Encephalitogenic potential of the myelin basic protein peptide (amino acids 83-99) in multiple sclerosis: results of a phase II clinical trial with an altered peptide ligand

Myelin-specific T lymphocytes are considered essential in the pathogenesis of multiple sclerosis. The myelin basic protein peptide (a.a. 83-99) represents one candidate antigen; therefore, it was chosen to design an altered peptide ligand, CGP77116, for specific immunotherapy of multiple sclerosis. A magnetic resonance imaging-controlled phase II clinical trial with this altered peptide ligand documented that it was poorly tolerated at the dose tested, and the trial had therefore to be halted. Improvement or worsening of clinical or magnetic resonance imaging parameters could not be demonstrated in this small group of individuals because of the short treatment duration. Three patients developed exacerbations of multiple sclerosis, and in two this could be linked to altered peptide ligand treatment by immunological studies demonstrating the encephalitogenic potential of the myelin basic protein peptide (a.a. 83-99) in a subgroup of patients. These data raise important considerations for the use of specific immunotherapies in general.

Ketogenic diets in the treatment of epilepsy: short-term clinical effects

The classical 4:1 ketogenic diet, the medium-chain triglyceride (MCT) diet and a modified MCT diet were used in the treatment of 55 children and four adults with intractable epilepsy. During a three-month treatment period 51 of 63 studies (81 per cent) showed greater than 50 per cent reduction in seizure frequency. This improvement was independent of diet used and type of seizure experienced by patients. The diets were found to be acceptable and of therapeutic benefit to the children, but treatment of the four adult patients with the MCT diet was unsuccessful. There was no correlation between EEG changes and clinical response. The three ketogenic diets were shown to be effective in the short-term management of children whose epilepsy is poorly controlled with anticonvulsant drugs.

Improved glucose control in maturity-onset diabetes treated with high-carbohydrate-modified fat diet

Fourteen patients with established maturity-onset diabetes were treated as outpatients with a high-carbohydrate-(about 60% of total daily energy requirements)-modified fat diet (ratio of polyunsaturated fatty acids to other fatty acids greater than or equal to 1:1) for six weeks. Commercially available and acceptable cereal foods and tuberous vegetables high in both digestible and non-digestible carbohydrates were used. Simple sugars were restricted. Compared with their usual, low-carbohydrate diabetic diet this diet resulted in a fall in basal plasma glucose concentration (average of values measured at 0300, 0500, and 0700), mean preprandial plasma glucose concentration (average of values measured at 0800, 1230, and 1730), and percentage of glycosylated haemoglobin. Modifying dietary fat also decreased the fasting plasma cholesterol concentration. The findings suggest that it is no longer justifiable to prescribe a low-carbohydrate diet for maturity-onset diabetes.

Vitamin C intoxication and hyperoxalemia in chronic hemodialysis patients

We studied vitamin C levels in 25 stable patients on chronic hemodialysis who were taking 0.5-1 g vitamin C orally daily and/or dialyzed against dialysate containing 33.3 micrograms/ml of vitamin C. We also studied the relationship between serum vitamin C and oxalate levels in 7 patients on chronic hemodialysis. All patients had markedly elevated pre- and postdialysis levels of vitamin C. The predialysis levels of vitamin C showed extremely good correlation to the serum oxalate levels. Overingestion of vitamin C in food or as supplementation may lead to excessive serum levels of vitamin C, resulting in hyperoxalemia that may contribute to vascular disease in patients on chronic hemodialysis.

High-carbohydrate diets and insulin-dependent diabetics

A high-carbohydrate-(HC)-modified fat diet was compared with a standard low-carbohydrate (LC) diabetic diet in 11 insulin-dependent diabetics. Basal and preprandial plasma glucose concentrations were appreciably lower when the patients received the HC diet derived chiefly from readily available cereal and vegetable sources (mean (+/- SE of mean) basal concentrations 6.7 +/- 1.2 mmol/l (121 +/- 22 mg/100 ml) with the LC diet and 4.3 +/- 0.7 mmol/l (77 +/- 13 mg/100 ml) with the HC diet; mean preprandial concentrations 11.1 +/- 1.2 mmol/l (200 +/- 22 mg/100 ml) LC diet and 8.9 +/- 1.3 mmol/l (160 +/- 23 mg/100 ml) HC diet). total and low-density lipoprotein cholesterol concentrations were lower when patients took the HC diet (mean 4.4 +/- 0.2 and 2.4 +/- 0.2 mmol/l (189 +/- 8 and 124 +/- 8 mg/100 ml) respectively), and the ratio of high-density lipoprotein cholesterol to total cholesterol tended to rise. The average percentage of glycosylated haemoglobin did not differ between the two diets. Thus several measures of carbohydrate and lipid metabolism appear to be more satisfactory when patients receive a HC diet, which is an acceptable alternative to that still recommended to most insulin-requiring patients.

