Evaluation of a measurement strategy for Parkinson's disease: assessing patient health-related quality of life.

This study evaluated the feasibility and psychometric properties of self-completed and telephone interview versions of a patient health-related quality-of-life (HQL) questionnaire for Parkinson's disease that included the SF-36 Health Survey (SF-36), the Parkinson's Disease Questionnaire (PDQ-39), and the Medical Outcomes Study Sexual Function Survey. Parkinson's disease patients (n = 150) completed the questionnaire twice: once at the study site and once over the telephone in a randomized order. Ninety-four percent of enrolled patients completed the first HQL assessment and 88% completed both assessments. Cronbach's alpha exceeded 0.70 for all scales except for the self-completed PDQ-39 Social Support subscale (0.57) and the telephone interview PDQ-39 Social Support (0.60) and Cognitions (0.67) subscales and the SF-36 General Health (0.60) and Social Function (0.61) subscales. There were no statistically significant differences in mean HQL scale scores across the two modes of administration. Mean scores for 3 of the PDQ-39 subscales and the Summary Index were significantly poorer (p < 0.05) for patients at later clinical stages. Similarly, patients with dyskinesias reported significantly poorer scores for 4 of the PDQ-39 subscales and the Summary Index and patients with self-reported comorbidities reported poorer SF-36 Physical Function and General Health subscale scores than patients without dyskinesias and comorbidities, respectively. This study suggests that the self-completed and telephone interview versions of the patient HQL questionnaire are feasible and valid for future clinical trial applications.

A multicenter trial on the efficacy of using tirilazad mesylate in cases of head injury.

OBJECT: The authors prospectively studied the efficacy of tirilazad mesylate, a novel aminosteroid, in humans with head injuries. METHODS: A cohort of 1120 head-injured patients received at least one dose of study medication (tirilazad or placebo). Eighty-five percent (957) of the patients had suffered a severe head injury (Glasgow Coma Scale [GCS] score 4-8) and 15% (163) had sustained a moderate head injury (GCS score 9-12). Six-month outcomes for the tirilazad- and placebo-treated groups for the Glasgow Outcome Scale categories of both good recovery and death showed no significant difference (good recovery in the tirilazad-treated group was 39% compared with the placebo group in which it was 42% [p=0.461]; death in the tirilazad-treated group occurred in 26% of patients compared with the placebo group, in which it occurred in 25% [p=0.750]). Subgroup analysis suggested that tirilazad mesylate may be effective in reducing mortality rates in males suffering from severe head injury with accompanying traumatic subarachnoid hemorrhage (death in the tirilazad-treated group occurred in 34% of patients; in the placebo group it occurred in 43% [p=0.026]). No significant differences in frequency or types of serious adverse events were shown between the treatment and placebo groups. CONCLUSIONS: Striking problems with imbalance concerning basic prognostic variables were observed in spite of the large population studied. These imbalances concerned pretreatment hypotension, pretreatment hypoxia, and the incidence of epidural hematomas. In future trials of pharmacological therapy for severe head injury, serious consideration must be given to alternative randomization strategies. Given the heterogeneous nature of head injury and the identification of populations that do relatively well with standard therapy, target populations with a higher risk for mortality and morbidity may be more suitable for clinical trials of such agents.

Methylprednisolone and membrane properties of primary cultures of mouse spinal cord.

The present study attempts to define the capacity of methylprednisolone sodium succinate (MP) to protect neuronal membranes against a free radical challenge in primary cultures of fetal mouse spinal cord. Incubation of these cultures with MP significantly increased the Na+,K(+)-ATPase activity, an effect that was blocked by the RNA synthesis inhibitor, actinomysin D and the protein synthesis inhibitor, cycloheximide, suggesting an induction of protein synthesis by MP. In contrast, incubation with FeCl2 for 1 or 2 h significantly inhibited Na+,K(+)-ATPase activity and elevated the levels of thiobarbituric acid-reactive substances (TBARS). Pretreatment with MP prevented the rise in TBARS and partially prevented the decrease in Na+,K(+)-ATPase activity for the first hour of FeCl2 incubation, an effect that was lost during the second hour. A second dose of MP after the first hour of incubation with FeCl2 partially restored Na+,K(+)-ATPase activity and reduced TBARS levels after the second hour of exposure to FeCl2. Co-incubation of MP with cycloheximide completely prevented the decrease in Na+,K(+)-ATPase activity seen after a 2-h incubation with FeCl2 and eliminated the need for a second dose of MP after the first hour of incubation with FeCl2. These findings suggest a capacity for rapid protein induction and antioxidant activity for MP in vitro.

The kappa opioid-related anticonvulsants U-50488H and U-54494A attenuate N-methyl-D-aspartate induced brain injury in the neonatal rat.

