B-20 Neuropsychological Profile in an Individual with Mitochondrial Encephalopathy, Lactic acidosis, and Stroke-like episodes (MELAS): A Case Study

Objective

Mitochondrial Encephalopathy, Lactic acidosis, and Stroke-like episodes (MELAS) is a rare and debilitating mitochondrial disease that affects bodily systems at the neurological level. The purpose of this study is to contribute to the paucity of research regarding the neuropsychological presentation and functional impact of MELAS.

Method

Mr. James is a 23-year-old male of Thai descent who initially presented with 2-3 days of headaches followed by generalized seizures and altered mental status. Over the course of one year, Mr. James experienced recurrent seizures with postictal confusion, and transient aura-like episodes. Patient was diagnosed with MELAS based off a combination of clinical findings, including magnetic resonance imaging (MRI) spectroscopy (SPECT) and molecular genetic testing. Extensive evaluation revealed persistent bilateral multifocal cortical/subcortical lesions, diffuse edema like signal and expansion involving the bifrontal, bitemporal, and bilateral subinsular cortices. Neuropsychological sequalae included physical, cognitive, and emotional changes from baseline.

Results

Mr. James was given a comprehensive neuropsychological battery in order to identify marked changes from his pre-morbid levels of neuropsychological functioning. Consistent with the literature, his profile revealed hallmark expressive and receptive language difficulties and markedly reduced bilateral fine motor functioning. In addition, problems with higher order executive skills (i.e., cognitive flexibility, problem-solving, and hypothesis testing) were elucidated, correlating with individual findings on neuroimaging.

Conclusions

Neuropsychological evaluation of Mr. James contributes to the dearth of research surrounding MELAS. These findings also highlight the importance of neuropsychological testing as part of the comprehensive evaluation for diagnostic clarification, and provide recommendations of the functional impact for others affected with this disease.

Policing pubs: what happens to crime?

The aim of this study was to test the effect of heightened police enforcement of the NSW Liquor and Registered Clubs Acts on overall criminal offences and, specifically, the number of assaults. Ten police patrols were included in the study. Five of these patrols were allocated to the experimental condition and five were allocated to the control condition. Beat police in the experimental controls conducted frequent but random visits to predesignated licensed premises over a 2-month period. Police in the control patrols maintained their normal duties. Numbers of offences in the experimental and control patrols were then compared for 2 months before the intervention, for the 2-month intervention phase and for 2 months post-intervention. Results of the study indicated a significant increase in the number of offences in the experimental patrols during the intervention phase. Reasons for this increase are discussed.

Debriefing after failed paediatric resuscitation: a survey of current UK practice

OBJECTIVES

Debriefing is a form of psychological "first aid" with origins in the military. It moved into the spotlight in 1983, when Mitchell described the technique of critical incident stress debriefing. To date little work has been carried out relating to the effectiveness of debriefing hospital staff after critical incidents. The aim of this study was to survey current UK practice in order to develop some "best practice" guidelines.

METHODS

This study was a descriptive evaluation based on a structured questionnaire survey of 180 lead paediatric and emergency medicine consultants and nurses, selected from 50 UK trusts. Questions collected data about trust policy and events and also about individuals' personal experience of debrief. Free text comments were analyzed using the framework method described for qualitative data.

RESULTS

Overall, the response rate was 80%. 62% said a debrief would occur most of the time. 85% reported that the main aim was to resolve both medical and psychological and emotional issues. Nearly all involve both doctors and nurses (88%); in over half (62%) other healthcare workers would be invited, eg, paramedics, students. Sessions are usually led by someone who was involved in the resuscitation attempt (76%). This was a doctor in 80%, but only 18% of responders said that a specifically trained person had led the session. Individuals' psychological issues would be discussed further on a one-to-one basis and the person directed to appropriate agencies. Any strategic working problems highlighted would be discussed with a senior member of staff and resolved via clinical governance pathways.

CONCLUSIONS

Little is currently known about the benefits of debriefing hospital staff after critical incidents such as failed resuscitation. Debriefing is, however, widely practised and the results of this study have been used to formulate some best practice guidelines while awaiting evidence from further studies.

