The Association of Health Locus of Control with Clinical and Psychosocial Aspects of Living with Multiple Sclerosis

Health Locus of control (LOC) refers to one's beliefs regarding control over one's health. This study aimed to determine the relationship between LOC on clinical and psychosocial aspects associated with multiple sclerosis (MS). 5059 participants with MS completed a questionnaire pack including the Multidimensional Health Locus of Control Scale. Associations between LOC and sociodemographic (age, gender, educational level) and clinical variables (duration, disability, depression, anxiety, self-efficacy, QoL) were explored. LOC was found to be significantly associated with all of the clinical variables and age, but not gender or educational level. When controlling for level of disability, Chance (CLOC) was associated with higher self-efficacy, lower anxiety and higher QoL than Powerful Others (PLOC), while Internal (ILOC) had no association. The proportion with ILOC preference was lower in increased disability. In MS, believing that health is controlled mainly by chance confers the most benefit with regard to quality of life. There is prima-facie evidence that LOC preference changes with MS progression, in a pattern that is protective against psychological distress.

Prevalence of depression in amyotrophic lateral sclerosis/motor neuron disease: multi-attribute ascertainment and trajectories over 30 months

Objective: Evidence is equivocal about the prevalence of depression in amyotrophic lateral sclerosis (ALS). This study uses a multi-attribute ascertainment of the prevalence of depression and examines this prevalence over time. Methods: Patients with ALS were recruited into the Trajectories of Outcome in Neurological Conditions (TONiC-ALS) study. Caseness was identified by the Modified-Hospital Anxiety and Depression Scale (M-HADS). In addition, participants provided data on co-morbidities and medication use. A combination of the three was used to derive the estimate for the prevalence of depression, treated or untreated. Longitudinal data were analyzed by trajectory analysis of interval level M-HADS-Depression data. Results: Among 1120 participants, the mean age was 65.0 years (SD 10.7), 60.4% male, and the median duration since diagnosis was 9 months (IQR 4-24). Caseness of probable depression at baseline, defined by M-HADS-Depression, was 6.45% (95%CI: 5.1-8.0). Taken together with antidepressant medication and co-morbidity data, the prevalence of depression was 23.1% (95%CI: 20.7-25.6). Of those with depression, 17.8% were untreated. Trajectory analysis identified three groups, one of which contained the most cases; the level of depression for each group remained almost constant over time. Conclusion: Depression affects almost a quarter of those with ALS, largely confined to a single trajectory group. Prevalence estimates based on screening for current depressive symptoms substantially under-estimate the population experiencing depression. Future prevalence studies should differentiate data based on current symptoms from those including treated patients. Both have their place in assessing depression and the response by the health care system, including medication, depending upon the hypothesis under test.

The WHOQOL-BREF: a modern psychometric evaluation of its internal construct validity in people with multiple sclerosis

PURPOSE

Symptoms of Multiple Sclerosis (MS) differentially impact upon quality of life (QoL) and a comprehensive measure is required for use in observational and interventional studies. This study examines the abbreviated World Health Organisation Quality of Life tool (WHOQOL-BREF) which was designed to be used as a broad measure of QoL across different cultures and diseases.

METHODS

Data were collected from 3186 subjects as part of the TONiC study in MS and was examined with a systematic, iterative approach using Rasch analysis to investigate the internal construct validity of the WHOQOL-BREF.

RESULTS

Mean age was 49.8 years (SD 11.8), disease duration was 11.2 years (SD 9.6) and 73.2% were female. Subjects represented all stages of MS with EDSS scores of 0-4, 4.5-6.5, 7-7.5 and ≥ 8 seen in 49.8%, 38.5%, 6.8% and 4.9% of patients, respectively. Using a super-item approach, it was possible to demonstrate fit to the assumptions of the Rasch model for 3 of the 4 domains of the WHOQOL-BREF (physical, psychological and environment) as well as a broad 24-item total score. In addition, item subsets derived from the stem of each question were shown to function as novel scales measuring impact and life satisfaction. We have provided transformation tables from ordinal raw scores to interval scales where data are complete.

CONCLUSIONS

The validation of multiple conceptual frameworks validates the WHOQOL-BREF as a powerful and flexible end-point for use in clinical trials and in testing conceptual models of factors influencing QoL in MS.

Development and validation of Spasticity Index-Amyotrophic Lateral Sclerosis

OBJECTIVES

Spasticity is a common and disabling feature of amyotrophic lateral sclerosis (ALS). There are currently no validated ALS-specific measures of spasticity. The aim of this study was to develop and use a self-report outcome measure for spasticity in ALS.

METHODS

Following semi-structured interviews with 11 ALS patients, a draft scale was administered across ALS clinics in the UK. Internal validity of the scale was examined using the Rasch model. The numerical rating scale (NRS) for spasticity and Leeds Spasticity scale (LSS) were co-administered. The final scale was used in a path model of spasticity and quality of life.

