Predicting the outcome of anomia therapy for people with aphasia post CVA: Both language and cognitive status are key predictors

The aim of this study was to determine whether it was possible to predict therapy gain from participants' performance on background tests of language and cognitive ability. To do this, we amalgamated the assessment and therapy results from 33 people with aphasia following cerebral vascular accident (CVA), all of whom had received the same anomia therapy (based on progressive phonemic and orthographic cueing). Previous studies with smaller numbers of participants had found a possible relationship between anomia therapy performance and some language and cognitive assessments. Because this study had access to a larger data set than previous studies, we were able to replicate the previous findings and also to verify two overarching factors which were predictive of therapy gain: a cognitive factor and a phonological factor. The status of these two domains was able to predict both immediate and longer-term therapy gain. Pre-treatment naming ability also predicted gain after the anomia therapy. When combined, both cognitive and language (naming or phonological) skills were found to be independent predictors of therapy outcome.     

Coronary revascularization in multivessel disease. Which is better, stents or surgery?

Coronary artery disease (CAD) remains the major cardiovascular health issue in contemporary clinical practice. Treatment options for multivessel CAD include medical therapy, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Here, the authors review the most recent data that compare intracoronary stenting to CABG in multivessel disease. They address therapeutic issues surrounding proper selection of the optimal revascularization strategy and give special consideration to high-risk populations, such as patients with diabetes.     

Population pharmacokinetics of levodopa in patients with Parkinson's disease treated with tolcapone

OBJECTIVE: To use pharmacostatistical models to evaluate the overall exposure of patients with Parkinson's disease to levodopa in the presence and absence of tolcapone. METHODS: Four hundred twelve patients with Parkinson's disease with fluctuating and nonfluctuating responses to levodopa participated in three multicentered, parallel, double-blind, placebo-controlled dose-finding studies and received either placebo or tolcapone in addition to levodopa-decarboxylase inhibitor therapy. Sparse blood samples were obtained from 393 patients for levodopa and 3-O-methyldopa assay, and the data were analyzed with use of the NONMEM program. RESULTS: The fraction of levodopa metabolized to 3-O-methyldopa was substantially reduced by the co-administration of tolcapone (by 65%, 74%, and 84% with tolcapone doses of 50, 200, and 400 mg, respectively, in fluctuators, and by 50% and 90% with doses of 200 and 400 mg, respectively, in nonfluctuators). This led to an overall reduction in levodopa clearance (CL) of approximately 15% to 25% in fluctuators and 20% to 30% in nonfluctuators. Because this was partly compensated for by a reduction in levodopa dose in these studies, the total daily exposure of patients to levodopa was only slightly increased (11% to 16%). The peak-trough fluctuations of plasma levodopa (Cmax-Cmin) were reduced in both populations in a dose-dependent fashion. CONCLUSIONS: Tolcapone effectively inhibited the formation of 3-O-methyldopa and resulted in a decrease in levodopa CL. The consequent increase in levodopa bioavailability was mostly offset by reductions in levodopa dose. It is possible that decreased fluctuations in plasma levodopa concentrations rather than increased levodopa exposure may explain the clinical benefits obtained with tolcapone.     

Bronchoalveolar lavage macrophage and lymphocyte phenotypes in lung transplant recipients.

Recent publications have demonstrated potentially pathologic changes in bronchoalveolar lavage (BAL) from clinically stable lung transplant recipients (SLTRs), but there are few available data on alveolar macrophages (AMs). We formulated the hypothesis that changes in BAL AM and lymphocyte phenotypes would be apparent even in SLTRs.A cross-sectional study using a standardized 3 x 60 ml BAL, investigating lymphocyte and AM phenotypes in 19 SLTRs, 5 subjects with bronchiolitis obliterans syndrome (BOS) and 18 normal control volunteers. BAL lymphocyte and AM markers were assessed using flow cytometry.We confirmed a significant elevation of neutrophils in all lung transplant recipients with a more marked elevation in the BOS subjects. Flow-cytometric analysis showed increased numbers of natural killer (NK; CD56/CD16-positive) cells, increased CD11b- and CD11c-positive CD3 lymphocytes, increased CD8-positive lymphocytes and increased HLA-DR expression in CD8 cells from the lung transplant recipients, when compared with normals (p <.005). In contrast, the expression of a number of AM surface markers, associated with a range of host defense functions against bacteria, fungi and viruses (CD11a, CD11b, CD11c, HLA-DR, CD14), was lower in both SLTRs and those with BOS (p <.05).These novel findings are consistent with complex lymphocyte and macrophage changes that may result from clinically silent infection, partially suppressed rejection, or both.     

