine: the future and integrative medicine

Vigorous and prolonged effort is required to gain true mastery of the healing arts. Conventional and complementary medicine have complementary strengths and weaknesses. Like the yin and yang of traditional Chinese medicine, they naturally flow into one another by a process of induction, creating balance. Integrative medicine is the frontier; it is the future. If we are to progress beyond our current understanding and ability to heal, we must work with theoretic models that allow us and our perception to operate "outside the box." For some, this understanding is intuitive. It is through cooperative and collaborative efforts of intuitively adept and technologically adept minds that we can integrate and advance our understanding; increase our ability to predict, prevent, and diagnose disease; and expand our therapeutic options.

FLRT3 is expressed in sensory neurons after peripheral nerve injury and regulates neurite outgrowth

We used a molecular screen to identify genes upregulated in regenerating adult rat dorsal root ganglion cells. FLRT3 mRNA and protein characterized by a fibronectin type III domain and a leucine-rich repeat motif was upregulated in damaged sensory neurons. The protein was then transported into their peripheral and central processes where the FLRT3 protein was localized to presynaptic axon terminals. In vitro, the FLRT3 protein was expressed at the cell surface, regulated neurite outgrowth in sensory neurons, but did not exhibit homophilic binding. FLRT3 was widely expressed in the developing embryo, particularly in the central nervous system and somites. However, in the adult, we found no evidence for accumulation or reexpression of the FLRT3 protein in damaged axons of the central nervous system. We conclude that FLRT3 codes for a putative cell surface receptor implicated in both the development of the nervous system and in the regeneration of the peripheral nervous system (PNS).

Census of clinics providing specialist lipid services in the United Kingdom

BACKGROUND

Screening for familial hypercholesterolaemia (FH) through family tracing of relatives is cost-effective, but access to the index patient through specialist lipid clinics is a determinant of the programme's success. This paper reports on numbers of FH patients and on specialist lipid clinic provision in the United Kingdom.

RESULTS

One hundred and forty-four clinics provide specialist lipid services. Over 20 per cent of clinics do not employ a nurse and 64 per cent employ only one doctor. Two thirds treat children. Thirty-four clinics (24 per cent) have computerized records, 58 plan to and 66 clinics were unable to estimate FH numbers. Data from the responding clinics identified 4665 'definite' and 6024 'probable' FH cases. By extrapolation, we estimate there are 19 794 FH patients treated in specialist centres, 17 per cent of the predicted number.

COMMENT

Specialist lipid clinic provision is patchy. Less than 10 per cent of the predicted FH patients in the UK are recorded on computerized databases limiting implementation of cascade testing. Substantial investment in the infrastructure of specialist lipid clinics is needed.

Free available chlorine in commercial broiler chicken drinking water in New Zealand

Free available chlorine (FAC) concentrations in drinking water supplied to broiler chickens grown commercially in New Zealand were monitored for 11 farms in two companies. Different sites within a growout house were examined at different times of the day to determine spatial and temporal differences in FAC concentrations. Taps provided water with significantly higher FAC concentrations than did drinkers. There were no significant differences between the concentrations of FAC taken from various drinkers around the growout house. There were differences in the variations of measurements taken from the same drinker within a growout house at different times of the day, with variations increasing in the afternoon. No growout houses provided an average FAC content of 2 ppm, the suggested standard in one company. Three growout houses consistently met the chlorine concentration of 0.2 ppm suggested by the New Zealand Drinking Water Standards.

BOLD fMRI activation induced by vagus nerve stimulation in seizure patients

OBJECTIVE

To identify the cerebral activated regions associated with the vagus nerve stimulation in epilepsy patients.

DESIGN

Blood oxygenation level dependent functional magnetic resonance imaging (BOLD fMRI) was employed to detect areas of the brain activated by vagus nerve stimulation in five patients with documented complex partial seizures.

METHODS

Functional MRI was done on a GE 1.5T Echospeed horizon scanner. Before each patient entered the scanner, the vagal nerve stimulator was set to a specific ON-OFF paradigm so that the data could be analysed using a box-car type of design. The brains were scanned both anatomically and functionally. The functional images were corrected for head motion and co-registered to the anatomical images. Maps of the activated areas were generated and analysed using the brain mapping software, SPM99. The threshold for activation was chosen as p < 0.001.