RESULTS

A total of 465 patients (mean age 64.7 years (SD 10), 59% male) with ALS participated. Spasticity was reported by 80% of subjects. A pool of 71 items representing main themes of physical symptoms, negative impact and modifying factors was subject to an iterative process of item reduction by Rasch analysis resulting in a 20-item scale-the Spasticity Index for ALS (SI-ALS)-which was unidimensional and free from differential item functioning. Moderate correlations were found with LSS and NRS-spasticity. Incorporating the latent estimate of spasticity into a path model, greater spasticity reduced quality of life and motor function; higher motor function was associated with better quality of life.

CONCLUSIONS

The SI-ALS is a disease-specific self-report scale, which provides a robust interval-level measure of spasticity in ALS. Spasticity has a substantial impact on quality of life in ALS.

Sexual functioning in multiple sclerosis: Relationships with depression, fatigue and physical function

Background:

Sexual dysfunction (SD) is common among people with multiple sclerosis, but there is limited information on its relationships.

Objective:

This national study examines the relationships between sexual function with demographic factors, physical function, fatigue and depression.

Methods:

Participants in the Trajectories of Outcomes in Neurological Conditions (TONiC) study completed the measures of fatigue, physical function and depression together with the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 (MSISQ-15), which covers sexual function (primary), symptoms that interfere with sexual function (secondary) and psychological issues (tertiary). All ordinal scores from the measures were converted to interval scale latent estimates via the Rasch model and used as single indicator latent variables in path analysis.

Results:

From 722 patients, 538 were sexually active of whom 431 (80.1%) answered questions on sexual functioning. Of these, only 18.5% reported no impact on any aspect of sexual function. Dysfunction was linked to disease subtype and Expanded Disability Status Scale (EDSS). Subtype influenced the relationship between symptoms and sexual function, which was fully mediated by psychological factors in secondary progressive patients. Depression was not directly associated with sexual functioning, but appeared as a consequence of the psychological issues associated with SD.

Conclusion:

SD is common among participants in this UK-wide study, and psychological aspects of SD contributed to depression.

Some Analytical Aspects of the Immunochemical Determination of the Selectivity of Proteinuria

The selectivity of proteinuria has been determined from the relative clearances of α1-acid glycoprotein, albumin, transferrin and IgG in 190 children and adolescents. The precision of the determination of selectivity (C.V. = 3%) is greater than that of the individual protein clearances determined by a double immunodiffusion method (C.V. = 13–22%). Neither sample storage for a limited period nor concentrating the urine affects the selectivity value significantly; serial determinations in one patient for 24 h showed no diurnal variation.

The effectiveness of selectivity in predicting the steroid response in the nephrotic syndrome was found to be slightly superior when determined from all four proteins than from transferrin and IgG alone. Inclusion of α2-macroglobulin relative clearance in the selectivity determination often significantly alters the value determined from the other four proteins alone. The reasons for this are discussed. Demonstration of α2M in urine which has not been concentrated, strongly suggests the presence of a structural glomerular lesion.

The Neurological Sleep Index: A suite of new sleep scales for multiple sclerosis

Objective

The objective of this study was to develop patient-reported outcome measures for sleep dysfunction and sleepiness in multiple sclerosis (MS), since there are currently no MS-specific measurement tools for these clinically important entities.

Methods

Items were generated from semi-structured interviews followed by cognitive debrief. A 42-item pool was administered to patients with MS at three neuroscience centres in the UK. Comparator scales were co-administered. Constructs were validated by Rasch analysis, guided by initial exploratory factor analysis.

Results

There were two supraordinate qualitative themes of diurnal sleepiness and non-restorative nocturnal sleep. Rasch analysis on 722 records produced three scales, which corresponded to diurnal sleepiness, non-restorative nocturnal sleep and fragmented nocturnal sleep. All had excellent fit parameters, were unidimensional and were free from differential item functioning. A summed raw score cut-point of 31/48 in the Diurnal Sleepiness Scale equated to the standard cut-point of 10 on the Epworth Sleepiness Scale (ESS).

Conclusion

Three high-quality measurement scales were developed, and together they compose the Neurological Sleep Index for MS (NSI-MS). The Diurnal Sleepiness Scale might provide an alternative to the ESS. The Non-Restorative Nocturnal Sleep Scale and the Fragmented Nocturnal Sleep Scale appear to be the only such measures for use in MS.

Is the Epworth sleepiness scale suitable for use in stroke?

BACKGROUND

The Epworth Sleepiness Scale (ESS-8) is frequently used in stroke but has never been validated for this condition. There is concern regarding the suitability of the driving item (item 8). A summed raw score of 10 or more (from a maximum of 24) signifies pathological sleepiness.

