Cognitive and emotional disorders in multiple sclerosis. Can a management strategy be envisioned?

There is a lack of precise data concerning the natural history of cognitive disorders in multiple sclerosis (MS), but recent neuropsychological studies have demonstrated that the incidence of such disorders in MS appears to be frequent (40-65% of cases), and have shown in particular that recent memory, conceptual reasoning, attention, executive functions, visuospatial perception and information processing speed are negatively affected. In contrast, language functions, general intelligence and implicit memory appear to be relatively well preserved. Although the presence and the degree of cognitive disorders does not seem to be directly linked to disease duration or to the extent of physical disability, the relationship between cognitive decline and brain lesions detected by magnetic resonance imaging (MRI) is still a subject of discussion. The prevalence of emotional and affective disorders is difficult to estimate. Their frequency has only rarely been investigated, and the lack of data on the natural history of these disorders and those factors which they have in common (the psychosocial consequences of this chronic and disabling disease, cognitive impairment, and brain lesions) further complicate the determination of treatment strategy. The adoption of appropriate strategies could limit the negative impact of this disease on the social functioning of MS patients.     

Can tissue transglutaminase be a marker of idiopathic inflammatory myopathies?

In the normal striated muscle, tissue transglutaminase (TG2) content is vestigial. However, this protein's presence has been reported to occur in myoblasts and myotubes during the fetal period. Its increased expression has been also found in the muscle tissue in the course of sporadic inclusion body myositis, as well as in polymyositis (PM) and dermatomyositis (DM), which are considered to be diseases of immunological origin. Based on in vitro studies, a substantial TG2 role in the infiltration of some T cell subsets into inflamed tissues has been suggested lately. In this study, the immunohistochemical reactions in the guinea pig experimental myositis specimens and in the ones from PM/DM patients were compared. The guinea pig tissue specimens were taken from muscles affected by experimental myositis induced by intramuscular injections of: 1/sera from 30 neoplasm patients with no metastases; 2/sera from 10 healthy people; 3/sera from 2 DM patients; 4/neuropeptides (SP, NPY or VIP) and from 5/the muscles affected by the reversed passive Arthus reaction (RPAR). The immunostaining for TG2 revealed substantial presence of this protein in single, damaged muscle fibers and a weak reaction in regenerating fibers appearing in PM/DM patients' specimens. From among experimental myositis specimens, a very intensive reaction appeared only in the damaged and regenerating muscle fibers present in the slides from guinea pig muscles injected with DM patients' sera. Such results suggest some presence of a specific factor(s) (the one(s) responsible for TG2 expression in the damaged muscle fibers) in DM patients' sera. The results suggest that transglutaminase can be a marker of inflammatory myopathies. A probable correlation between TG2 expression in muscles and organismal immunological factors, including the complement activation status, requires additional studies.     

Can face-to-face patient education be replaced by computer-based patient education? A randomised trial

OBJECTIVE: Computer-based patient education is an effective (therapeutic) tool. More and more studies prove that it can be an effective additive for face-to-face education, but it is still unclear if it is possible to educate patients by only using a computer. Our objective was to compare knowledge levels and satisfaction scores after computer-based patient education versus doctor-based patient education. METHODS: We started a randomised and stratified trial in a large plastic surgery clinic in the Netherlands. One hundred thirteen patients with carpal tunnel syndrome (CTS), scheduled for operation were included. One group received CTS education by a doctor using a checklist (group A). The other group received the same CTS education by specially designed interactive computer program (group B). After 2 weeks, knowledge levels and satisfaction scores were tested by using a questionnaire. RESULTS: One hundred thirteen patients were included, 96 patients finished the questionnaire. With respect to knowledge levels the doctor group (A) scored 20.2 points (max 40 points), and the computer group (B) scored 23.5 points. After correction the difference was 2.8 points (p=0.001). The total satisfaction score in group A was 7.6 and in group B 7.5; a difference of -0.16 (p=0.585). CONCLUSIONS: The results suggest that educating patients can result in a higher knowledge levels by using a computer than by using a doctor. Satisfaction seems equal after both methods of education. PRACTICE IMPLICATIONS: Knowing that you can educate patients without seeing a doctor or nurse seems promising. Patient can be educated by computer-based education programs leaving more time in a consultation for asking questions and discussing treatment options. The discussion will be at a more equal level of knowledge. Possibly it can save time and money resulting in a more efficient patient care, without dissatisfying our patients.     