Low prevalence of psychoses among the Hutterites, an isolated religious community

OBJECTIVE

The authors estimated the prevalence of psychoses among the Hutterites in Manitoba, Canada, who lived in 102 communal farms or colonies. The study stemmed from an earlier epidemiological survey of North American Hutterite colonies (1950-1953), in which a low prevalence of psychoses was documented.

METHOD

Psychiatrically ill individuals identified during the previous survey were rediagnosed with DSM-IV criteria. A current provincial health insurance claims database was queried anonymously for the period June 1992-May 1997, and the prevalence rate of disease among Hutterites, identified by distinctive surnames and unique postal addresses, was compared with the rate in the entire population of the province of Manitoba and in a comparison group of persons with Hutterite surnames but with addresses outside the Hutterite colonies.

RESULTS

The annual prevalence of schizophrenia among the communal Hutterites, estimated from the database search by using ICD-9 criteria, was consistent with the prevalence found in the prior epidemiological survey (annual mean of 1.2/1,000 population, compared with 1.3/1,000 in the prior survey). The database search yielded a significantly lower prevalence for schizophrenia and other functional psychoses among communal Hutterites as well as among the comparison group, compared to the total Manitoba population. There was also lower prevalence for affective psychoses and adjustment reaction disorders among the communal Hutterites, compared to the total Manitoba population. Rates for neurotic disorders were elevated both among the communal Hutterites and the comparison group.

CONCLUSIONS

The prevalence of specific psychoses was reduced among the Hutterites, although neurotic disorders were more prevalent. These findings suggest some specificity, although possible artifacts such as ascertainment bias must be considered. Further research is needed to examine genetic and environmental factors that may contribute to reduced prevalence of specific psychoses among the Hutterites.

Reducing stigma and discrimination associated with COVID-19: early stage pandemic rapid review and practical recommendations

AIMS

To develop recommendations for strategies and interventions to reduce stigma and discrimination related to coronavirus disease 2019 (COVID-19), through reviewing and synthesising evidence in relation to COVID-19 and other disease outbreaks and infectious/stigmatised conditions from systematic reviews and primary studies and recommendations from additional materials.

METHODS

Rapid review, drawing on the World Health Organization's (WHO) methodology for developing interim guidelines during health emergencies. PubMed/MEDLINE, PsycINFO, Cochrane Central and Campbell Collaboration searched up to mid-April 2020. Searches were supplemented by reference-searching and expert recommendations. Searches were designed to identify: (1) systematic reviews (<10 years), or (2) primary intervention studies (no date limit) reporting evidence on anti-stigma interventions (in relation to COVID-19 or other infectious/stigmatised conditions) or (3) additional relevant materials. Data were extracted on population, intervention, outcome and results. These data were compiled into evidence summary tables and narrative overviews. Recommendations on strategies for COVID-19 stigma-reduction were developed using the WHO 'Evidence to Decision' framework approach. The review protocol was registered with PROSPERO (registration ID: CRD42020177677).

RESULTS

The searches identified a total of 4150 potentially relevant records, from which 12 systematic reviews and 29 additional articles were included. Overarching considerations and specific recommendations focus on: (1) language/words used in relation to COVID-19 and affected people; (2) media/journalistic practices; (3) public health interventions; (4) targeted public health interventions for key groups and (5) involving communities and key stakeholders.

CONCLUSIONS

These recommendations represent the first consolidated evidence-based guidance on stigma and discrimination reduction in relation to COVID-19. Mitigating the impact of stigma is critical in reducing distress and negative experiences, and strengthening communities' resolve to work together during exceptional circumstances. Ultimately, reducing stigma helps addressing structural inequalities that drive marginalisation and exacerbate both health risks and the impact of stigma. Administrations and decision makers are urged to consider integrating these recommendations into the ongoing COVID-19 response.

