Group patient visits for Parkinson disease: a randomized feasibility trial.

BACKGROUND: Group patient visits are medical appointments shared among patients with a common medical condition. This care delivery method has demonstrated benefits for individuals with chronic conditions but has not been evaluated for Parkinson disease (PD). METHODS: We conducted a 12-month, randomized trial of group patient visits vs usual (one-on-one) care for patients with PD. Visits were led by one of 3 study physicians, included patients and caregivers, and lasted approximately 90 minutes. Those receiving group visits had 4 sessions over 12 months. The primary outcome measure was feasibility as measured by the ability to recruit participants and by the proportion of participants who completed the study. The primary efficacy outcome was quality of life as measured by the PD Questionnaire-39. RESULTS: Thirty patients and 27 caregivers enrolled in the study. Thirteen of the 15 patients randomized to group patient visits and 14 of the 15 randomized to usual care completed the study. Quality of life measured 12 months after baseline between the 2 groups was not different (25.9 points for group patient visits vs 26.0 points for usual care; p = 0.99). CONCLUSIONS: Group patient visits may be a feasible means of providing care to individuals with PD and may offer an alternative or complementary method of care delivery for some patients and physicians. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that group patient visits did not improve quality of life for individuals with PD over a 1-year period.

Managing antituberculosis drug therapy by therapeutic drug monitoring of rifampicin and isoniazid.

BACKGROUND: Current therapeutic regimens with rifampicin and isoniazid have proven successful in treating tuberculosis, however, toxicity, therapeutic failure, relapse and multiple drug resistance are serious concerns. Optimizing drug dose using therapeutic drug monitoring (TDM) may be a better approach than administering therapy as a standard dose. AIMS: To establish and evaluate a TDM service to optimize rifampicin and isoniazid therapy. METHODS: A TDM service for rifampicin and isoniazid was established in November 1998. Drug concentration data were collected, with relevant information to interpret the results. The reason for the request, information on concomitant drug administration and a questionnaire to assess clinical response to the drug results were also obtained. RESULTS: Ninety patient episodes were accepted for study. The rifampicin plasma concentrations showed significant scatter, with 46% of the rifampicin concentrations below the normal range and 2% above the normal range. Similarly, 48% of isoniazid concentrations were below the lower target of the normal range and 29% were above the upper normal limit. There was a greater proportion of isoniazid concentrations above the normal range in female patients. CONCLUSION: Significant pharmacokinetic variability was observed for rifampicin and isoniazid in the patient population studied. Further, a substantial number of plasma concentrations fell outside the suggested normal range for both drugs. Isoniazid plasma concentrations were significantly higher in female patients compared with male patients. Despite these abnormal results, the dose of rifampicin and isoniazid was altered in only 17% of patients, however, many patients received follow-up education because of the drug result. The service was considered valuable by 83% of respondents to the questionnaire. While TDM of rifampicin and isoniazid is a valuable tool to optimize the dose of these drugs in some patients, there is an urgent need for concentration-effect studies and possibly education on the principles and practice of TDM for these drugs.

Burow's solution in the treatment of active mucosal chronic suppurative otitis media: determining an effective dilution.

Burow's solution (13 per cent aluminium acetate) has been found to inhibit in vitro the growth of most commonly occurring bacteria found in the discharging ear. An in vitro study has shown that the minimum inhibitory concentration of Burow's solution for these organisms lies between a 1:80 and a 1:160 dilution. This paper reports on a clinical trial that incorporated 67 discharging ears to establish the most effective strength of aluminium acetate solution. There was no statistical difference in the effectiveness of full strength Burow's solution compared to 3.25 per cent aluminium acetate solution (a quarter strength Burow's solution). Response rates of 80.8 per cent and 75 per cent respectively following a two-week treatment period were achieved using these two solutions. A 1.3 per cent aluminium acetate solution (1/10 strength Burow's solution) was found to be markedly inferior. Bacteriological and audiological profiles were recorded for each patient.

A study of adaptive responses in cell signaling in migraine and cluster headache: correlations between headache type and changes in gene expression.