RESULTS

All patients showed activation in the frontal and occipital lobes. However, activation in the thalamus was seen only in the two patients with improved seizure control.

CONCLUSIONS

BOLD fMRI can detect activation associated with vagus nerve stimulation. There may be a relation between thalamic activation and a favourable clinical outcome.

The effect of pretransplant interferon therapy on the outcome of unrelated donor hematopoietic stem cell transplantation for patients with chronic myelogenous leukemia in first chronic phase

Various therapeutic options are available for patients with chronic myelogenous leukemia. Allogeneic stem cell transplantation, though often curative, is associated with high nonrelapse mortality and long-term morbidity, particularly when cells from unrelated donors are used. Many physicians and patients opt for a trial of interferon-alpha (IFN)-based therapy first, reserving transplantation for patients with inadequate response or intolerance to IFN. Data were analyzed on 740 patients receiving unrelated donor transplants for chronic myelogenous leukemia in first chronic phase provided by the International Bone Marrow Transplant Registry and the National Marrow Donor Program to see whether IFN pretreatment compromised transplantation outcome. A total of 489 (66%) had received IFN prior to transplantation; 251 (34%) had not. Disease characteristics in the 2 groups were similar at diagnosis but at the time of transplantation, hematologic parameters and weight were lower in IFN patients and the interval between diagnosis and transplantation was longer. After adjustment for baseline covariates, no effect of IFN exposure was found on overall survival, leukemia-free survival, nonrelapse mortality, engraftment, relapse, or acute or chronic graft-versus-host disease. Evaluation of effects based on duration of therapy and time off IFN prior to transplantation was limited by missing data and confounding with IFN intolerance and disease responsiveness. In conclusion, no evidence was found for an independent adverse effect of IFN pretreatment on the outcome of subsequent unrelated donor transplantation.

Screening for hypercholesterolaemia versus case finding for familial hypercholesterolaemia: a systematic review and cost-effectiveness analysis

BACKGROUND

In the majority of people with familial hypercholesterolaemia (FH) the disorder is caused by a mutation of the low-density lipoprotein receptor gene that impairs its proper function, resulting in very high levels of plasma cholesterol. Such levels result in early and severe atherosclerosis, and hence substantial excess mortality from coronary heart disease. Most people with FH are undiagnosed or only diagnosed after their first coronary event, but early detection and treatment with hydroxymethylglutaryl-coenzyme (HMG CoA) reductase inhibitors (statins) can reduce morbidity and mortality. The prevalence of FH in the UK population is estimated to be 1 in 500, which means that approximately 110,000 people are affected.

OBJECTIVES

To evaluate whether screening for FH is appropriate. To determine which system of screening is most acceptable and cost-effective. To assess the deleterious psychosocial effects of genetic and clinical screening for an asymptomatic treatable inherited condition. To assess whether the risks of screening outweigh potential benefits.

METHODS

DATA SOURCES

Relevant papers were identified through a search of the electronic databases. Additional papers referenced in the search material were identified and collected. Known researchers in the field were contacted and asked to supply information on unpublished or ongoing studies. INCLUSION/EXCLUSION CRITERIA: SCREENING AND TREATMENT: The review included studies of the mortality and morbidity associated with FH, the effectiveness and cost of treatment (ignoring pre-statin therapies in adults), and of the effectiveness or cost of possible screening strategies for FH. PSYCHOSOCIAL EFFECTS OF SCREENING: The search for papers on the psychological and social effects of screening for a treatable inherited condition was limited to the last 5 years because recent developments in genetic testing have changed the nature and implications of such screening tests. Papers focusing on genetic testing for FH and breast cancer were included. Papers relating to the risk of coronary heart disease with similarly modifiable outcome (non-FH) were also included. DATA EXTRACTION AND ASSESSMENT OF VALIDITY: A data assessment tool was designed to assess the quality and validity of the papers which reported primary data for the social and psychological effects of screening. Available guidelines for systematically reviewing papers concentrated on quantitative methods, and were of limited relevance. An algorithm was developed which could be used for both the qualitative and quantitative literature. MODELLING METHODS: A model was constructed to investigate the relative cost and effectiveness of various forms of population screening (universal or opportunistic) and case-finding screening (screening relatives of known FH cases). All strategies involved a two-stage process: first, identifying those people with cholesterol levels sufficiently elevated to be compatible with a diagnosis of FH, and then either making the diagnosis based on clinical signs and a family history of coronary disease or carrying out genetic tests. Cost-effectiveness has been measured in terms of incremental cost per year of life gained.

