The Need of Support and Service Questionnaire (NSSQ): a brief scale to assess needs in clients with long-term mental disabilities

We present the Need of Support and Service Questionnaire (NSSQ), a new instrument developed to provide professionals in psychiatric care and community social services with a tool to assess needs of support and service in mentally disabled clients. The final version of the instrument was designed after comments from professionals in psychiatric care, community social services, and the clients and their relatives. A reliability study (test-retest, n=77), inter-rater (n=69) and a validity study (n=529) were performed. In the validity study, comparisons were done with the Camberwell Assessment of Need (CAN) scale, the Global Assessment of Functioning (GAF) scale and the Social and Occupational Functioning Assessment Scale (SOFAS). The test-retest and inter-rater reliability were 0.86 and 0.76, respectively. The percentage of agreement on the individual items ranged from 83.1% to 100.0% (test-retest) and 76.8% to 100.0% (inter-rater reliability). The corresponding kappa coefficients ranged from 0.63 to 1.00 (test-retest) and 0.33 to 1.00 (inter-rater reliability). The comparison between NSSQ and CAN items demonstrated high sensitivity and specificity as well as satisfactory likelihood ratios (LRs). The correlations between GAF and SOFAS scores and the number of needs of support, number of needs of service and the total number of needs of support and service were -0.49, -0.32 and -0.47, and -0.48, -0.26 and -0.45, respectively. All correlations were statistically significant (P<0.01). The results demonstrated that the psychometric characteristics of the NSSQ were satisfactory. Moreover, professionals without any formal training easily used it.     

Management of acute cerebellar stroke

Acute cerebellar infarction or hemorrhage may initially manifest in a clinically indolent manner only to later deteriorate into a life-threatening neurologic catastrophe. At the other end of the spectrum, some patients with cerebellar stroke may present in a moribund comatose state. In both patient groups, it is often unclear at what point surgical intervention should be considered either to prevent further neurologic deterioration or to try to salvage a meaningful neurologic recovery. In this review, we present clinical cases that illustrate decision points in the management of patients with acute cerebellar stroke, with emphasis on clinical and imaging characteristics. We conclude with an analysis of clinical decision making in the management of patients with space-occupying cerebellar stroke. The management of acute cerebellar infarction or hemorrhage often requires difficult and prompt decisions by treating neurologists, and certain easily identifiable clinical and imaging findings may assist in appropriate patient triage and timely neurosurgical intervention.     

Instability of the DSM-IV Subtypes of ADHD from preschool through elementary school

CONTEXT: The DSM-IV definition of attention-deficit/hyperactivity disorder (ADHD) distinguished 3 subtypes that had not been extensively studied. OBJECTIVE: To determine whether the ADHD subtypes are stable enough over time to be valid. DESIGN: Longitudinal study with a greater-than 89% retention rate in 7 assessments over 8 years. SETTING: Outpatient clinics. PARTICIPANTS: Volunteer sample of 118 4- to 6-year-olds who met DSM-IV criteria for ADHD, including impairment in 2 settings in at least 1 assessment. MAIN OUTCOME MEASURE: Meeting DSM-IV criteria for the subtypes of ADHD during years 2 through 8. RESULTS: The number of children who met criteria for ADHD declined over time, but most persisted. Children who met criteria for the combined subtype (CT, n = 83) met criteria for ADHD in more subsequent assessments than children in the predominantly hyperactive-impulsive subtype (HT, n = 23). Thirty-one (37%) of 83 CT children and 6 (50%) of 12 children in the predominantly inattentive subtype (IT) met criteria for a different subtype at least twice in the next 6 assessments. Children of the HT subtype were even more likely to shift to a different subtype over time, with HT children who persisted in ADHD mostly shifting to CT in later assessments. The subtypes exhibited consistently different mean levels of hyperactive-impulsive symptoms during years 2 through 8 that corresponded with their initial subtype classifications, but initial subtype differences in inattention symptoms diminished in later years. CONCLUSIONS: In younger children, the CT and IT may be stable enough to segregate groups for research, but they seem too unstable for use in the clinical assessment of individual children. Children rarely remain in the HT classification over time; rather, they sometimes desist from ADHD but mostly shift to CT in later years. Using continuous ratings of hyperactivity-impulsivity symptoms as a diagnostic qualifier should be considered as an alternative to classifying nominal subtypes of ADHD in DSM-V.     

Micro-computed tomography of the lungs and pulmonary-vascular system

Three-dimensional imaging of the intact lung and its vasculature is essential if the hierarchical and volumetric aspects of its structures and functions are to be quantitated. Although this is possible with clinical multislice helical CT scanners, the spatial resolution does not scale down adequately for small rodents for which cubic voxel dimensions of 50-100 microm are required. Micro-computed tomography (micro-CT) provides the necessary spatial resolution of 3D images of the intact thoracic contents. Micro-CT can provide higher resolution so that basic micro-architectural structures, such as alveoli, can be individually visualized and quantitated. Dynamic events, such as the respiratory and cardiac cycles, can be imaged at multiple time points throughout a representative cycle by coordinating the scan sequence (i.e., gating) to the cycle phase of a sequence of cycles. Fusion of the micro-CT image data with other image data, such as micro-SPECT or histology, can enhance the information content beyond the mainly structural information provided by micro-CT. Conventional attenuation-based X-ray imaging can involve significant X-ray exposures at high spatial resolutions, and this could affect the phenotype (e.g., via interstitial fibrosis) and genotype (e.g., via mutation), so its use in longitudinal studies using micro-CT may be limited in some cases. However, because of recent developments in which the phase shift or refraction of X-rays rather than attenuation is used, the X-ray exposure may be significantly reduced.     