A pilot study of recombinant insulin-like growth factor-1 in seven multiple sderosis patients

The purpose of this open-label, crossover study was to determine the safety and efficacy of recombinant insulin-like growth factor-1 (rhIGF-1) using magnetic resonance imaging (MRI) and clinical measures of disease activity in seven multiple sderosis (MS) patients. Monthly clinical and MPI examinations were performed during a 24-week baseline and a 24-week treatment period with rhIGF-1. The primary outcome measure was contrast enhancing lesion (CEL) frequency on treatment compared to baseline. Secondary outcome measures included dinical and MRI measures of disease activity including: white matter lesion load (WMLL), magnetization transfer ratio (MTR), T1-Hypointensity volume, cervical spine cross-sectional area and proton magnetic resonance spectroscopic (MRS) imaging for determining regional metabolite ratios. rhIGF-1 (Cephalon) was administered at a dose of 50 mg subcutaneously twice a day for 6 months. rhIGF-1 was safe and well tolerated with no severe adverse reactions. There was no significant difference between baseline and treatment periods for any MRI or clinical measures of disease activity. Although rhIGF-1 did not alter the course of disease in this small cohort of MS patients, the drug was well tolerated. Further studies using rhIGF-1 alone or in combination with other therapies may be of value because of the proposed mechanism of action of this growth factor on the oligodendrocyte and remyelination.

Long-term, ambulatory, subcutaneous insulin infusion versus multiple daily injections in brittle diabetic patients

We compared the blood glucose control of four intact and eight kidney recipient, metabolically unstable, ketosis-prone, insulin-dependent diabetic patients under two different regimens: (a) intensive conventional treatment with two to four insulin injections daily (48 patient-months) and (B) subcutaneous, portable insulin delivery system (IDS) (54 patient-months). Both regimens included frequent home blood glucose and 24-h urine glucose determinations and daily telephone follow-up to maximize compliance with treatment. Analyzed as a group the fasting blood glucose for intact patients (A: 172 +/- 13 mg/dl; B: 141 +/- 12, P less than 0.02) and the nonfasting blood glucose for kidney recipient patients (A: 165 +/- 10; B: 138 +/- 5, P less than 0.01) were significantly lower during treatment with the IDS than with multiple injections. Six out of 12 patients (2/4 intact and 4/8 kidney recipient patients) showed significant and consistent improvement of blood glucose concentrations. Four showed marginal and inconsistent improvement. Two patients (one intact and one kidney recipient) improved on the IDS but maintained the improvement when changed back to conventional treatment. The 24-h urine glucose, maximal glucose excursions, number of blood glucoses less than or equal to 40 mg/dl, and glycosylated hemoglobin decreased significantly in some patients on the pump. We conclude that subcutaneous, portable insulin delivery devices can significantly improve the metabolic control of some ambulatory, unstable diabetic patients during long-term treatment beyond that obtained with intensive, multiple-injection, conventional treatment. Normalization of the metabolic control, however, is not obtained. These infusion systems still pose several problems during ambulatory use, which could have serious consequences in patients less compliant and/or followed less closely than ours.

Pacemaker malfunction following transthoracic countershock

Electrical cardioversion or defibrillation may be necessary in patients with implanted artificial cardiac pacemakers. Sudden discharge of high electrical energy employed in DC transthoracic countershock procedures may damage the sensitive pacemaker circuitry and result in malfunction. We report a case in which, following synchronized DC countershock, a non-programmable demand pacemaker functioned in the R-wave triggered mode rather than the R-wave inhibited mode as designed. Further, the pacemaker output voltage was reduced to about half its specified output. Such a malfunction may not be readily apparent, and requires careful analysis following electric shock.

A multiyear study of blood cholinesterase activity in urban pesticide applicators

This article is a review of blood cholinesterase activity in a cohort of urban pesticide applicators ranging from 1680 to over 3800 workers. During the period 1981-1991, 208, 788 blood samples were taken for measurement of cholinesterase activity with an average of 6 samples per year from each worker. A total of 150 workers or 0.44% of the cohort was removed from exposure to cholinesterase-inhibiting insecticides because of decreased cholinesterase activity. No worker required treatment for signs of cholinesterase inhibition.

Coxsackie B and adenovirus receptor, integrin and major histocompatibility complex class I expression in human prostate cancer cell lines: implications for gene therapy strategies

Gene therapy strategies based on modifying tumour cells using high efficiency adenoviral vectors have shown promise in the clinic. Recently the Coxsackie and adenovirus receptor (CAR) has been shown to mediate adenoviral entry into tumour cells, although previous studies also suggested a role for MHC class I heavy chain. Detailed evaluation of the expression of both CAR and MHC class I in prostate cancer cell lines would have important implications for therapeutic strategies. We have found that, unlike cell lines derived from other malignancies, in human and murine prostate cancer loss of CAR expression appears to be relatively infrequent and does not correlate with loss of MHC class I expression. These findings, together with the demonstration of appreciable levels of cell-surface expression of integrins, suggest that cancer vaccine strategies based on modifying whole prostate cancer cells should be feasible using the current generation of recombinant adenoviral vectors, without deleterious effects on either the virus vector or the target cell.