The project was an investigation into whether changes in the expression of G-proteins underlie altered cell signaling in migraine and cluster headache. The basis for this assumption is that altered physiological responses are seen in migraineurs and that differences in cell signaling are detected biochemically in various cell types isolated from peripheral blood. Levels of three G-protein mRNAs--Gs alpha, Gi alpha, and Gq alpha, were quantified in lymphocytes from clinically well-defined migraine and cluster headache patients and correlated with headache type and influence of drug treatment. Gi alpha mRNA was reduced by 50% in all migraine patients compared with control subjects; similarly in patients with or without aura, in patients with a migraine headache at the time of sampling, and patients in a quiescent state. No reduction in the levels of Gs alpha of Gq alpha mRNA were seen in migraine patients. A smaller reduction was seen in cluster headache patients, most marked in those without medication. Levels of Gs alpha mRNA were significantly reduced in cluster headache patients compared with migraine patients. The marked down-regulation of Gi alpha mRNA in migraine, whether quiescent or acute, indicates either an adaptive response to headache in this group of patients or that low levels of Gi alpha mRNA make individuals more susceptible to migraine.

Clinical and functional investigation of 10 missense mutations and a novel frameshift insertion mutation of the gene for copper-zinc superoxide dismutase in UK families with amyotrophic lateral sclerosis.

Mutations of the gene SOD-1, which encodes the enzyme copper-zinc superoxide dismutase, occur in patients with a familial form of amyotrophic lateral sclerosis (ALS). We investigated 71 families with more than one individual affected by ALS for clinical features and SOD-1 mutations. Mutations were identified in 14 families, indicating the presence of SOD-1 mutations in around 20% of this population. There were 10 different heterozygote missense point mutations in eight different codons, and a novel two-base frameshift insertion (132insTT), which leads to substitution of aspartic acid for glutamic acid at codon 132, and a premature stop codon at 133, with predicted truncation of the protein. SOD enzyme activity was reduced to around 50% of normal in individuals with SOD-1 mutations, and may be a useful predictor for the presence of these mutations. A predilection for disease onset in the lower limbs appears to be a distinguishing feature of familial ALS with SOD-1 mutations, and accords with findings in transgenic mouse models. In general, the finding of an SOD-1 mutation does not accurately predict a prognosis or disease severity.

Cellular adaptation in migraineurs with chronic daily headache.

Ergotamine and analgesic misuse are now recognized as causes of chronic daily headache and the condition responds well to drug withdrawal with reduced headache frequency. In this study, we have investigated whether medication misuse is associated with an alteration in membrane transduction which is sensitive to drug withdrawal. This was carried out by assay of the thrombin-stimulated generation of inositol phosphates in platelets from 12 migraine patients with chronic daily headache and analgesic misuse, 7 migraine patients with chronic daily headache and ergotamine misuse and 7 control subjects. After drug withdrawal, a significant decrease in headache frequency was seen at one month in both patient groups. Withdrawal of analgesics produced a significant decrease in thrombin-stimulated inositol phosphate production at one month; this was further decreased a month later with a reduction in Bmax of 60% and no significant change in KD. A similar pattern was obtained in ergot misuse patients, with the KD value decreasing by 56% one month after drug withdrawal. These results provide evidence of an adaptation in transduction with misuse of analgesics and ergotamine which correlates with headache frequency.

Excitotoxin induction of ornithine decarboxylase in cerebral cortex is reduced by phospholipase A2 inhibition.

The enzyme ornithine decarboxylase (ODC) has been shown to be induced by a number of conditions such as cold-injury, kindling, ischaemia and excitotoxin injection. In previous studies we have characterised the cortical response to kainate injection into the nucleus basalis and shown a substantial increase in both ODC mRNA and enzyme activity which reaches a maximum at 8h. This response is completely prevented by treatment with MK-801, indicating the involvement of NMDA receptors in mediating this response. Whilst NMDA receptors are known to gate a cation channel leading to increased calcium entry, an additional effect on the release of arachidonic acid has been reported. The possibility that NMDA receptor mediated activation of phospholipase A2 and release of arachidonic acid might mediate this ODC response was investigated in this study by treatment with the phospholipase inhibitors quinacrine and dexamethasone. Treatment of animals with quinacrine (100 mg/kg) at the time of injection of kainate into the nucleus basalis caused a significant attenuation of the induction of ODC in cerebral cortex of 43%. No further attenuation was seen at higher doses. A similar reduction in ODC induction was seen after treatment with dexamethasone (1 mg/kg) but a greater effect could be obtained (65% attenuation) at higher doses. The possible involvement of arachidonic acid derivatives in mediating ODC induction was further investigated by treatment with the cyclo-oxygenase inhibitor indomethacin and the lipoxygenase inhibitor nordihydroguaiaretic acid (NDGA). Indomethacin was able to significantly attenuate the induction of ODC (greater than 60%) whilst NDGA (30 mg/kg) was ineffective. These results indicate the possible role of arachidonic acid derivatives in the regulation of the expression of ODC in cerebral cortex after excitotoxin injection.