Genes mediating environment interactions in type 1 diabetes

The relative risk of type 1 (autoimmune) diabetes mellitus for a sibling of an affected patient is fifteen times that of the general population, indicating a strong genetic contribution to the disease. Yet, the incidence of diabetes in most Western communities has doubled every fifteen years since the Second World War - a rate of increase that can only possibly be explained by a major etiological effect of environment. Here, the authors provide a selective review of risk factors identified to date. Recent reports of linkage of type 1 diabetes to genes encoding pathogen pattern recognition molecules, such as toll-like receptors, are discussed, providing a testable hypothesis regarding a mechanism by which genetic and environmental influences on disease progress are integrated.     

A psychophysical study of visual extinction: ipsilesional distractor interference with contralesional orientation thresholds in visual hemineglect patients

Visual extinction was investigated in left (n=15) and right (n=25) brain-damaged patients with or without visual neglect, and in normal control subjects (n=14), using a psychophysical paradigm. Orientation discrimination thresholds were determined for both left and right hemifield gratings presented either in isolation or simultaneously with a contralateral distractor grating. To minimize the influence of possible sensory-perceptual deficits, the luminances of both target and distractor gratings were chosen to be 20 times the luminances necessary to discriminate between horizontal and vertical grating orientations. The location of the target grating was always cued, making the distractor grating task irrelevant. Even after equalizing the visibility of left and right hemifield stimuli, neglect patients still displayed an increased interference effect from an ipsilesional distractor (and no interference from a contralesional distractor). Left or right brain-damaged controls did not show this asymmetric interference of irrelevant distractors, even the patients who demonstrated extinction on standard extinction testing. This suggests that visual extinction is a critical component of the visual neglect syndrome and that it involves an attentional deficit.     

Electrophysiological signs of permanent axonal loss in a follow-up study of patients with Guillain-Barré syndrome

The neurophysiological mechanisms for persisting impairment of motor function after Guillain-Barre syndrome (GBS) were assessed in 37 unselected patients 1-13 years after diagnosis. For evaluation of reinnervation and axonal loss, macroelectromyography (macro-EMG) including measurement of fiber density (FD) was performed. Data from neuropathy symptom score, neuropathy disability score, nerve conduction studies, and quantitative sensory examination were ranked and summed to a neuropathy rank sum score (NRSS). The isokinetic muscle strength at the ankle was measured. Signs of axonal loss with increase of either macro motor unit potential (macro-MUP) amplitude or FD occurred in 76% of patients. The macro-MUP amplitude correlated with muscle strength and with NRSS. Patients with evidence of residual neuropathy had increased macro-MUP amplitude and FD as well as decreased muscle strength compared to patients without evidence of residual neuropathy. We conclude that axonal loss takes place in a substantial number of GBS patients and is associated with permanent muscle weakness caused by insufficient reinnervation. Possible patterns of pathology are discussed in relation to the macro-EMG findings.     

Intravenous immunoglobulin ameliorates experimental autoimmune encephalomyelitis and reduces neuropathological abnormalities when administered prophylactically

BACKGROUND AND METHODS: Immunomodulation with intravenous immunoglobulin (IVIG) represents a way of interfering with the disease process in multiple sclerosis (MS). In this study, the effects of IVIG on neurological symptoms and central nervous system (CNS) pathology were evaluated in experimental autoimmune encephalomyelitis (EAE), an MS animal model. EAE was induced in susceptible Dark Agouti rats by active immunization with a spinal cord homogenate, and infusions of 1 g/kg IVIG were given prophylactically or therapeutically.RESULTS: The administration of IVIG at the time of immunization significantly suppressed the development of neurological symptoms compared with infusions of placebo (mean EAE score 0.6+/-0.3 versus 2.3+/-0.4). Moreover, the prophylactic IVIG administration resulted in a significant inhibition of the inflammatory response in CNS tissue (inflammation score 1.1+/-0.2 versus 1.8+/-0.2 after placebo). No beneficial effects were obtained by therapeutic IVIG infusions as the EAE disease course and the degree of inflammation and demyelination in the CNS were not different from animals receiving treatment with placebo.CONCLUSIONS: The present study indicates that IVIG reduces the symptoms of EAE by suppression of the CNS inflammation that characterizes CNS pathology in these animals. Taking into account data from clinical trials of IVIG in MS, the results further suggest that IVIG acts primarily during the induction phase of the immune response thus preventing the development of relapses in MS.