SPINAL STENOSIS IN FAMILIAL TRANSTHYRETIN AMYLOIDOSIS

Background

Transthyretin-associated amyloidosis (ATTR) is the commonest cause of hereditary amyloidosis. Age at onset is 50–60 years with average life-expectancy of 7–14 years. Lumbar spinal stenosis also presents in late middle-age; related to disc degeneration, spondylolisthesis and age-related degenerative processes, such as WT-TTR amyloid deposition. Mutant-TTR has not been described in this scenario. Recent therapeutic developments in ATTR, with disease modifying potential, make histological evaluation clinically relevant.

Case

Family history prompted screening in an asymptomatic female carrier (heterozygous I84S) at age 42. At age 47 she developed sensory disturbance and pain in the left leg, brought on by exercise and relieved by rest. One year on, exercise tolerance <100 meters and she had sphincter disturbance. Examination revealed decreased pinprick sensation in the L5 dermatome and asymmetry of ankle and knee jerks, pulses were present. A disc bulge at L2/3 with superimposed narrowing of the lumbar canal due to ligamentum flavum hypertrophy was seen on MRI. Immunohistochemistry labelled ATTR deposits in the excised connective tissue. There was neurological improvement post-operatively but amyloid-symptoms qualified her for inclusion in ATTR treatment trials.

Discussion

We recommend histological examination for amyloid on tissue from spinal decompression and TTR gene analysis if this is positive.

The impact of contracting and prompting substance abuse treatment entry: a pilot trial

Contracting and prompting clients to attend substance abuse treatment aftercare substantially improves treatment adherence and outcome. However, this approach has not been evaluated for improving entry into initial treatment. We recruited 102 individuals scheduled to begin a 28-day substance use disorder (SUD) residential treatment program and randomly assigned them to receive either our standard treatment (STX) or STX plus attendance contracting and prompting (CP). CP participants showed fewer subsequent hospitalization days, lower hospitalization costs, greater improvement in alcohol problem scores, and lower legal problem scores at a 3-month follow-up than the STX group. The two groups did not differ on treatment entry rate, time in treatment, or drug use problem scores. The clinical utility of CP procedures and areas for future research are discussed.

Adherence to substance abuse treatment: clinical utility of two MMPI-2 scales

In this study, we examined the ability of the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) Addiction Acknowledgment scale (AAS; Weed, Butcher, McKenna, & Ben-Porath, 1992) and Negative Treatment Indicators scale (TRT; Butcher, Graham, Williams, & Ben-Porath, 1990) to predict adherence to and outcomes from substance abuse treatment. There was no evidence that the AAS was related to treatment adherence or outcome in our sample. However, results did reveal a significant positive relation between scores on the TRT scale and readmission to the hospital. Further analyses identified an optimal score for use in similar clinical populations and settings, and characteristics of high and low scorers. Compared to low scorers, high TRT scorers were more likely to not return for treatment after an initial screening interview. If they did return for treatment, high TRT scorers were more likely to experience fewer treatment days and to be rated as having lower motivation, poorer participation, and poorer comprehension of program materials. These findings provide promising initial evidence of the utility of the TRT scale for identifying patients who may be at a high risk for unsuccessful substance abuse treatment.

Evaluation of bacterial interference and beta-lactamase production in management of experimental infection with group A beta-hemolytic streptococci

The in vivo effects of penicillin and cefprozil therapy on the interaction between organisms commonly recovered from inflamed tonsils were studied by using a subcutaneous abscess model in mice. These organisms were group A beta-hemolytic streptococci (GABHS), Streptococcus salivarius (which is capable of interfering with GABHS), and Staphylococcus aureus. In mice infected with GABHS and S. salivarius alone or in combination, penicillin eliminated both organisms and cefprozil eliminated GABHS and S. aureus but not S. salivarius. Penicillin did not, however, reduce the number of GABHS or S. salivarius in the presence of S. aureus. The present study demonstrated the ability of beta-lactamase-producing S. aureus to protect GABHS from penicillin. However, no such protection was present following the administration of cefprozil. Furthermore, the preservation of S. salivarius that interferes with GABHS growth may provide protection from reinfection with GABHS. This study supports and provides an explanation for the increased efficacies of cephalosporins administered orally over that of penicillin when treating patients with acute GABHS pharyngitis or tonsillitis.

Use of a feeding procedure in the treatment of a stress-related anxiety disorder

A feeding procedure was used with a Vietnam veteran who became highly anxious when near a springhouse that resembled the site where he had been wounded in Vietnam. After 36-hr of food deprivation, the patient ate his favorite meal while sitting next to the springhouse. Treatment successfully reduced both anxiety and avoidance behavior. Results of a 10-month follow-up showed no relapse.

Role-reversed systematic desensitization in the treatment of a writing phobia

A role-reversal technique was employed to teach cognitive coping skills to a patient with a writing phobia. The patient presented desensitization scenes to the therapist and devised coping strategies for lessening anxiety. Treatment resulted in a reduction of anxiety and an increased ability to write in the presence of other people. A 10-mo. follow-up showed no relapse.