OBJECTIVE

To determine the construct validity of the ESS-8 by Rasch analysis and in particular to determine whether omission of item 8 confounds the scale.

METHOD

A pack containing the ESS-8 and questions regarding sleep and demographics was sent to 999 patients who had experienced a stroke within the past 4 years. Data were assessed for fit to the Rasch model.

RESULTS

Analysis of 269 records revealed a unidimensional scale that was free from differential item functioning by age and sex with good overall fit to the Rasch model. Item 4 had disordered thresholds. Analysis of the ESS without item 8 (ESS-7) also revealed a valid scale. Equating person locations between the ESS-8 and ESS-7 showed no differences below a summed raw score of 18.

CONCLUSION

The ESS-8 has good construct validity for use in stroke and is reliable at the cutpoint of 10. Summed raw scores below 18 will be unaffected if nondrivers either score as zero or simply omit item 8. The scale is therefore robust for detecting cases of pathological sleepiness in stroke but may not be suitable for measuring high levels of sleepiness in a sample containing both drivers and nondrivers. Instead, the ESS-7 could be used for this purpose.

Perceived changes and minimum clinically important difference of the Neurological Fatigue Index for multiple sclerosis (NFI-MS)

The determination of the minimum clinically important difference (MCID) is an important aspect of scale development. The Neurological Fatigue Index for multiple sclerosis (NFI-MS) was administered before and after expected change or stability in fatigue in 208 multiple sclerosis (MS) patients. The overall change scores of the NFI-MS accorded with perceived direction of change; importantly, no change was seen when none was perceived. Using the interval level NFI-MS scores, the largest MCID equated to 2.49 points on the Summary scale, 2.36 points on the Physical scale, 0.84 points on the Cognitive scale, 0.97 on the Diurnal Sleep scale and 1.95 on the Nocturnal Sleep scale. Our conclusion is that the NFI-MS responds as expected to changes in fatigue and has desirably small MCID scores.

The unidimensional self-efficacy scale for MS (USE-MS): developing a patient based and patient reported outcome

Background:

Self-efficacy concerns the individual’s belief that he or she is capable of performing a certain task and producing a desired effect, i.e. it reflects the person’s perceptions of their capability for specific tasks, as distinct from their actual ability. Self-efficacy has been shown to influence motivation, psychological well-being, adherence with treatment regimes and quality of life in multiple sclerosis and other conditions.

Objective:

To develop a unidimensional scale of MS self-efficacy with robust psychometric properties, suitable for patient self report.

Methods:

A questionnaire pack covering three MS self-efficacy scales, the Dispositional Resilience Scale and demographic data was posted to MS patients from two MS databases. Data underwent Rasch analysis.

Results:

Response rate was 309/600 (51.5%). None of the existing MS self-efficacy scales were unidimensional. A new 12-item scale, created by combining items from our two scales, was shown to fit the Rasch model, was unidimensional, and invariant for gender, education and disease duration.

Conclusion:

The Unidimensional Self-Efficacy scale for MS (USE-MS) provides a simple summated scale for an ordinal estimate of a persons’ self efficacy. A transformation to interval scaling is available for use in the calculation of change scores and effect sizes.

Rasch analysis of the Modified Fatigue Impact Scale (MFIS) in multiple sclerosis

BACKGROUND

The 21-item Modified Fatigue Impact Scale (MFIS) has been recommended as an outcome measure for use in multiple sclerosis and is commonly used to generate an overall score of fatigue.

OBJECTIVE

To test if the MFIS total score is valid by application of the Rasch measurement model.

METHOD

The MFIS was sent by post to patients with clinically definite multiple sclerosis in two centres in the UK. Data were fitted to the Rasch model.

RESULTS

Analysis was based on 415 records (55% response). The 21-item scale did not fit the Rasch model mainly because of multidimensionality. The scale was found to contain a "physical" dimension and a "cognitive" dimension, consistent with the original subscale structure. Valid physical and cognitive subscales were derived after deletion of some items.

CONCLUSION

The MFIS cannot be used to generate a single overall score of fatigue. The conceptual interaction between the two dimensions remains unclear, which poses problems when interpreting change scores in these individual scales. Studies in which a global MFIS score was used as either an outcome measure or selection tool may need to be re-evaluated.