Psychopathy in juvenile offenders. Can temperament and attachment be considered as robust developmental precursors?

Attempts to predict adult psychopathy generally focus on aggressive and antisocial behavior exhibited in childhood and adolescence. Yet, children with conduct problems constitute a heterogeneous group, and many of the unique interpersonal and affective features associated with the construct of psychopathy only apply to a small subset of children displaying antisocial behavior. The current review seeks to derive an understanding of the specific precursors of the apparently amoral, affectionless, and self-centered orientation that psychopathic youngsters display towards other people. The focus is on the notions of temperament and attachment in early childhood, and their links to the emergence of moral emotions later in life. Based on a developmental perspective, the data currently available are examined, highlighting the insights gained from this body of work and outlining the conceptual and methodological challenges that still need to be addressed.     

Can microcarrier-expanded chondrocytes synthesize cartilaginous tissue in vitro?

Tissue engineering is a promising approach for articular cartilage repair; however, it is challenging to produce adequate amounts of tissue in vitro from the limited number of cells that can be extracted from an individual. Relatively few cell expansion methods exist without the problems of de-differentiation and/or loss of potency. Recently, however, several studies have noted the benefits of three-dimensional (3D) over monolayer expansion, but the ability of 3D expanded chondrocytes to synthesize cartilaginous tissue constructs has not been demonstrated. Thus, the purpose of this study was to compare the properties of engineered cartilage constructs from expanded cells (monolayer and 3D microcarriers) to those developed from primary chondrocytes. Isolated bovine chondrocytes were grown for 3 weeks in either monolayer (T-Flasks) or 3D microcarrier (Cytodex 3) expansion culture. Expanded and isolated primary cells were then seeded in high density culture on Millicell? filters for 4 weeks to evaluate the ability to synthesize cartilaginous tissue. While microcarrier expansion was twice as effective as monolayer expansion (microcarrier: 110-fold increase, monolayer: 52-fold increase), the expanded cells (monolayer and 3D microcarrier) were not effectively able to synthesize cartilaginous tissue in vitro. Tissues developed from primary cells were substantially thicker and accumulated significantly more extracellular matrix (proteoglycan content: 156%-292% increase; collagen content: 70%-191% increase). These results were attributed to phenotypic changes experienced during the expansion phase. Monolayer expanded chondrocytes lost their native morphology within 1 week, whereas microcarrier-expanded cells were spreading by 3 weeks of expansion. While the use of 3D microcarriers can lead to large cellular yields, preservation of chondrogenic phenotype during expansion is required in order to synthesize cartilaginous tissue.     

Can infections be imaged in implanted devices?

Approximately 30,000 to 60,000 patients per year in the United States are candidates for heart transplants, mechanical assist devices, or both. These procedures, devices, and the associated short- and long-term care required are expensive and command significant utilization of health care resources. Because device related infection and thrombosis are potentially devastating complications of implanted device utilization, early diagnosis of infection, thrombosis, or both, would be helpful for initiation of early therapy to prevent untoward clinical events. Therefore, the development of a robust imaging technology for identification of infection could be cost effective if early assessment, diagnosis, and therapy of infected devices led to improvements in morbidity and mortality.     

Can critically timed sleep deprivation be useful in pregnancy and postpartum depressions?

Background: The aim of this study was to test the efficacy of critically timed sleep deprivation in major mood disorders (MMD) occurring during pregnancy and postpartum. Methods: Nine women who met DSM-IV criteria for a MMD with onset during pregnancy or within 1 year postpartum underwent a trial of either early-night sleep deprivation (ESD), in which they were sleep deprived in the early part of one night and slept from 03:00–07:00 h, or late-night sleep deprivation (LSD), in which they were deprived of sleep in the latter part of one night and slept from 21:00–01:00 h. Mood was assessed before the night of sleep deprivation, after the night of sleep deprivation, and after a night of recovery sleep (sleep 22:30–06:30 h) by trained clinicians, blind to treatment condition, using standardized scales. Results: More patients responded to LSD (nine of 11 trials: 82%) compared with ESD (two of six trials: 33%) and they responded more after a night of recovery sleep (nine of 11 nights: 82%) than after a night of sleep deprivation (six of 11 nights: 55%). Pregnant women were the only responders to ESD and the only nonresponders to LSD. Limitations: The small and heterogeneous sample size prevents us from making more definitive conclusions based on statistical analyses. Conclusions: Although the findings are preliminary, the results suggest that with further study, critically timed sleep deprivation interventions may benefit women with pregnancy or postpartum major mood disorders and potentially provide a viable alternative treatment modality for those women who are not candidates for pharmacologic or psychotherapeutic interventions. Such interventions are needed to help prevent the devastating effects of depression during pregnancy and the postpartum period on the mother, infant, her family and society.     