The Cape Mendocino, California, Earthquakes of April 1992: Subduction at the Triple Junction

The 25 April 1992 magnitude 7.1 Cape Mendocino thrust earthquake demonstrated that the North America-Gorda plate boundary is seismogenic and illustrated hazards that could result from much larger earthquakes forecast for the Cascadia region. The shock occurred just north of the Mendocino Triple Junction and caused strong ground motion and moderate damage in the immediate area. Rupture initiated onshore at a depth of 10.5 kilometers and propagated up-dip and seaward. Slip on steep faults in the Gorda plate generated two magnitude 6.6 aftershocks on 26 April. The main shock did not produce surface rupture on land but caused coastal uplift and a tsunami. The emerging picture of seismicity and faulting at the triple junction suggests that the region is likely to continue experiencing significant seismicity.

Partnership for the implementation of mental health policy in Nigeria: a case study of the Comprehensive Community Mental Health Programme in Benue State

Background

71% of countries in the World Health Organisation’s (WHO’s) African Region have a stand-alone mental health policy or plan, but only 14% have fully implemented it. In Nigeria, integration of mental health into primary care has been a stumbling block to the implementation of the 1991 National Mental Health Policy, 2013 Policy on Mental Health Services Delivery and the National Mental, Neurological and Substance Use Programme and Action Plan. A partnership between public and private not-for-profits in Benue State, the Comprehensive Community Mental Health Programme (CCMHP) has successfully integrated mental health into primary care in alignment with the national mental health policy and the WHO’s mental health Gap Action Programme Intervention Guide (mhGAP-IG). There is a need to document such examples in order to inform policy implementation in Nigeria and other low- and middle-income countries (LMICs).

Methods

We followed the Case Study Methodology to Monitor and Evaluate Community Mental Health Programmes in LMICs. Four field visits were conducted between 2013 and 2017 to document the first phase of activities of CCMHP, covering the period of January 2011 through June 2016.

Results

In its first phase, CCMHP trained 19 community psychiatric nurses and 48 community health extension workers in mhGAP-IG, establishing 45 new mental health clinics in primary care facilities across Benue, a state more populous than many countries. As a result, 13,785 clients (55% male, 45% female) were enrolled in mental health services either in primary care or in one of two pre-existing community-based rehabilitation facilities. Most are adults over age 18 (82.75%), and present to services with epilepsy (52.38%) or psychosis (38.41%).

Conclusion

The case of CCMHP demonstrates it is possible to rapidly scale-up mental health services in line with national mental health policy using the mhGAP-IG, even in a challenging, low-resource setting. Multi-sectoral partnerships may help to overcome some of the barriers to successful integration of mental health into general healthcare by capitalising on the resources and expertise of both state and non-state actors. However, a difficult political context could threaten the sustainability of the programme if funder requirements force a rapid transition to full government ownership.

Circadian temperature rhythm and circadian-circaseptan (about 7-day) aspects of murine death from malaria

About-7-day (circaseptan) and circadian rhythms were sought and found in host-parasite relations of mice infected with Plasmodium berghei. Five inbred male DBA mice, about 18 weeks of age, were implanted with transsensors for temperature telemetry. Core temperature, monitored every 10 min for 3 days before the intravenous or intraperitoneal inoculation of 10(5) infected erythrocytes and thereafter until death, was analyzed by cosinor. A statistically highly significant circadian rhythm exhibited similarly synchronized acrophases. Core temperatures on the days immediately after malarial infection were mostly within the range of temperatures observed before injection. A mesor-hypothermic stage preceded death by several days. In a second study, 24 male BALB/c and 42 male DBA mice, 12 weeks of age, housed in three rooms on different regimens of light and darkness (alternating at 12-hr intervals), staggered by 8 hr, were inoculated ip with 10(4) infected erythrocytes, one-half at noon, the other half at midnight, within 0.5 hr of blood withdrawal. Thus, one endeavored to cover six circadian host stages (02, 06, 10, 14, 18, and 22 hr after light-on). At 54 and 51% overall mortality (irrespective of inoculation time), a circadian rhythm in susceptibility to malaria was demonstrated in these mice by the single cosinor fit of a 24-hr period (P less than 0.003 and less than 0.020, respectively). The single cosinor fit of a 7-day period further demonstrated a circaseptan rhythm (P = 0.014) in the mortality of both strains following the inoculation of P. berghei. The acrophase (360 degrees = 168 hr) was at -325 degrees from the inoculation time with 95% confidence limits extending from -276 to -378 degrees. Such predictable time relations of P. berghei to its murine host await the exploration of mechanisms underlying the circadian and infradian (7-day) rhythmicities here demonstrated and quantified with their uncertainties. Irrespective of mechanisms, information on such periodicities may also guide attempts to optimize treatment by timing according to the interactions of plasmodial virulence and host resistance that remain to be quantified separately.