Central trigeminal involvement in multiple sclerosis using high-resolution MRI at 3 T

Trigeminal neuralgia and sensory disturbance is common in multiple sclerosis (MS). Recent literature suggests that signal abnormalities in the cisternal trigeminal nerve and pontine root entry zone are seen in approximately 3% of MS patients, using conventional diagnostic MRI. The objective of this study was to determine the prevalence of trigeminal lesions using high-resolution MRI at 3T. Forty-seven patients with clinically definite MS, chosen at random from the outpatient population of a neuroscience centre underwent MRI on a Siemens 3T Trio machine. Three 3D sequences of T2 TSE (turbo spin echo), T2 FLAIR (fluid attenuated inversion recovery) and T1 IR (inversion recovery) were acquired in the coronal plane. The sequences were of contiguous 1 mm slices with in-plane resolution of up to 0.5 mm by 0.5 mm. Images were read by both a neurologist and a neuroradiologist. Any clinical history of trigeminal symptoms was determined for all subjects. The results showed that 11 patients (23%) had high signal in the trigeminal root entry zone and either the trans-cisternal nerve or pontine nucleus; example images are given. MRI changes did not correspond to clinical symptoms (chi square probability 1.000). The study concludes that high-resolution MRI at 3T yielded a high prevalence of detectable trigeminal abnormality in the MS sample studied. MRI involvement did not correspond to trigeminal symptoms.

A medical definition of fatigue in multiple sclerosis

BACKGROUND

The symptom of fatigue has been described in a variety of ways but absence of a single taxonomy may be hindering research into this prevalent symptom.

OBJECTIVE

To define the symptom of fatigue, as experienced by patients with multiple sclerosis (MS), in terms of a common framework, typical of a medical history.

DESIGN

Qualitative phase followed by cross-sectional questionnaire survey.

METHOD

Forty patients, with clinically definite MS, underwent semi-structured interviews which were analysed within a common framework of: experience (with derived themes of motor, cognitive, somatic/energy, sleep, other features) cadence (i.e. short-term variability), chronicity, precipitating and aggravating factors, relieving factors, severity and associated features. The prevalence of each feature of fatigue, emergent from the interviews, was subsequently determined by questionnaire survey of a further 635 MS patients.

RESULTS

Despite variance across patients, fatigue could be described within the derived themes and framework. Nearly all themes were endorsed by the majority of questionnaire respondents. In summary, fatigue could be defined as reversible motor and cognitive impairment, with reduced motivation and desire to rest. It could appear spontaneously or may be brought on by mental or physical activity, humidity, acute infection and food ingestion. It was relieved by daytime sleep or rest without sleep. It could occur at any time but was usually worse in the afternoon.

CONCLUSION

A framework, not only derived from patient experience but also meaningful in a medical context, was shown to be capable of describing fatigue in a large cross-section of MS patients. The definition may facilitate inter-disease comparison of fatigue as well as physiological enquiry.

Treatment for ataxia in multiple sclerosis

BACKGROUND

Disabling tremor or ataxia is common in multiple sclerosis (MS) and up to 80% of patients experience tremor or ataxia at some point during their disease. A variety of treatments are available, ranging from pharmacotherapy or stereotactic neurosurgery to neurorehabilitation.

OBJECTIVES

To assess the efficacy and tolerability of both pharmacological and non-pharmacologic treatments of ataxia in patients with MS.

SEARCH STRATEGY

The following electronic resources were searched: Cochrane MS Group trials register (June 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2006), National Health Service National Research Register (NRR) including the Medical Research Council Clinical Trials Directory (Issue 2, 2006), MEDLINE (January 1996 to June 2006), and EMBASE (Jan 1988 to June 2006). Manual searches of bibliographies of relevant articles, pertinent medical and neurology journals and abstract books of major neurology and MS conferences (2001-2006) were also performed. Direct communication with experts and drug companies was sought.

SELECTION CRITERIA

Blinded, randomised trials which were either placebo-controlled or which compared two or more treatments were included. Trials testing pharmacological agents must have had both participant and assessor blinding. Trials testing surgical interventions or effects of physiotherapy, where participants could not have been blinded to the treatment, must have had independent assessors who were blinded to the treatment. Cross-over trials were included.

DATA COLLECTION AND ANALYSIS

Three independent reviewers extracted data and the findings of the trials were summarised. A meta-analysis was not performed due to the inadequacy of outcome measures and methodological problems with the studies reviewed.

MAIN RESULTS

Ten randomised controlled trials met the inclusion criteria. Six placebo-controlled studies (pharmacotherapy) and four comparative studies (one stereotactic neurosurgery and three neurorehabilitation) were reviewed. No standardised outcome measures were used across the studies. In general, pharmacotherapies were unrewarding and data on neurosurgery or rehabilitation is insufficient to lead to a change in practice.

AUTHORS' CONCLUSIONS

The absolute and comparative efficacy and tolerability of pharmacotherapies to treat ataxia in MS are poorly documented and no recommendations can be made to guide prescribing. Although studies on neurosurgery and neurorehabilitation showed promising results, the absolute indications for treating with those methods cannot be developed. Standardised, well validated measures of ataxia and tremor need to be developed and employed in larger randomised controlled trials with careful blinding.