Reversal of neurotoxin-induced ornithine decarboxylase activity in rat cerebral cortex by nimodipine. A potential neuroprotective mechanism.

An increase in the activity of the enzyme ornithine decarboxylase has been shown to be associated with ischemia and other lesions of the nervous system. We have previously characterized the induction of ornithine decarboxylase in cerebral cortex following excitotoxin lesion of the nucleus basalis and have shown it to be sensitive to treatment with MK-801 up to 4 hours after the lesion and to be associated with an early increase in ornithine decarboxylase mRNA. In this study, we have used this model to investigate the effect of dihydropyridines on this response to lesion. Injection of 1 micrograms kainate into the nucleus basalis causes a large increase in ornithine decarboxylase activity that is maximal at 8 hours (292 pmol/mg/hr) when there is a 200-fold increase in ornithine decarboxylase activity compared with unoperated control animals (1.4 pmol/mg/hr). Treatment of animals with nimodipine either 5 minutes before or 60 minutes after lesion did not affect the maximal ornithine decarboxylase response at 8 hours. However, repeated injections (four of nimodipine, 10 mg/kg) significantly (p less than 0.001) attenuated the response to lesion by 75%. Injections were given 5 minutes before lesion and at 1.0, 3.5, and 6.0 hours after lesion. The efficacy of this treatment regimen indicated that maintaining a blockade of dihydropyridine-sensitive channels over this period was necessary to attenuate this induction of ornithine decarboxylase. To investigate the critical period over which dihydropyridines might be effective, their action at the earlier time point of 4 hours was tested where a significant induction of ornithine decarboxylase occurs (60 pmol/mg/hr).(ABSTRACT TRUNCATED AT 250 WORDS)

Modulation of gamma-aminobutyric acid release in cerebral cortex by fluoride, phorbol ester, and phosphodiesterase inhibitors: differential sensitivity of acetylcholine release to fluoride and K+ channel blockers.

In this study we have used fluoride as a tool to investigate the involvement of G protein-coupled effector systems in the regulation of the depolarization-induced release of gamma-aminobutyric acid (GABA) from rat cerebral cortex. To distinguish among the activating effects of NaF on G proteins linked to different effectors, such as adenylate cyclase, polyphosphoinositide phospholipase C, and K+ channels, agents specific to these effectors have been used in parallel. NaF induced a marked dose-dependent facilitation of the K(+)-evoked release of [14C]GABA, with an EC50 of 1.26 mM, increasing release by 103% at 5 mM NaF. No effect on basal release was seen up to 3 mM NaF, and no modulation of [3H]acetylcholine (ACh) release was seen up to 5 mM NaF. Phorbol 12,13-diacetate (PDA) produced a similar dose-dependent facilitation of the K(+)-evoked release of [14C]GABA, potentiating the release of [14C]GABA by 50% at 10 microM PDA. The phosphodiesterase inhibitors, 3-isobutyl-1-methylxanthine (IBMX) and theophylline, inhibited the K(+)-evoked release of [14C]GABA, and IBMX reversed the NaF facilitation of GABA release in a dose-dependent manner (pA2 2.57). The K+ channel blocker (IA current) tetrahydroaminoacridine (THA), which markedly inhibits the K(+)-evoked release of [14C]GABA, also reversed the NaF facilitatory effect, but the release of [3H]ACh was less sensitive to the inhibitory effect of THA. On the other hand, the K+ channel blocker, tetraethylammonium, which has no effect on the release of [14C]GABA, caused a significant facilitation of K(+)-evoked release of [3H]ACh. From these studies, it is concluded that GABA release in cerebral cortex is subject to regulation by G protein-linked effector systems that are distinct from those affecting the release of [3H]ACh in cerebral cortex.

Immunodiagnosis of sleeping sickness due to Trypanosoma brucei gambiense by detection of antiprocyclic antibodies and trypanosome antigens in patients' sera.