Heated tumour cells of autologous and allogeneic origin elicit anti-tumour immunity

Vaccination with established tumour cell lines may circumvent the problem of obtaining autologous tumour cells from patients, but may also need immunological adjuvants. Up-regulation of heat shock proteins within tumour cell vaccines has resulted in increased immunogenicity in some models, but this has yet to be demonstrated for allogeneic (MHC-disparate) cell vaccines. This was investigated here using a rat model for prostate tumour cell vaccination. Heating of tumour cells (42 degrees C, 1 h) elicited significant increases in HSP70 expression. Vaccination with heated autologous PAIII cells elicited protection against PAIII challenge in 60% of rats >50 days compared to 0% with unheated vaccine and was associated with an increased Th1 (IFNgamma) immune response. Heated allogeneic MLL cells elicited significant protection against PAIII challenge, in contrast to unheated cells. The principle was confirmed in two mouse models, although the allogeneic melanoma vaccine K1735 elicited the best protection when heated and administered mixed with autologous dendritic cells. Thus, while heating of vaccine cells in some models is highly beneficial, and is a means of enhancing immunogenicity without genetic modification or inclusion of potentially toxic adjuvants, additional immune enhancement may be required.

Kohl: a lead-hazardous eye makeup from the Third World to the First World

Kohl is a widely used traditional cosmetic. It is mainly worn around the eyes in Asia, Africa, and the Middle East. It may be a pervasive source of lead poisoning in those areas and among individuals from those areas who have immigrated to developed nations. Samples of kohl were purchased in Morocco, Mauritania, Great Britain, and the United States. Some of these samples originated from Pakistan, India, and Saudi Arabia. Kohl is widely believed to consist of antimony, but analysis consistently revealed only trace amounts of antimony. Nine of the twenty-two samples tested contained less than 0.6% lead; however, seven samples had lead levels in excess of 50%. The remainder ranged from 3.31 to 37.3%. Third-world-manufactured kohls were purchased in the United States and Britain, suggesting that this hazard is no longer confined to the third world. Those kohls that contained lead were sold in violation of laws on lead in cosmetics in both of these nations. Third-world physicians and health care workers appear to be unaware of possible lead uptake from unsuspected traditionally used items. Physicians in developed nations with patients from Asia, the Middle East, and North Africa need to factor in the possibility of past or present lead intake from unorthodox sources such as kohl.

Immunotherapy of murine prostate cancer using whole tumor cells killed ex vivo by herpes simplex viral thymidine kinase/ganciclovir suicide gene therapy

Whole cell cancer vaccines are currently under clinical evaluation. Their immunogenicity may depend on the mode of death of the vaccine cells prior to uptake by professional antigen-presenting cells and crosspriming of T cells. Destruction of tumor in vivo by genetic prodrug activation therapy leads to a marked local and systemic immune response, local T-cell infiltration and the establishment of T-cell memory. We postulated that this immunostimulation may be due to induction of danger signals and the inherent immunogenicity of products of HSVtk/ganciclovir kill. Using established models of murine prostate cancer, we have evaluated the efficacy of anti-tumor vaccines comprising irradiated allogeneic or autologous whole cells expressing HSVtK, which are first killed in vitro by prodrug activation using ganciclovir. HSVtk/ganciclovir-induced cell kill was through the induction of apoptosis. The vaccine was found to be effective in both models and superior to traditional irradiated whole tumor cells even after single doses. Protection against tumor challenge was associated with marked proliferative and Th1 cytokine responses. This approach would be applicable clinically in terms of ease of vaccine production, safety, storage and avoidance of potential toxicities of in vivo gene transfer.