3D MRI in multiple sclerosis: a study of three sequences at 3 T

The objective of this study was to assess the feasibility of using 3D acquisition at 3 T for imaging patients with multiple sclerosis (MS). Feasibility was assessed by three criteria based on acquisition time, specific absorption rate (SAR) and image quality. 47 patients with clinically definite MS underwent imaging in a Siemens 3T Trio MR scanner. Patient safety data were obtained following the scan sessions. The study had local ethics approval. The following three-dimensional (3D) sequences, all acquired coronally, were used: T2 fluid attenuated inversion recovery (FLAIR) (repetition time (TR) 6000 ms, echo time (TE) 353 ms, inversion time (TI) 2200 ms), 0.5x0.5x1 mm voxels, acquisition time 10 min 38 s; T2 turbo spin echo (TSE) (TR 3000 ms, TE 354 ms), 1x1x1 mm voxels, acquisition time 8 min 29 s; T1 inversion recovery (IR) (TR 2040 ms, TE 5.56 ms, TI 1100 ms), matrix 512x448 (0.5x0.5 mm pixels), 0.5x0.5x1 mm voxels, acquisition time 7 min 38 s. Total acquisition time was 26 min 45 s. Example images are presented. 3D scanning at 3 T provides highly detailed, high quality images with acquisition times tolerated by MS patients, even by those with severe disability. The volumetric data are suitable for a wide variety of post-processing techniques; the authors suggest that 3D studies at 3 T should be considered as the possible brain imaging protocol for either cross-sectional or longitudinal studies in MS and that the 3D T2 FLAIR sequence should be considered for the purposes of radiological diagnosis.

Increased pre-operative platelet counts are a possible predictor for reduced sensitivity to heparin

We investigated a possible relationship between pre-operative platelet count and reduced sensitivity to heparin in 87 patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Sensitivity to heparin was determined by measuring the slope of the heparin dose response (HDR) before surgery. Pre-operative platelet counts were measured as part of routine analysis of the patients' coagulation status. Patients with an HDR slope of <80 s u. ml(-1), were considered to have a reduced sensitivity to heparin and activated clotting time data were collected from these patients before and after heparin administration before CPB. A significant correlation was determined between pre-operative platelet levels and HDR slope (P<0.001). Platelet counts were significantly greater in heparin-resistant patients compared with those who had the expected response to the anticoagulant (P<0.05). This could be caused by an increased capacity to produce platelet factor 4, which neutralizes heparin.

Neosporosis in a pup

CASE

A 13-week-old female boxer pup was found to be suffering from rigidity of the left hindleg. Antibiotic and anti-inflammatory treatment over a 3-week period failed to improve the condition and the pup was humanely killed.

METHODS

Serological examination for Neospora antibodies was carried out by the indirect fluorescent antibody test and for Toxoplasma gondii antibodies with a latex agglutination test. A variety of tissues were examined histologically, and the central nervous system by immunohistochemistry and the polymerase chain reaction.

RESULTS

The IFAT for anti-Neospora antibodies showed a titre of 1:51 200 in the clinically affected pup while the latex agglutination test for Toxoplasma antibodies was negative. The dam and one of two tested litter-mates had anti-Neospora IFAT titres of 1:1600, the other litter mate was negative. All three were not clinically affected. Histological, immunohistochemical and polymerase chain reaction examinations of the affected pup confirmed the diagnosis of Neospora infection.

CONCLUSION

In the live animal, serological examination is thought to be the most useful specific test. Post-mortem examination by traditional histology, immunohistochemistry and the polymerase chain reaction confirmed the diagnosis. The case is discussed in the context of present knowledge about Neospora infection in New Zealand.

Harnessing peer networks as an instrument for AIDS prevention: results from a peer-driven intervention

OBJECTIVE

Since 1985, community outreach efforts to combat acquired immunodeficiency syndrome (AIDS) among injecting drug users (IDUs) in the United States have overwhelmingly depended on a provider-client model that relies on staffs of professional outreach workers. We report on a comparison of this traditional outreach model with an innovative social network model, termed "a peer-driven intervention" (PDI). The latter provides IDUs with guidance and structured incentives that permit them to play a much more active role in the outreach process, thereby harnessing peer pressure on behalf of human immunodeficiency virus (HIV) prevention efforts.

METHODS

We compare the performance of a traditional outreach intervention (TOI) and a PDI that were implemented in medium-sized towns in eastern and central Connecticut. Comparisons are based on the number and representativeness of IDUs recruited at each site, the effectiveness of HIV prevention education, compliance rates with AIDS risk reduction recommendations, and relative cost. The analyses are based on 522 initial interviews and 190 six-month follow-up interviews conducted during the first two years of each intervention's operation.