Documented sera from 39 Trypanosoma brucei gambiense sleeping sickness patients from Ivory Coast (Côte d'Ivoire) were tested using the Procyclic Agglutination Trypanosomiasis Test (PATT) for the presence of anti-trypanosome antibodies and using an antigen-capture double antibody enzyme-linked immunosorbent assay (ELISA) for the presence of trypanosomal antigens. All 39 sera contained antiprocyclic antibodies and trypanosome antigens whereas 5 control sera did not. The results show that the PATT (for antibody detection) and the double antibody ELISA (for antigen detection) are useful for immunodiagnosis of African sleeping sickness due to T.b. gambiense and that these assays should be simplified for further testing and evaluation in the field.

Inhibitory effect of 1,2,3,4-tetrahydro-9-aminoacridine on the depolarization-induced release of GABA from cerebral cortex.

1,2,3,4-Tetrahydro-9-aminoacridine (THA) has an inhibitory effect on the activity of acetylcholinesterase which has led to its use in the treatment of Alzheimer's disease. Other actions of THA include the inhibition of voltage-dependent ion channels. In this paper we describe the effect of THA on the depolarization-induced release of [14C]-gamma-aminobutyric acid (GABA) from tissue slices of rat cerebral cortex. THA produced a dose-dependent inhibition of the 30 mM K+-evoked release of [14C]-GABA with an IC50 of 56 microM. The maximal response was an 84% inhibition of the evoked response. THA (up to a concentration of 1 mM) had no effect on the basal release of GABA. A similar inhibitory effect on the K+-evoked release of [14C]-GABA was seen with 4-aminopyridine (4-AP) but no inhibition was obtained with tetraethylammonium up to a concentration of 20 mM. The maximal inhibitory effect of 4-AP (39%) occurred at 1 mM (IC50 of 112 microM) and this response was much smaller in magnitude than that obtained with THA.

Effect of lesion of the nucleus basalis of rat on acetylcholine release in cerebral cortex: time course of compensatory events.

Excitotoxin lesion of the nucleus basalis of the rat causes a substantial reduction in the K+-evoked release of [3H]acetylcholine (ACh) from tissue slices of ipsilateral frontal and parietal cortex. Decreases in the K+-evoked release of [3H]ACh (nCi/mg protein) of 71% and 47% are seen 21 days after lesion in the frontal and parietal cortex respectively. However, in later periods a considerable reversal of this deficit occurred which was complete in parietal cortex at 102 days, when the K+-evoked release of [3H]ACh was not significantly different from the controls. In the frontal cortex where a greater decrease in acetylcholinesterase (AChE) is obtained, a similar but attenuated reversal occurred, the K+-evoked release of [3H]ACh reaching 75% of the control value at 128 days after lesion. The compensatory changes in [3H]ACh release were paralleled by changes in AChE in both regions. Despite the reduced level of release following lesion, the K+-evoked release of [3H]ACh was responsive to the inhibitory effect of the cholinergic agonist, oxotremorine. Lesions outside the nucleus basalis produced no changes in the release of [3H]ACh from frontal or parietal cortex. All lesions were verified histologically. The compensatory changes reported are discussed in terms of the growth of 'sprouts' from the spared cholinergic axons. This study clearly demonstrates that compensatory changes in complex systems such as transmitter release which markedly affect cholinergic function do occur in response to lesion in common with other presynaptic parameters.

Use of procyclic trypanosomes for detection of antibodies in sera from vervet monkeys infected with Trypanosoma rhodesiense: an immunodiagnostic test for African sleeping sickness.

Uncoated procyclic culture forms of African trypanosomes were used in immunofluorescence and simple agglutination assays to detect antibodies in the sera of vervet monkeys infected with T. b. rhodesiense. Antibodies to procyclic surface antigens were found in sera from animals with active, untreated infections or sera taken soon after treatment with trypanocidal drugs. The antibodies were detectable within 7 days of infection. No specific antibodies were detected in sera prior to infection or long after drug cure. The results indicate that antigens expressed on the surface of procyclic culture forms of T. brucei spp. are useful for the detection of antibodies produced in response to infection with T. b. rhodesiense and may allow the development of a simple immunodiagnostic test for African sleeping sickness. In addition, the use of a form of the trypanosome of a different differentiation state from the infecting organism illustrates the utility of this approach for detection of antibodies to common antigens.