RESULTS

MODELLING COST-EFFECTIVENESS: FH is a life-threatening condition with a long presymptomatic state. Diagnostic tests are reasonably reliable and acceptable, and treatment with statins substantially improves prognosis. Therefore, it is appropriate to consider systematic screening for this condition. Case finding amongst relatives of FH cases was the most cost-effective strategy, and universal systematic screening the least cost-effective. However, when targeted at young people (16 year olds) universal screening was also cost-effective. Screening patients admitted to hospital with premature myocardial infarction was also relatively cost-effective. Screening is least cost-effective in men aged over 35 years, because the gains in life expectancy are small. (ABSTRACT TRUNCA

Can sequencing shed light on cell cycling?

Every organism must have cells that can replicate indefinitely. Can the draft human genome sequence tell us how the cell cycle works and how it evolved? We studied two protein families--the cyclins and their partners the cyclin-dependent kinases (Cdks)--and a conserved regulatory circuit, the spindle checkpoint. Disappointingly, we discovered a few novel cyclins and no new Cdks or components of the spindle checkpoint, and could shed little light on the organization of the cell cycle.

Autotransplants for Hodgkin's disease in first relapse or second remission: a report from the autologous blood and marrow transplant registry (ABMTR)

Although patients with relapsed Hodgkin's disease have a poor prognosis with conventional therapies, high-dose chemotherapy and autologous hematopoietic stem cell transplantation (autotransplantation) may provide long-term progression-free survival. We reviewed data from the Autologous Blood and Marrow Transplant Registry (ABMTR) to determine relapse, disease-free survival, overall survival, and prognostic factors in this group of patients. Detailed records from the ABMTR on 414 patients with Hodgkin's disease in first relapse (n = 295) or second complete remission (CR) (n = 119) receiving an autotransplant from 1989 to 1995 were reviewed. Median age was 29 (range, 7-64) years. Median time from diagnosis to relapse was 18 (range, 6-219) months; median time from relapse to transplant was 5 (range, <1-215) months. Most patients received high-dose chemotherapy without total body irradiation for conditioning (n = 370). The most frequently used high-dose regimen was cyclophosphamide, BCNU, VP-16 (CBV) (n = 240). The graft consisted of bone marrow (n = 246), blood stem cells (n = 112), or both (n = 56). Median follow-up was 46 (range, 5-96) months. One hundred-day mortality (95% confidence interval) was 7 (5-9)%. One hundred and sixty-five of 295 patients (56%) transplanted in relapse achieved CR after autotransplantation. Of these, 61 (37%) recurred. Twenty-four of 119 patients (20%) transplanted in CR recurred. The probability of disease-free survival at 3 years was 46 (40-52)% for transplants in first relapse and 64 (53-72)% for those in second remission (P < 0.001). Overall survival at 3 years was 58 (52-64)% after transplantation in first relapse and 75 (66-83)% after transplantation in second CR (P < 0.001). In multivariate analysis, Karnofsky performance score <90% at transplant, abnormal serum LDH at transplant, and chemotherapy resistance were adverse prognostic factors for outcome. Progression of Hodgkin's disease accounted for 69% of all deaths. Autotransplantation should be considered for patients with Hodgkin's disease in first relapse or second remission. Future investigations should focus on strategies designed to decrease relapse after autotransplantation, particularly in patients at high risk for relapse.

Short Report: Engraftment of T-cell-depleted allogeneic haematopoietic stem cells using a reduced intensity conditioning regimen

Graft-versus-host disease (GVHD) remains a significant complication in patients undergoing allogeneic stem cell transplantation (SCT) using a reduced intensity conditioning regimen. Although T-cell depletion (TCD) reduces the risk of GVHD after a myeloablative conditioning regimen, it is associated with an increased risk of graft failure. We have therefore examined whether TCD compromises engraftment using a fludarabine-based conditioning regimen. Fifteen patients have been transplanted using such a regimen of whom 13 underwent ex vivo TCD. All but one patient demonstrated durable engraftment and no patient receiving a TCD product developed severe GVHD. Thus, TCD may play a role in GvHD prophylaxis using such regimens.