RESULTS

Both interventions produced significant reductions in HIV risk behaviors, as measured using self-reports. The PDI outperformed the traditional intervention with respect to the number of IDUs recruited, the ethnic and geographic representativeness of the recruits, and the effectiveness of HIV prevention education. In addition, the costs of recruiting IDUs into the intervention and educating them about HIV in the community was only one-thirtieth as much in the PDI as in the traditional intervention.

CONCLUSIONS

The findings suggest that given guidance and nominal incentives, IDUs can play a more extensive role in community outreach efforts than the traditional model allows. The findings also suggest that both interventions reduce HIV-associated risk behaviors, but the PDI reaches a larger and more diverse set of IDUs, and does so at much less expense.

Impact of zidovudine plus lamivudine or zalcitabine on health-related quality of life

OBJECTIVE

To assess the impact of treatment with zidovudine plus lamivudine or zalcitabine on health-related quality of life (HRQOL) in patients with HIV.

DESIGN

HRQOL assessments were conducted as part of a double-blind, randomized, 24-week (extended to 52 wk) efficacy and safety study. The Medical Outcomes Study HIV Health Survey (MOS-HIV), which assesses 10 physical and psychological domains of HRQOL, was self-administered by patients at baseline and at weeks 16, 32, 52, or at treatment discontinuation.

SETTING

Twenty-one outpatient centers in the US, Canada, and Puerto Rico.

PATIENTS

The study enrolled 254 HIV-positive patients (CD4+ 100-300 cells/mm3); 206 patients completed the MOS-HIV at baseline and at least once during treatment. Post hoc analyses stratified patients into two subgroups: AIDS (CD4+ < 200 cells/mm3) and non-AIDS (CD4+ > or = 200 cells/mm3).

INTERVENTIONS

Patients received zidovudine 200 mg three times daily plus one of the following: lamivudine 150 mg twice daily, lamivudine 300 mg twice daily, or zalcitabine 0.75 mg three times daily.

MAIN OUTCOME MEASURE

Change in MOS-HIV scores from baseline to last completed questionnaire.

RESULTS

Following an average of 36 weeks of treatment, there were statistically significant differences across treatment groups in mean change scores on the physical functioning, role functioning, and vitality scales, with stable or increased (improved) scores in the zidovudine plus lamivudine 150 mg group and decreased scores in the zidovudine plus zalcitabine and zidovudine plus lamivudine 300 mg groups for most scales. Post hoc analyses found that in the non-AIDS subgroup, only the zidovudine plus lamivudine 150 mg group had increases in mean MOS-HIV scores (on 8 of 10 scales); in the AIDS subgroup, all but two MOS-HIV scores (in the zidovudine plus zalcitabine group) decreased in all three treatment groups.

CONCLUSIONS

These results suggest that, of the three combination therapies studied, zidovudine plus lamivudine 150 mg was most likely to maintain or improve HRQOL in HIV-positive patients.

Tensometry of carbon fibres and elastomers at the diffractometer at BL20B of the Photon Factory

Two systems have been developed for the simultaneous recording of the SAXS and the WAXS patterns from carbon fibre and elastomer samples which are placed under stress. The systems have been designed to fit inside the versatile vacuum diffractometer (BIGDIFF) at the Photon Factory. In one system, use is made of the ability to move the imaging-plate cassette. In the other, use has been made of an imaging-plate changer which can deliver up to 13 plates into position with a duty cycle of about 60 s. In this case each imaging plate can record SAXS/WAXS patterns in the range 0.5-20 degrees due to the passage of the beam through the specimen which is mounted in a specially designed tensometer. Because BIGDIFF is a vacuum diffractometer and parasitic scattering is small, exposure times as short as 2 s can give acceptable SAXS/WAXS patterns. The systems have been used for the study of both the change of structure with strain, and the relaxation processes which occur as a result of the sample being strained at a fixed rate by a predetermined amount.

Ranitidine prevents duodenal ulcers associated with non-steroidal anti-inflammatory drug therapy

The results of four similarly designed, randomized, double-blind, placebo-controlled studies conducted to evaluate ranitidine as prophylaxis for NSAID-associated damage are reviewed. A total of 673 patients receiving therapeutic dosages of NSAIDs for arthritic or musculoskeletal conditions also received either ranitidine 150 mg twice daily (n = 343) or placebo (n = 330) for four weeks (two studies) or eight weeks (two studies). Endoscopic grading of mucosal lesions was based on a modified Lanza scoring system. All patients had normal baseline endoscopies. After four weeks of treatment a significant protective effect against duodenal mucosal lesions including duodenal ulcers (three studies) and gastric mucosal lesions including gastric ulcers (one study) was observed in patients who received ranitidine compared with those who received placebo. A meta-analysis of the four studies confirmed that significantly fewer patients receiving ranitidine than placebo developed duodenal ulcers (1% vs. 6%, P = 0.01). Endoscopic data at eight weeks from the two longer-term studies showed that duodenal ulcers occurred in ranitidine- and placebo-treated patients at a rate of 1% (2/137) vs. 8% (10/126) (P = 0.02), respectively, in one trial, and 0% (0/57) vs. 8% (4/49) (P = 0.02), respectively, in the other trial. No protective effect in the stomach was evident at eight weeks. We conclude that ranitidine is effective in preventing NSAID-associated duodenal ulcers and may be appropriate prophylaxis for certain high-risk patients.

