Serum antibodies against central nervous system proteins in human demyelinating disease

An immunoblotting technique has been used to screen serum samples from patients with demyelinating disease for antibody directed against central nervous system proteins. Antibodies of the IgM, IgG and IgA class directed against one or more of the particulate fraction proteins tubulin, myelin basic protein, 69 K neurofilament protein, glial fibrillary acidic protein, myelin associated glycoprotein or Wolfgram protein were present in 94, 54 and 47%, respectively, of multiple sclerosis sera examined. IgM antibodies against tubulin and myelin basic protein predominated. A similar antibody spectrum was seen in a significant proportion of sera from patients with optic neuritis, subacute sclerosing panencephalitis and motor neurone disease, in which primary or secondary demyelination occurs. Antibodies of all three classes directed against the 169 K and 220 K neurofilament proteins and against some unidentified proteins of human peripheral nerve, kidney, liver, spleen and skeletal muscle were detected in sera from healthy subjects and patients with neurological disease.     

‘I know they are not trained in dementia’: Addressing the need for specialist dementia training for home care workers

Global population ageing has meant a rapid increase in the numbers of older people with dementia, most of whom live in their own homes. Staying at home is an important determinant of health and well‐being. As care needs increase, the quality of community support which older people receive directly influences their capacity to remain in their own homes. While many are supported informally by family carers, formal support provided by home care workers often enables them to remain at home for longer period. However, providing community‐based care for people with dementia can be challenging. Workers often lack training in dementia‐specific care for clients with increasingly complex needs, and typically work without direct supervision. As the demand for person‐centred home care for people with dementia increases, specialist dementia training for home care workers is urgently needed. In this qualitative study, we used in‐depth interviews of a purposive sample, comprising 15 family carers and four older people with dementia, to understand the experience of receiving community care. Data analysis was guided by Braun and Clarke's approach to thematic analysis and revealed the following five overlapping themes, relating to home care workers’ understanding of dementia, person‐centred care, communication and rapport, mutual collaboration, and the influence of organisational constraints on continuity of care. Although participants acknowledged that service providers operated under challenging circumstances, they were frustrated with home care workers’ lack of dementia knowledge and inconsistent staff rostering. Conversely, an understanding of the lived experience of dementia, effective communication and rapport, and continuity of care contributed significantly to a positive experience of receiving care. The findings of this study will be used to inform the essential elements of a training program aimed at enabling and empowering a skilled, specialist home care workforce to support older people with dementia to live well at home for as long as possible.     

Psychometric evaluation of a patient-rated troubling symptom scale for generalized anxiety disorder clinical trials

Background: The majority of clinical outcome assessments developed for generalized anxiety disorder (GAD) may not efficiently and sensitively reflect heterogeneous symptom clusters from a patient perspective. The Patient-Rated Troubling Symptoms Scale for Anxiety (PaRTS-A) instrument was developed to provide an individualized assessment of patient relevant GAD symptoms. Objective: The objective of this analysis was to evaluate the psychometric characteristics of the PaRTS-A. Methods: Data were taken from a 6-week clinical trial evaluating the efficacy of adjunctive risperidone therapy in GAD patients undergoing standard treatment. Patients completed the PaRTS-A, the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), and the Sheehan Disability Scale (SDS) as well as impressions of improvement. Physicians completed the Hamilton Anxiety Rating Scale (HAM-A). A instrument characteristics were assessed through statistical tests of reliability, reproducibility, construct and discriminant validity, and responsiveness. Results: In the item response theory (IRT) analysis, the PaRTS-A items fit into a single construct of anxiety. Internal consistency reliability exceeded 0.70. The PaRTS-A total score was moderately correlated with the Q-LES-Q and the SDS. The PaRTS-A distinguished between patients with high and low HAM-A scores (p<0.001). The PaRTS-A was responsive to changes in clinical status and the minimal important difference was identified. Conclusion: The PaRTS-A provides a unique patient-rated assessment of anxiety symptoms. The instrument may provide clinicians with useful information regarding patient's self-rated anxiety disorder symptoms and the hierarchy of symptoms that they considered most troubling. Our analysis suggests that the PaRTS-A is an internally consistent, valid, and responsive instrument that may be a beneficial adjunct to other instruments in clinical trials.     