Clinical review: The critical care management of the burn patient

Between 4 and 22% of burn patients presenting to the emergency department are admitted to critical care. Burn injury is characterised by a hypermetabolic response with physiologic, catabolic and immune effects. Burn care has seen renewed interest in colloid resuscitation, a change in transfusion practice and the development of anti-catabolic therapies. A literature search was conducted with priority given to review articles, meta-analyses and well-designed large trials; paediatric studies were included where adult studies were lacking with the aim to review the advances in adult intensive care burn management and place them in the general context of day-to-day practical burn management.     

Imaging Findings in MR Imaging–Guided Focused Ultrasound Treatment for Patients with Essential Tremor

BACKGROUND AND PURPOSE:MR imaging–guided focused sonography surgery is a new stereotactic technique that uses high-intensity focused sonography to heat and ablate tissue. The goal of this study was to describe MR imaging findings pre- and post-ventralis intermedius nucleus lesioning by MR imaging–guided focused sonography as a treatment for essential tremor and to determine whether there was an association between these imaging features and the clinical response to MR imaging–guided focused sonography.MATERIALS AND METHODS:Fifteen patients with medication-refractory essential tremor prospectively gave consent; were enrolled in a single-site, FDA-approved pilot clinical trial; and were treated with transcranial MR imaging–guided focused sonography. MR imaging studies were obtained on a 3T scanner before the procedure and 24 hours, 1 week, 1 month, and 3 months following the procedure.RESULTS:On T2-weighted imaging, 3 time-dependent concentric zones were seen at the site of the focal spot. The inner 2 zones showed reduced ADC values at 24 hours in all patients except one. Diffusion had pseudonormalized by 1 month in all patients, when the cavity collapsed. Very mild postcontrast enhancement was seen at 24 hours and again at 1 month after MR imaging–guided focused sonography. The total lesion size and clinical response evolved inversely compared with each other (coefficient of correlation = 0.29, P value = .02).CONCLUSIONS:MR imaging–guided focused sonography can accurately ablate a precisely delineated target, with typical imaging findings seen in the days, weeks, and months following the treatment. Tremor control was optimal early when the lesion size and perilesional edema were maximal and was less later when the perilesional edema had resolved.

MR imaging–guided focused sonography surgery is a new stereotactic technique that uses high-intensity focused sonography to heat and ablate tissue rapidly under closed-loop image guidance and control throughout all steps of the intervention process. MR imaging allows precise intraprocedural localization of the ablation target, verification of safety margins for the sonography treatment, and real-time monitoring of thermal ablation dynamics.^1–7 MR imaging–guided focused sonography is now accepted in the treatment of soft-tissue disorders, including prostate cancer and uterine fibroids. Intracranial applications for brain tumors^8,9 and neuropathic pain syndromes^10,11 are currently under investigation. More recently, MR imaging–guided focused sonography was tested in a clinical trial as a treatment for essential tremor.Essential tremor is a common and disabling movement disorder with an estimated prevalence of 0.3%–5.55%.^12–17 Patients with essential tremor may suffer more from the mental effects on quality of life, such as lower perceived health status,¹⁸ than from actual physical symptoms.¹⁹ Essential tremor may be medically refractory: up to 30% of patients do not respond to first-line therapy and may consider surgical options.²⁰ Improved imaging and refined electrophysiologic localization have demonstrated that the ventralis intermedius nucleus (Vim) of the thalamus is the most effective target. The ventralis intermedius nucleus was the target for the MR imaging–guided focused sonography treatment in the clinical trial mentioned above.The goal of this study was to describe findings on MR imaging both pre- and post-Vim lesioning by MR imaging–guided focused sonography as a treatment for essential tremor in the 15 patients enrolled in the trial and to determine whether there was an association between these imaging features, the number and/or energy of sonications, and the clinical response to MR imaging–guided focused sonography.     

Roles assumed by a community coalition when creating environmental and policy‐level changes

A significant amount of federal, state, and local resources are spent organizing large‐scale community coalitions designed to address the issues of alcohol, tobacco, and other drug (ATOD) use in communities. Thus far, results regarding the effectiveness of community coalitions in reducing ATOD rates are mixed. This article discusses the importance of strategies designed to impact environmental‐level changes (e.g., policies, laws), which, in turn, can impact individual use. The development of prevention structures that consistently and continuously promote prevention efforts must be established before significant change in use rates can occur and be sustained. In order to identify the roles assumed by a coalition in order to affect policy‐level changes, this article examines the specific efforts of the Lexington/Richland Drug and Alcohol Abuse Coalition in Columbia, South Carolina. Review of meeting minutes and interviews with staff and coalition members suggest that the coalition assumed three central roles: developer, facilitator, and arbitrator. The coalition's success in influencing community policies and sanctions is attributed to its responsiveness and ability to assume diverse roles, depending on the specific needs of the community. Changes in policies/laws and sanctions are presented as evidence of the coalition's success in impacting and reinforcing community‐wide prevention structures thought to reduce the abuse of alcohol and other drugs. © 2003 Wiley Periodicals, Inc. J Comm Psychol 31: 661–670, 2003.