Can Computer Meridian Diagnostic be useful in diagnosis and management of diseases?

The need for the development of appropriate guidelines for effective or safe use of antioxidants and herbs has always been a concern, especially for the alternative medicine practices. Computer Meridian Diagnostic (CMD) is one of emerging computer-based diagnostic technologies available to alternative medicine practitioners. However, case report of the agents monitored with CMD is uncommon; and concerted effort to bring this into conventional medical practice is yet to be. This hypothesis builds on an anecdotal observation of anti-stress effect monitored with CMD, with a view to highlight a potential tool that requires expatiation, as well as proof of concept and validation studies for possible integration in conventional and traditional medicine practices for therapeutic monitoring.     

Can antiviral treatment for hepatitis C be safely and effectively delivered in primary care?: A narrative systematic review of the evidence base

Background

The burden of hepatitis C (HCV) treatment is growing, as is the political resolve to tackle the epidemic. Primary care will need to work more closely with secondary care to succeed in reducing the prevalence of chronic HCV.

Aim

To identify research relating to the provision of antiviral treatment for HCV in primary care.

Design and setting

A narrative systematic review of six databases.

Method

Medline, Embase, Cinahl, PsycINFO, Web of Science, and Cochrane were searched. Relevant journals were searched by hand for articles to be included in the review. Reference lists of relevant papers were reviewed and full-text papers were retrieved for those deemed to potentially fulfil the inclusion criteria of the review.

Results

A total of 683 abstracts led to 77 full-text articles being retrieved, of which 16 were finally included in the review. An evidence base emerged, highlighting that community-based antiviral treatment provision is feasible and can result in clinical outcomes comparable to those achieved in hospital outpatient settings. Such provision can be in mainstream general practice, at community addiction centres, or in prisons. GPs must be trained before offering such a service and there is also a need for ongoing specialist supervision of primary care practice. Such training and supervision can be delivered by teleconference, although, even with such ready availability of training and supervision, only a minority of GPs are likely to want to provide antiviral treatment.

Conclusion

There is emerging evidence supporting the effectiveness of antiviral treatment provision for patients with chronic hepatitis C in a wide variety of primary care and wider community settings. Training and ongoing supervision of primary care practitioners by specialists is a prerequisite. There is an opportunity through future research activity to evaluate typologies of patients who would be best served by primary care-based treatment and those for whom hospital-based outpatient treatment would be most appropriate.     

Can extracellular fluid volume expansion in hemodialysis patients be safely reduced using the hemocontrol biofeedback algorithm? A randomized trial

Extracellular fluid volume (ECFV) expansion in hemodialysis patients is associated with increased mortality. Attempts to remove excess fluid often result in intradialytic hypotension (IDH). Blood volume monitoring has been used to aid selection of ultrafiltration rates and dialysate conductivity to minimize IDH. Automating ultrafiltration and dialysate conductivity using the Hemocontrol Biofeedback System (HBS) has reduced IDH in IDH-prone subjects. We undertook a randomized controlled trial to determine if the HBS could safely reduce ECFV in ECF-expanded subjects. Patients with ECFV >45% of total body water were randomized to receive hemodialysis by either HBS or best clinical practices for 6 months. The primary endpoint was change in ECFV; exploratory variables included frequency of IDH, interdialytic weight gain, and changes in serum Na. Treatment with HBS did not result in any change in ECFV, even after multivariable adjustment. The frequency of IDH was however significantly lower with HBS when compared with best clinical practices without differences in other variables.     

Can virtue be taught?

Applying standards of virtue that define the "good doctor" in a complex and technologically sophisticated health care system is often challenging and sometimes confusing. What are the characteristics of a "good doctor," who wishes to live up to high ethical and professional standards but who also must live and work in a health care system in which moral ambiguity is pervasive? Medical educators are urgently faced with such questions as their schools try to equip students with the skills and capacities required of the virtuous physician. The author describes how Aristotelian concepts of virtue can be used to guide medical educators in defining and teaching virtue. He then discusses how such traits as the ability to tolerate moral differences and ambiguity, the ability to develop thoughtful individual moral positions, and the capacity to respect and understand various cultural traditions may be what might be considered virtues in today's health care system. A "good" doctor, then, would be someone who is thoughtful, fair-minded, respectful of differences, and committed to his or her professional values.     

