Treatment of cognitive impairment in multiple sclerosis: position paper

Cognitive impairment in multiple sclerosis (MS) is common, debilitating and burdensome. Key evidence from trials was reviewed to enable recommendations to be made to guide clinical practice and research. Behavioural and pharmacological interventions on cognition reported in published studies were reviewed. Most studies evaluating behavioural treatment for impairment in learning and memory, deficits of attention and executive function have demonstrated some improvement. Controlled studies in relapsing remitting MS indicate interferon (IFN) β-1b and IFN β-1a were associated with modest cognitive improvement. The effects of symptomatic therapies such as modafinil and donepezil are inconsistent. Most studies yielding positive findings have significant methodological difficulties limiting the confidence in making any broad treatment recommendations. There are no published reports of glatiramer acetate, natalizumab and fingolimod being effective in improving cognition in controlled trials. The effects of disease modifying therapies in other forms of MS and clinically isolated syndrome have not yielded positive results. Data linking behavioural therapy, symptomatic treatment or disease modifying treatment, to either reducing cognitive decline or improving impaired cognition are limited and inconsistent. The treatment and prevention of cognitive impairment needs to remain a key research focus, identifying new interventions and improving clinical trial methodology.     

Rating a Sports Medicine Surgeon’s “Quality” in the Modern Era: an Analysis of Popular Physician Online Rating Websites

Background

Consumer-driven healthcare and an increasing emphasis on quality metrics have encouraged patient engagement in the rating of healthcare. As such, online physician rating websites have become mainstream and may play a potential role in future healthcare policy.

Questions/Purposes

The purpose of this study was to evaluate online patient ratings for US sports medicine surgeons, determine predictors of positive ratings and analyze for inter-website scoring correlation.

Methods

The American Orthopedic Society for Sports Medicine (AOSSM) member directory was sampled. Surgeon demographic and rating data were searched on three online physicians rating websites: HealthGrades.com (HG), RateMDs.com (RM) and Vitals.com (V). Written rating comments were categorized as relating to the following: surgeon competence, surgeon affability and process of care. Bivariate linear regression, Pearson correlation and multivariable analyses were used to determine factors associated with positive ratings.

Results

Two hundred seventy-five sports medicine surgeons were included. Two hundred seventy-one (99%) had ratings on at least one of the three websites. Sports surgeons were rated highly across all three websites (mean >4.0/5); however, there was only a low to moderate degree of correlation among websites. On HG, female surgeons and surgeons in academia were more likely to receive higher overall ratings. Across all three websites, increased number of years in practice inversely correlated with ratings; this relationship neared significance for HG and was significant for RM. A surgeon’s online presence or geographic location was not associated with higher ratings. In multivariable regression analysis for ratings on HG, female sex was the only significant predictor of higher ratings. Two thousand three hundred forty-one written comments were analyzed: perceived surgeon competence and communication influenced the direction of ratings for the top and bottom tier surgeons.

Conclusion

There was a low degree of correlation among online websites for surgeon ratings. Female surgeons and those with fewer years in practice appear to have higher ratings on these websites; comment content analysis suggests that high and low ratings are influenced by perceived surgeon competence and affability.

     

Preferences for symmetry in faces change across the menstrual cycle

Symmetry in human male faces may be a cue to heritable fitness benefits and is found attractive. Preferences for facial masculinity, another proposed marker of genetic quality, have been found to vary in ways that may maximise evolutionary relevant benefits and masculinity is found to be of increased attractiveness at peak fertility across the menstrual cycle. Here we show that women prefer more symmetric faces at peak fertility (Study 1) and that such shifting preferences may be potentially strategic preferences as we found them to occur only for judgements concerning short-term relations and when women already had a partner (Study 2). Such preferences potentially indicate a strategy that maximises the quality of extra-pair/short-term partners or a quality dependent response to hormones. Such strategic preferences for symmetry may support the role of symmetry in signalling potential good-gene benefits.     

Aero-medical evacuation with interventional lung assist in lung failure patients

OBJECTIVE: Acute respiratory failure can make long distance transport by air extremely difficult. Despite pressurised cabins, the pressure will fall to about three quarters of one atmosphere, and the oxygen partial pressure will fall proportionally. Interventional lung assist (iLA) is a well documented treatment in the critical care unit, but has not been evaluated scientifically in long range aero-medical evacuation. The present animal study was performed to test the feasibility of treating lung failure with iLA during intercontinental air evacuation in a military setting. METHODS: Eight adult female pigs were cannulated in the right axillary artery and the right jugular vein. An arterio-venous iLA device (Novalung) was connected. The ventilator was adjusted to below half of the needed minute volume before the use of iLA. The animals went through different modalities of transportation in ambulances, helicopters and aircraft. Two of the pigs were tested in a hypobaric chamber, and the remaining two animals underwent a 7.5 h intercontinental transportation from Denmark to Greenland in a Hercules C130J transport airplane. RESULTS: It was possible to maintain physiological PaCO(2) and PaO(2) in normal flight altitudes with iLA. Compared to pump-driven ECMO systems iLA is safer and more efficient. The current study demonstrates the feasibility of iLA during military aero-medical evacuation.     