Impact of prior immunological exposure on vaccine delivery by Salmonella enterica serovar Typhimurium

Recombinant Salmonella have been employed as vaccine vectors to deliver DNA and protein vaccines of viral, bacterial and parasitic origin. However, the effectiveness of Salmonella delivery may be hampered by prior immunological exposure to Salmonella. We investigated the effects of prior exposure to the Salmonella typhimurium aroAD strain BRD509 on its ability to deliver the non-toxic C fragment of tetanus toxin (TT). BALB/c mice were orally immunised with BRD509 containing the C fragment expression plasmid pTETtac4, C fragment DNA vaccine pAT153/Cfrag or BRD509 alone and, along with age matched un-vaccinated controls, were immunised again 6 months later with BRD509 (pTETtac4). Prior exposure to Salmonella was found to significantly reduce the ability of the bacteria to colonise the Peyer's patches and mesenteric lymph nodes, spread systemically to the liver and spleen and significantly impair antibody responses to Salmonella LPS and TT. Results show that prior exposure to Salmonella significantly compromises its efficacy as a vaccine vector and these negative effects do not diminish with time. In addition, findings suggest Salmonella vaccine vectors cannot be employed to deliver multiple doses of a vaccine antigen.     

Postoperative care of neurosurgical patients: general principles

The primary aim of care immediately after neurosurgery is to detect and prevent neurological deterioration while supporting systemic and neurological homoeostasis. Surgical-, anaesthetic- or disease- related factors may contribute to a slow return or failure to regain a patient's preoperative status. A period of specific monitoring and observation by nursing and medical staff accustomed to neurosurgical and neurocritical care procedures should be planned for the immediate postoperative period. In many neurosurgical centres the period of postoperative observation may be relatively short (e.g. limited uneventful craniotomies); however, if complicating factors such as cerebral oedema, intracranial haemorrhage, seizures or significant premorbid conditions are present, a period of higher dependency care over several days may be anticipated. In common with all postoperative care safe management of the airway, weaning of ventilatory support, control of circulation and fluid balance, feeding, sedation and analgesia are the mainstays of care. Meticulous attention to each of these is essential in the post neurosurgical patient as poor management can profoundly affect neurological outcome. Thus a robust perioperative plan is mandatory for management of the airway, control of blood pressure, and to ensure continuation of preoperative medication. Furthermore, the plan may entail elective creation of tracheostomy and percutaneous endoscopic gastrostomy. The early postoperative neurosurgical patient continues to require a high degree of clinical vigilance.     

Risperidone for the treatment of acute mania in children and adolescents with bipolar disorder: a randomized, double-blind, placebo-controlled study

Objectives:  To evaluate the efficacy, safety, and tolerability of risperidone monotherapy for the treatment of an acute mixed or manic episode in children and adolescents with bipolar I disorder.
Methods:  This randomized, placebo-controlled, double-blind, 3-arm study (N = 169) included children and adolescents (ages 10–17 years) with a DSM-IV diagnosis of bipolar I disorder, experiencing a manic or mixed episode. Study participants were randomized to placebo (n = 58), risperidone 0.5–2.5 mg/day (n = 50), or risperidone 3–6 mg/day (n = 61) for 3 weeks. The primary efficacy measure was change in Young Mania Rating Scale (YMRS) total score from baseline to end point. Safety assessments included adverse event (AE) monitoring and scores on extrapyramidal symptom rating scales.
Results:  Improvement in mean YMRS total score was significantly greater in risperidone-treated subjects than in placebo-treated subjects [mean change (SD) −9.1 (11.0) for placebo; −18.5 (9.7) for risperidone 0.5–2.5 mg (p < 0.001); −16.5 (10.3) for risperidone 3–6 mg (p < 0.001)]. The most common risperidone-associated AEs were somnolence, headache, and fatigue. Mean (SD) weight gain was 0.7 (1.9) kg, 1.9 (1.7) kg, and 1.4 (2.4) kg in the placebo, risperidone 0.5–2.5 mg, and risperidone 3–6 mg groups, respectively, during this 3-week study.
Conclusions:  At daily doses of 0.5–2.5 mg and 3–6 mg, risperidone was effective and well tolerated in children and adolescents experiencing acute manic or mixed episodes of bipolar I disorder. Results indicate that risperidone 0.5–2.5 mg has a better benefit–risk profile than risperidone 3–6 mg.