Missionaries, measles, and manuscripts: revisiting the Whitman tragedy.

The missionaries Marcus Whitman, a doctor, and Narcissa Whitman, his wife, and twelve other members of the Waiilatpu Mission were murdered in November 1847 by a small contingent of the Cayuse Indians in the Oregon Territory. The murders became known as the "Whitman Massacre." The authors examine the historical record, including archived correspondence held at the Yale University Libraries and elsewhere, for evidence of what motivated the killings and demonstrate that there were two valid perspectives, Cayuse and white. Hence, the event is better termed the "Whitman Tragedy." A crucial component, a highly lethal measles epidemic, has been called the spark that lit the fuse of the tragedy.

Quality of life for veterans with multiple sclerosis on disease-modifying agents: Relationship to disability.

Our objective was to compare self-reported health-related quality of life (HRQOL) for U.S. veterans with multiple sclerosis (MS) on disease-modifying agents with provider reports of HRQOL from standard disability measures. We conducted a 3-year prospective observational study of 204 subjects who used interferon beta or glatiramer acetate and compared subjects' responses on the Veterans Short-Form 36 (VSF-36) (36-item short-form functional status assessment for veterans) with the Kurtzke Expanded Disability Status Scale (EDSS) and the Functional System (FS) scales, which are standard MS disability scales. EDSS and FS scores were significantly correlated with some VSF-36 domains (physical function [r = -0.57], role physical [r = -0.37], and physical component summary [r = -0.40]) and weakly correlated with other domains. HRQOL scores did not predict disability or compliance with therapy. We observed decrements in HRQOL at relatively low disability levels. HRQOL measures directly associated with physical function were correlated with standard MS disability scales. Researchers need to clarify the role of HRQOL in clinical outcomes assessment, as shown by the lack of outcome sensitivity and predictive value of the VSF-36.

Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition.

BACKGROUND AND PURPOSE: To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease. SUMMARY OF REVIEW: A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors. CONCLUSIONS: There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.

Behavioral consequences of infections of the central nervous system: with emphasis on viral infections.

Infections of the central nervous system can damage the brain and cause abnormal behavior. In this article, the authors examine how behavior is affected by damage to different parts of the brain. They then focus on damage caused by specific infections of the brain and how these can result in abnormal behavior with legal consequences. Examples of such infections include neurosyphilis, encephalitis lethargica, herpes simplex encephalitis, and various other viral encephalitides, both acute and chronic. The AIDS dementia complex, which results from HIV infection of the brain, causes behavioral abnormalities in addition to motor and cognitive impairments. In some cases of violence and other criminal behavior, this can be a consequence of central nervous system infection, and the authors suggest that criminal sanctions in such events are inappropriate in the absence of volitional criminal intent.

Smallpox and smallpox vaccination: neurological implications.

Compulsory vaccination was discontinued in the U.S. in 1972; the world was declared free of smallpox infection in 1980. Since that time, no new smallpox infections have been recognized, and only limited numbers of military and laboratory personnel have been vaccinated. As a result, the majority of the U.S. and the world population have no or diminished immunity to smallpox. Widespread vaccination, beginning with the military and health care workers, is now being undertaken. Public health strategies for immunizing the general population include preexposure voluntary vaccination, case surveillance with ring vaccination, and mass vaccination at the time of attack. Cutaneous complications of vaccination occur in immunosuppressed subjects and in those with atopic dermatitis. Among the most serious complications is postvaccinal encephalomyelitis (PVEM). A related condition, postvaccinial encephalopathy (PVE), may be seen in children less than two years of age. There are no markers to predict who will develop PVEM. In the past, mortality was high, ranging from 10 to 50%. The neuropathology of PVEM suggested an immune-mediated attack on the CNS, but the target of the immune response is unknown. Comprehensive programs are needed for surveillance and confirming case definitions for neurologic complications. Multi-institutional controlled trials of antiviral and immune modulating therapy of PVEM should be considered. Neurologists should be actively involved in the planning process for vaccination programs and in the treatment of neurologic complications.