Can the left hepatic vein always be safely selectively clamped during hepatectomy? The contribution of anatomy

The minimization of blood loss is the main objective during hepatic resection to minimize perioperative mortality and morbidity. Selective clamping of the hepatic veins, combined with pedicle clamping, may make it possible to spare the non-resected territories from ischemia. These clamping procedures are particularly useful in the treatment of hepatic metastases of colorectal cancers, because preoperative chemotherapy may temporarily alter the hepatic parenchyma, increasing its susceptibility to ischemia. During left lobectomy or left hepatectomy, extraparenchymatous control of the left and median hepatic veins (the LHV and MHV, respectively) and of the common trunk (CT) requires exact knowledge of this anatomical region. Biometric analyses were carried out on extraparenchymatous portions of the LHV, MHV and CT of 20 fresh cadavers and 10 living subjects, to assess the feasibility of selective clamping without liver mobilization. Fourteen of the 20 cadaveric subjects (70%) had a common trunk between the LHV and the MHV. The extraparenchymatous portion of the LHV was between 4 and 13 mm long, depending on the presence or absence of a CT. The angle between the sagittal plane of the inferior vena cava and the LHV was about 18.3° on average, in the absence of liver mobilization. Selective clamping of the left hepatic vein was possible only when the extraparenchymatous portion of this vein was at least 6 mm long. The selective clamping of this vein is, therefore, less straightforward than that of the right hepatic vein, given the high frequency of a common trunk shared with the median hepatic vein and of a short extraparenchymatous segment.     

Can mastalgia be another somatic symptom in fibromyalgia syndrome?

OBJECTIVE:The purposes of this study were to determine the coexistence of mastalgia and fibromyalgia, to investigate the effects of this combination on pain patterns, and to discuss the status of breast pain in the diagnostic algorithm of fibromyalgia syndrome.METHODS:Sixty-one female patients reporting breast pain during the last three months and 53 female patients diagnosed with fibromyalgia syndrome were enrolled in this study. The Breast Pain Questionnaire was administered to all participants in the mastalgia group and to those in the fibromyalgia syndrome group who had experienced mastalgia during the past three months. The patients in the fibromyalgia syndrome group were evaluated using the 2010 preliminary American College of Rheumatology classification criteria. All of the patients in the mastalgia group were evaluated for the diagnosis of fibromyalgia syndrome by a single physiatrist. The coexistence and pain patterns of mastalgia and fibromyalgia were assessed statistically.RESULTS:Approximately half of the patients with fibromyalgia syndrome (47.2%) reported having mastalgia at the time of admission and 37.7% of the patients with mastalgia met the diagnostic criteria for fibromyalgia syndrome. The patients with mastalgia in the fibromyalgia syndrome group had significantly higher total breast pain scores compared with the women in the mastalgia group. In addition, the patients with fibromyalgia syndrome in the mastalgia group had significantly higher Widespread Pain Index and Symptom Severity Scale scores than the patients with fibromyalgia syndrome.CONCLUSIONS:We suggest that mastalgia can be an aspect of the central sensitivity syndrome and can be added to the somatic symptoms of fibromyalgia.     

Can bipolar disorder-specific neuropsychological impairments in children be identified?

This study examined neuropsychological deficits among children with bipolar disorder while attending to its comorbidity with attention-deficit/hyperactivity disorder (ADHD). Seventy-three unmedicated children (ages 6-17 years) with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) bipolar disorder plus ADHD (BPD + ADHD) were compared with 102 unmedicated children with ADHD without bipolar disorder, and 120 children without bipolar disorder or ADHD. Ninety-four percent of participants were Caucasian, 58% were male, and 42% were female. On average participants were of middle to upper socioeconomic status. Participants were assessed with a comprehensive neuropsychological battery and measures of academic achievement, school failure, and special education placement. Participants with BPD + ADHD and with ADHD were impaired in interference control, verbal learning, and arithmetic achievement and had higher rates of special school services. Across all of the measures of neuropsychological functioning, the only difference observed between youths with BPD + ADHD and youths with ADHD was that youths with BPD + ADHD performed more poorly on one measure of processing speed. Thus, comorbidity with ADHD may account for many of the neuropsychological deficits observed in children with bipolar disorder.