Effects of antihypertensive agents on circadian blood pressure and heart rate patterns. Review

Blood pressure and heart rate exhibit a circadian rhythm, with both rising rapidly during the morning hours and then decreasing throughout the day to a nadir around 3 AM. Current evidence suggests a possible link between cardiovascular events, such as myocardial infarction and sudden cardiac death, which have been shown to occur most frequently during the morning hours, and the rapid rise in blood pressure and heart rate during this same time period. We review data from ambulatory blood pressure studies to ascertain which antihypertensive agents provide the most satisfactory control of blood pressure and heart rate during the hours of 6 AM to 12 noon. Of the forms of drug therapy studied, labetalol, a combined alpha- and beta-blocker, and two calcium channel blockers, nifedipine and verapamil, appear to be the most effective in blunting the rise in arterial blood pressure during these critical morning hours.

Peak expiratory flow in normal Ethiopian children and adults in Addis Ababa

The peak expiratory flow rate was determined using the Wright peak flow meter in normal Ethiopian children and adults residing in Addis Ababa (altitude 2500 m). The sample studied was of 84 boys, 69 girls (4-17 years) and 177 men, 148 women (18-70 years). Normality was determined by history alone. Linear multiple regression analysis was used to construct prediction equations that depended upon height and age. The results serve as reference values specifically for Ethiopians residing at altitude. Comparison of the PEFR values determined in 47 Caucasians (22 males, 27 females) working in Addis Ababa, with those from a group of Ethiopians matched for age and height indicated that the mean PEFR was significantly greater in the Caucasians by 7.3% in males and by 8.2% in females.

A critical appraisal of a rapid radiographic method of determining total lung capacity

We have demonstrated that the total lung capacities of normal caucasian adults, can be satisfactorily estimated by means of a regression equation derived from a single set of three measurements taken from a specially exposed plain X-ray film of the chest. However, these equations differ from those found by workers who have studied patients with lung disease. It is concluded from this that different regression equations are to be expected for normal and diseased lungs, and that, the appropriate equation will depend not only on the presence of disease, but also on its type and severity. It is also concluded that the rapid radiographic method of estimating total lung capacity can make little contribution to the diagnostic assessment of lung disease. However, the regression equations appropriate to particular ethnic groups could be used to measure TLC in normal subjects rapidly and inexpensively in places where specialised respiratory equipment and trained personnel are lacking.

Pulmonary hypersensitivity in the alginate industry

Salts of alginic acid are complex polymerised polysaccharides which are chemically extracted from seaweed. Workers in the alginate industry are exposed to dust from dried milled seaweed and pure alginate compounds. In this survey of one of the two factories in Britain producing alginates, we found evidence of pulmonary hypersensitivity to seaweed dust in seven per cent of the total work force, and evidence of precipitating antibody to sodium alginate and seaweed extracts in the serum of 4.5 per cent of the work force. Challenge testing of a number of employees with symptoms showed a dual response with immediate airways obstruction, and a later loss of lung volume, with associated impairment of transfer factor.

Sex hormone suppression and sexual impotence in hypoxic pulmonary fibrosis

Eight men with hypoxia associated with idiopathic pulmonary fibrosis were studied. Serum testosterone concentrations were low in two subjects and fell to subnormal levels in two others as the clinical condition and arterial oxygen tension deteriorated. There was a significant correlation between serum testosterone concentrations and arterial oxygen tensions (p less than 0.05). Three patients showed evidence of suppression of luteinising hormone secretion at the pituitary level. Only occasional abnormalities of thyroid and prolactin concentrations were noted. Most of the men suffered from organic sexual impotence, which is considered to be due at least in part to endocrine disturbance. These findings are similar to observations in patients with hypoxic chronic obstructive airways disease and support the hypothesis that hypoxia of lung disease suppresses the hypothalamo-pituitary-testicular axis.