Evidence-based pharmacologic management of pulmonary arterial hypertension

BACKGROUND: Pulmonary arterial hypertension (PAH) is a debilitating chronic disorder of the pulmonary vasculature characterized by elevated mean pulmonary arterial pressure, right-sided heart failure, and early mortality. OBJECTIVES: This paper reviews the available information on PAH, including its pathophysiology, classification of its severity, current treatment options, drug interactions, pharmacokinetics, and cost considerations. The results of clinical trials of the available treatments are summarized, and a suggested treatment algorithm is provided as a guide to the medical management of PAH. METHODS: Pertinent articles were identified by a search of MEDLINE through May 2007 using the terms primary pulmonary hypertension, pulmonary arterial hypertension, prostacyclin, pulmonary vasodilators, endothelin-receptor antagonists, and phosphodiesterase inhibitors. Trials with prospective, randomized designs were given precedence, and prospective studies having nonrandomized, open-label designs or using historical controls were included if they contributed useful knowledge. Retrospective studies were not included. Results: In two 12-week, randomized, open-label trials in patients with moderate to severe PAH (N = 81 and N = 111), exercise capacity, measured on the 6-minute walk test (6-MWT), was significantly improved with intravenous epoprostenol compared with conventional therapy (+31 vs -29 m, respectively, in one study [P = 0.002]; +46 vs -48 m in the other [P < 0.001]). In one of these trials, intravenous epoprostenol also was associated with a significant survival benefit (P < 0.003). In a 12-week, randomized, doubleblind, placebo-controlled trial in 470 patients with moderate to severe PAH, subcutaneous treprostinil plus conventional therapy was associated with a significant improvement on the 6-MWT compared with conventional therapy alone (+10 vs 0 m, respectively; P = 0.006). In a 16-week, randomized, double-blind, placebo-controlled trial in 213 patients with mild to moderate symptoms, the oral endothelin-receptor antagonist bosentan was associated with a significant improvement on the 6-MWT compared with placebo (+36 vs -8 m, respectively; P 20% decrease in pulmonary arterial pressure and pulmonary vascular resistance immediately after challenge) had a survival rate of 94% at 1, 3, and 5 years. CONCLUSIONS: Patients who respond to an acute trial of a vasodilator may be treated with an oral calcium channel blocker, whereas oral therapies such as sildenafil and bosentan have been effective in patients with mild to moderate symptoms. Infusions of the prostacyclin analogues epoprostenol and treprostinil appear to be the treatment of choice for moderate to severe PAH, and agents with alternate routes of delivery such as inhaled iloprost may be advantageous in adjunctive roles. Future trials that focus on the long-term effects of currently available agents, as well as on combination therapy, are needed.     

Inter-Rater Reliability of the PIPES Tool: Validation of a Surgical Capacity Index for Use in Resource-Limited Settings

Introduction

In response to the need for simple, rapid means of quantifying surgical capacity in low resource settings, Surgeons OverSeas (SOS) developed the personnel, infrastructure, procedures, equipment and supplies (PIPES) tool. The present investigation assessed the inter-rater reliability of the PIPES tool.

Methods

As part of a government assessment of surgical services in Santa Cruz, Bolivia, the PIPES tool was translated into Spanish and applied in interviews with physicians at 31 public hospitals. An additional interview was conducted with nurses at a convenience sample of 25 of these hospitals. Physician and nurse responses were then compared to generate an estimate of reliability. For dichotomous survey items, inter-rater reliability between physicians and nurses was assessed using the Cohen’s kappa statistic and percent agreement. The Pearson correlation coefficient was used to assess agreement for continuous items.

Results

Cohen’s kappa was 0.46 for infrastructure, 0.43 for procedures, 0.26 for equipment, and 0 for supplies sections. The median correlation coefficient was 0.91 for continuous items. Correlation was 0.79 for the PIPES index, and ranged from 0.32 to 0.98 for continuous response items.

Conclusions

Reliability of the PIPES tool was moderate for the infrastructure and procedures sections, fair for the equipment section, and poor for supplies section when comparing surgeons’ responses to nurses’ responses—an extremely rigorous test of reliability. These results indicate that the PIPES tool is an effective measure of surgical capacity but that the equipment and supplies sections may need to be revised.