Evaluation of lethal and non-lethal sampling methods for the detection of white sturgeon iridovirus infection in white sturgeon, Acipenser transmontanus (Richardson)

Pectoral fin tissue of white sturgeon was investigated as a potential non-lethal sample source for the detection of white sturgeon iridovirus (WSIV) infection. Histopathology and polymerase chain reaction (PCR) results using fin tissue were compared with the standard lethal histopathology sampling method that utilizes head tissue. Tissues for each of the three sampling methods were collected weekly for 8 weeks from individual sturgeon undergoing an experimental cohabitation challenge with fish infected with the Abernathy isolate of WSIV. Non-lethal fin histopathological evaluation did not reveal infection during the first 3 weeks of sampling, while non-lethal PCR and the lethal method were variable. However, all three sampling methods were equally capable of identifying infection from 4 to 8 weeks post-exposure. Of the survivors tested, all were negative by PCR and the lethal method, and only one fish was identified as being positive by non-lethal fin histopathology. In another experiment, all three sampling methods were applied to asymptomatic WSIV carriers in a case study conducted at the Kootenai Tribal Sturgeon Conservation Hatchery. Results showed that both lethal and non-lethal fin histopathology were equally effective in detecting infection, but PCR was unable to identify this strain of WSIV. Depending on the virus isolate, these results suggest that non-lethal sampling of fin tissue (histopathology or PCR) is comparable with the lethal sampling method at identifying WSIV infection once infection is established, and under certain circumstances may provide an alternative to lethal sampling.

Emergency department investigation of deep vein thrombosis

OBJECTIVES

To apply a previously validated clinical model for predicting pre-test probability of deep vein thrombosis (DVT) to patients attending an emergency department with symptoms suggestive of DVT and assess its reproducibility in the patient population. To measure the diagnostic value of the SimpliRED D-dimer assay in effectively excluding DVT.

METHOD

Prospective study between March 1999 and October 2000 of adult patients attending with suspected DVT. Patients were assessed using Wells' clinical prediction tool and risk stratified. SimpliRED D-dimer estimations were then performed and compression ultrasonography arranged. The pre-test probabilities of DVT in the low, moderate, and high risk groups of Wells' original cohort were compared with the authors' figures and the sensitivity, specificity, and predictive values of the SimpliRED assay calculated for the patient population.

RESULTS

Application of Wells' criteria to patients in the department permitted stratification into high, moderate, and low risk groups (prevalence of DVT 58.3%, 8.9%, and 1.5% respectively). SimpliRED D-dimer assay sensitivity was 63.4% with specificity of 74.8%, with a likelihood ratio of 2.52 for a positive test and 0.49 for a negative test.

CONCLUSIONS

Clinical risk stratification allowed patients to be categorised into high, moderate, and low risk groups, albeit with less discriminatory power than originally described by Wells. The low sensitivity of the SimpliRED D-dimer assay when used routinely in a busy emergency department raises substantial doubt over the use of this test to rule out DVT, even in low risk patients.

Open label tissue plasminogen activator for stroke: The Oregon experience

BACKGROUND

Tissue plasminogen activator (t-PA) is the first effective treatment for stroke. This study sought to explore the outcome of patients treated with t-PA in the community after approval of its use in the treatment of stroke in June, 1996.

METHODS

All patients with acute stroke within the 6-hospital Oregon Stroke Center network were screened for potential t-PA treatment. Baseline and 24-hour outcome assessments were performed with the use of the National Institutes of Health Stroke Scale (NIHSS) and computed tomography (CT); 3-month outcome was evaluated by using the Modified Rankin scale.

RESULTS

Thirty-three patients who met the criteria for t-PA therapy were treated within 3 hours of symptom onset. All but 2 strokes were in the anterior circulation; 48.5% were cardioembolic. The NIHSS scores at 24 hours after administration of t-PA (mean, 14.7) showed modest gains from baseline NIHSS scores (mean, 16.6). Twelve patients (36%) had minimal or no deficits at 3 months. Three patients (9%), all of whom had baseline NIHSS scores of 20 or more, had symptomatic intracranial hemorrhages, 2 of which were fatal (6%).

CONCLUSION

This study shows the feasibility of treating acute stroke with t-PA in the community. The percentage of fully recovered patients at 3 months mirrored those in the National Institute of Neurologic Disorders and Stroke (NINDS) trial.