Definitive nonsurgical therapy of epithelial malignancies of the anal canal. A report of 12 cases

Twelve patients with epidermoid carcinoma of the anal region ranging in age from 40-89 years were treated with combined chemotherapy (CT) and radiotherapy (RT) in lieu of abdominal-perineal resection. Ten patients received no prior treatment and two patients were treated for local recurrence following limited surgical excision. Two courses of 5-FU infusion and mitomycin C were given 3-4 weeks apart simultaneously with whole pelvis RT to 3000-4140 rad. One patient received an additional tumor volume dose of 3094 rad by interstitial Iridium implant and one patient received an orthovoltage boost of 1000 rad to the anal ring. All patients completed treatment. Complete regression of the anal mass occurred in all patients. Biopsies of the anal region performed after completion of therapy revealed no evidence of residual cancer. Ten of the 12 patients are alive without evidence of disease 4-24 months (median, 14 months) after completion of treatment. Two patients have died seven months after treatment of unrelated causes and were tumor-free at autopsy. All patients developed proctitis, diarrhea, and moist perineal desquamation which resolved by four weeks posttreatment. Based on their experience and that of others recently reported, the authors conclude that the described CT-RT protocol offers a definitive alternative to surgery of epidermoid cancer of the anal region.

Sex hormone binding globulin: effect of synthetic steroids on the assay and effect of oral contraceptives

The effect that synthetic steroid components of different oral contraceptives have on the assay system for measurement of sex hormones binding globulin (SHBG)-binding capacity, has been examined. Interference with the assay was not demonstrable at therapeutic levels of the drugs. d-Norgestrel was the only steroid studied which bound to SHBG with an affinity comparable to the endogenous sex hormones; it also tended to decrease SHBG-finding capacity, whereas preparations containing low levels of norethisterone increased the binding capacity. We suggest that measurement of changes in SHBG-binding capacity in subjects taking oral contraceptives may prove useful in indicating changes in sex hormone balance, particularly in view of the well-recognised side-effect of these drugs.

The effect of human pregnancy on the pulmonary transfer factor for carbon monoxide as measured by the single-breath method

1. The pulmonary transfer factor for carbon monoxide was measured by the single-breath method in 21 pregnant women with no previous history of cardiac or respiratory disease. Measurements were made at monthly intervals throughout pregnancy and once post partum. 2. The transfer factor was higher in the first trimester of pregnancy than in the non-pregnant state. There was a fall in the transfer factor during pregnancy until 26 weeks gestation, after which no further decrease was observed. 3. The changes in transfer factor were not explained by alterations in haemoglobin concentration or alveolar volume. 4. Simultaneous serial estimation of plasma 17beta-oestradiol were performed in all the subjects. There was no obvious direct relation between changes in the concentration of this hormone and transfer factor measurements.

Large airways function during normal pregnancy

Specific airways conductance and forced expiratory volume in one second were measured monthly from the first trimester until term in 30 subjects in the course of a normal pregnancy. Measurements were also made in the postpartum period. There was no significant change in these measurements either throughout pregnancy or compared with postpartum values. Our results suggested that the function of the larger pulmonary airways was not altered in pregnancy.

Effects of beta-adrenergic blockade and stimulation on airways in normal subjects

The effects of propranolol and salbutamol on conventional pulmonary function tests and closing volume have been studied in ten normal subjects. Propranolol and salbutamol had minor effects on measurements of airways resistance but had no effect on closing volume which is particularly sensitive to changes in peripheral airways. It was concluded that propranolol had negligible overall effect on central and peripheral airways properties in normal subjects, and it would appear that β-adrenergic activity has little measurable influence on peripheral airways in normal man at rest.

The significance of variation in the selectivity of proteinuria

The selectivity of proteinuria has been determined immunochemically at least 4 times over periods of 3 years or more in 27 children and adolescents who had been investigated by renal biopsy. Variations of the selectivity outside the limits of experimental error were observed in 14 patients, in 8 of whom there was a progressive decline. Six of these 8 had focal and segmental glomerular lesions, including one case of Alport's syndrome, and 2 had proliferative glomerulonephritis. Two different anomalies of relative IgG clearance were noted: in proliferative glomerulonephritis there was a constantly low clearance, and in focal glomerulosclerosis an elevated clearance increasing with time. Indirect evidence suggests that the latter may be due to the presence of low molecular weight IgG fragments in serum and urine.

Cardiogenic oscillations of nitrogen and argon concentration in expired gas in man

1. The cardiogenic oscillations in the concentration of nitrogen and argon in expired gas, which are seen after the inspiration from residual volume of pure oxygen or a bolus of argon, have been studied in normal subjects and in patients with atrial fibrillation. 2. In the upright position of the subject, the peaks of nitrogen and argon concentration coincide with ventricular systole, although there is a transit delay along the tracheobronchial tree before any change of concentration occurs at the mouth. 3. Studies in different postures demonstrated that the effect of the heart is predominantly due to a reduction in cardiac volume during systole with a decrease in airflow from regions adjacent to the heart. These areas contain a different concentration of nitrogen and argon in the alveolar air from the more apical regions. 4. It has been shown that the results are consistent with the present concepts of the influence of gravity on the distribution of inspired air.