Stimulatory effect of N-methyl aspartate on locomotor activity and transmitter release from rat nucleus accumbens.

N-Methyl-aspartate (NMA), an agonist at central glutamate receptors, elicited prolonged and intense locomotor activity when injected into the nucleus accumbens septi (NAS) in subconvulsive doses (3-10 micrograms bilaterally). This effect was antagonised by intra-accumbens injection of the specific NMA antagonist, aminophosphonovaleric acid (APV) in a dose (3.0 micrograms bilaterally) that was without intrinsic effect when given on its own. Intra-accumbens injection of APV also suppressed locomotor hyperactivity elicited by intra-accumbens injection of DA (50 micrograms bilaterally) in rats pretreated with nialamide. In vitro release of [3H]-acetylcholine in accumbens tissue slices was significantly increased in the presence of NMA (30 microM) or N-methyl-D-aspartate (NMDA) (15 microM). Both effects were antagonised by APV (30 microM). Similar results were obtained with tissue slices of rat corpus striatum. These results suggest that locomotor stimulation by intra-accumbens NMA is mediated by an action on the mesolimbic dopaminergic neuron, either directly or via a cholinergic interneuron. In addition, activity at the glutamate synapse may be enhanced by the presence of DA affecting glutamate release and/or reuptake.

Muscarinic receptors discriminated by pirenzepine are involved in the regulation of neurotransmitter release in rat nucleus accumbens.

The effect of pirenzepine, a selective muscarinic antagonist, was tested on the oxotremorine facilitation of the K+-evoked release of [14C]-dopamine from tissue slices of rat nucleus accumbens. The effect of pirenzepine was compared with that of scopolamine and other antagonists which show no heterogeneity in their action on muscarinic receptors in order to determine whether a selective action at a single receptor subtype, M1 or M2, could be distinguished. Pirenzepine and scopolamine both antagonized the oxotremorine-induced (EC50 = 3 X 10(-7) M) facilitation of [14C]-dopamine release with pA2 values of 7.5 and 8.9 respectively. This result indicated that the high affinity pirenzepine receptor (M1) was involved in this response. Low concentrations of 3-quinuclidinyl benzilate (3 X 10(-10) M), N-methylscopolamine (3 X 10(-9) M) and methyl atropine (10(-8) M) also abolished this facilitatory effect of oxotremorine.

Analysis of muscarinic receptor concentration and subtypes following lesion of rat substantia innominata.

Cholinergic neurones located in the nucleus basalis of Meynert (NBM) in the substantia innominata (SI) of primates are known to project to cerebral cortex and cell loss in NBM is thought to be associated with the cholinergic deficit seen in Alzheimer's disease. We have examined in rats the effect of lesion of SI with kainate (1 microgram/0.5 microliter) on acetylcholine esterase (AChE) activity, muscarinic receptor number and subtypes in cerebral cortex at 1, 2 and 4 weeks. The area of lesion was assessed histologically. AChE activity was significantly reduced in frontal and parietal cortex ipsilateral to the lesion compared to the contralateral side by 37 and 30%, respectively, at 1 week. The reduction in parietal cortex at 4 weeks (16%) was significantly attenuated. Muscarinic receptor number was reduced in cerebral cortex ipsilateral to the lesion at the 3 time periods measured, being reduced by 14 and 17% in the frontal and parietal cortex, respectively, at 1 week. Changes in receptor number and AChE activity correlated with the size of lesion. Low affinity agonist binding sites and high affinity pirenzepine binding sites were also analyzed and found to be significantly reduced by lesion of SI. The proportions of high and low affinity agonist binding sites and subtypes of pirenzepine binding sites were, however, not significantly affected by lesion.

Nimodipine has an inhibitory action on neurotransmitter release from human cerebral arteries.

The effect of the dihydropyridine nimodipine was studied on the resting and K+-evoked release of [3H]acetylcholine (ACh) and [3H]5-hydroxytryptamine (5HT) from postmortem human cerebral arteries. Nimodipine, at a concentration of 30 microM, significantly reduced the K+-evoked release of [3H]ACh from anterior and middle cerebral arteries by 36 and 70%, respectively, and the K+-evoked release of [3H]5HT from basilar and middle cerebral arteries by 55 and 66%, respectively. The mode of action of nimodipine is interpreted in terms of a specific effect on the depolarisation-induced calcium current occurring in neuronal elements present in these preparations but absent from brain.