G protein-mediated neuronal DNA fragmentation induced by familial Alzheimer's disease-associated mutants of APP

Missense mutations in the 695-amino acid form of the amyloid precursor protein (APP695) cosegregate with disease phenotype in families with dominantly inherited Alzheimer's disease. These mutations convert valine at position 642 to isoleucine, phenylalanine, or glycine. Expression of these mutant proteins, but not of normal APP695, was shown to induce nucleosomal DNA fragmentation in neuronal cells. Induction of DNA fragmentation required the cytoplasmic domain of the mutants and appeared to be mediated by heterotrimeric guanosine triphosphate-binding proteins (G proteins).

The effect of damage of the brachium of the superior colliculus in neonatal and adult hamsters and the use of peripheral nerve to restore retinocollicular projections

Using horseradish peroxidase (HRP) tracing technique, we were able to confirm the critical age in hamsters as reported previously (SO et al., 1981). Thus, following transection of the retinal fibers at the brachium of the superior colliculus (BSC) on postnatal-day 4 (P4) or later, no retinocollicular projections were observed in the adult stage. However, the retinal fibers were observed to reinnervate the superior colliculus (SC) if the BSC was cut on P3 or earlier. Physiological recording showed a close to normal retinocollicular map following a BSC damage on P0. Although retinal fibers did not reinnervate the SC following a BSC cut on or after P4, they could be observed to grow along a membrane over the damaged site. Bridging the site of BSC damage in adult hamsters using a segment of peripheral nerve (PN), retinal fibers labelled with WGA-HRP were observed to reinnervate the SC along the PN graft and visual evoked responses could be recorded in the SC showing the PN graft is effective in restoring damaged central visual pathways in adult mammals.

Laparoscopy for intrauterine insemination and embryo recovery in superovulated ewes at a commercial embryo transfer unit

Of 111 variable age, pedigree ewes subjected to a range of superovulatory regimens and then submitted to embryo recovery by laparoscopy, nine had adhesions corresponding to a mid-line laparotomy (presumably from a previous attempt to recover embryos) and could not have their embryos recovered by the laparoscopic technique. Of the remainder, 27 ewes (26.5%) had less than three ovulations or had prematurely regressing corpora lutea at the selected time for embryo recovery (Days 5 to 6 following insemination), and no attempt was made to recover embryos from them. For the 75 ewes subjected to laparoscopic ovum recovery following laparoscopic intrauterine insemination, the average number of ovulations (+/- SEM) was 7.9 +/- 0.6; the average ovum recovery (mean of values for each ewe) was 51.7% +/- 3.5; and the percentage of recovered ova that were fertilized was 87.3%. For a further nine 3-yr-old crossbred ewes the mean values for ovulation and ovum recovery were 7.6 +/- 1.2 and 70.1 +/- 7.7, and were not significantly different for the two insemination methods used (laparoscopic intrauterine vs cervical). In general, ovulation rates for ewes given pregnant mare serum gonadotrophin (PMSG) tended to be lower (5.2 +/- 0.7) than for those given porcine follicle stimulating hormone (pFSH, 7.7 +/- 0.8) or human menopausal gonadotrophin (hMG, 7.7 +/- 2.3). Ova recovery rates were similar on Days 5 and 6 (Day 0 = insemination), and were not affected by method of insemination (laparoscopic intrauterine vs cervical).

Curious neurologic sequelae in galactosemia

Two siblings with classic transferase deficiency galactosemia that was detected at birth have been treated with lactose restriction since the neonatal period. Both patients developed a unique and progressive neurologic syndrome of mental retardation, tremor, and ataxia. Careful review of the family history and medical records, the absence of metabolic disturbances other than those related to galactosemia, and the aggregate physical findings and neurodiagnostic studies ruled out other neurologic disorders in these siblings. It is therefore proposed that these patients represent a subgroup of transferase-deficient galactosemic patients, who develop characteristic neurologic sequelae with conventional dietary management. The existence of this subgroup should be considered in evaluations of therapeutic responses in cohorts of patients with galactosemia. Further, galactosemia should be included in the differential diagnosis of tremor and ataxia in the setting of mental retardation.