The neuroprotective effects of the kappa opioid-related anticonvulsants U-50488H and U-54494A were tested in a model of N-methyl-D-aspartate (NMDA)-induced brain injury in the neonatal rat. Seven-day-old rat pups were injected intracerebrally with 7.5 nmol NMDA. Five days later, the ensuing unilateral hemisphere weight reduction was measured and used to assess the severity of insult. Control animals (n = 85) exhibited a 21.7 +/- 0.5% hemisphere weight reduction. Animals treated with U-54494A in split doses before and after NMDA administration showed significant neuroprotection at 10, 15, and 20 mg/kg, with the maximum effect observed at 15 mg/kg (33.8% protection). Animals treated with U-50488H on a similar dosing schedule showed significant neuroprotection at all doses tested, with peak protection observed at 30 mg/kg (51.8% protection). Both compounds exhibited a neuroprotective effect when hemisphere cross-sectional area and hippocampal histology were assessed. Treatment with U-54494A after NMDA administration also afforded neuroprotection at various doses, as measured by hemisphere weight disparity, with peak protection occurring at a dose of 20 mg/kg (32.4% protection). These data show that both U-50488H and U-54494A afford neuroprotection against NMDA-induced neuronal injury in the neonatal rat brain.

U-78517F: a potent inhibitor of lipid peroxidation with activity in experimental brain injury and ischemia.

U-78517F (2-[4-[2,6-di-(1-pyrrolidinyl)-4-pyridinyl)-1-piperazinyl] methyl]-3,4-dihydro-2,5,7,8-tetramethyl-2H-1-benzopyran-6-ol, dihydrochloride), which combines the antioxidant ring portion of alpha-tocopherol together with the amine of the previously described 21-aminosteroids (e.g., U-74006F), is a novel inhibitor of iron-catalyzed lipid peroxidation. U-78517F was found to have a 50% inhibitory concentration (IC50) of 0.6 microM against 200 microM ferrous chloride-initiated lipid peroxidation in rat brain homogenates, compared to 8 microM for U-74006F, 28 microM for alpha-tocopherol and 43 microM for the ring portion of alpha-tocopherol (i.e., trolox). Both stereoisomers of the racemic U-78517F proved to be equally active antioxidants. Against lipid peroxidation initiated by xanthine/xanthine oxidase, U-78517F was even more potent, with an IC50 of 0.01 microM. U-78517F was also observed to protect cultured mouse spinal neurons against iron-induced damage, with an IC50 of approximately 0.5 microM. When administered to male CF-1 mice i.v. at 5 min after a severe concussive head injury. U-78517F produced a dose-related improvement in the 1-hr neurological recovery. The minimum effective i.v. dose was 1.0 micrograms/kg. Measurement of U-78517 concentrations in the brains of mice after administration of a 10-mg/kg i.v. dose revealed effective antioxidant levels for as long as 2 hr. Evidence of an in vivo antioxidant action was provided by the attenuation of iron-induced blood-brain barrier disruption (i.e., Evans' blue extravasation) in rats pretreated with U-78517F.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of delayed administration of U74006F (tirilazad mesylate) on recovery of locomotor function after experimental spinal cord injury.

Beginning at either 30 minutes, 2 hours, 4 hours, or 8 hours after 180 g compression of the cat L2 spinal cord for 5 minutes, infusion of U74006F was initiated. In this series, the cats received a total U74006F dose of 5 mg/kg/48 hours. An additional group of injured cats was treated at 8 hours postinjury with a three-fold higher dose of U74006F (i.e., a total 48-hour dose of 15 mg/kg). Controls received an equal volume of vehicle (citrate-buffered saline) delivered over 48 hours. The cats were evaluated weekly for 4 weeks for recovery of overground locomotion based on an 11-point scale by an investigator blinded to the time and type (i.e., vehicle or drug) of material administered. By 4 weeks postinjury, there was no significant difference in the locomotor recovery of cats that received U74006F at either 30 minutes, 2 hours, 4 hours, or 8 hours after injury. However, only recovery in the groups treated at 30 minutes, 2 hours, or 4 hours after injury was significantly greater than vehicle-treated controls. Locomotor function in cats receiving either 5 mg/kg/48 hours or 15 mg/kg/48 hours of U74006F at 8 hours postinjury was not significantly different from that of the vehicle-treated animals. Mean (+/- SEM) 4-week recovery scores were 6.8 +/- 0.9, 5.9 +/- 1.0, 7.2 +/- 1.1, and 4.7 +/- 2.9 out of 11 for cats treated at 30 minutes, 2 hours, 4 hours, or 8 hours postinjury, respectively, with the 5 mg/kg/48 hour dose. The mean recovery score for cats treated at 8 hours after injury with the 15 mg/kg/48 hour dose was 3.4 +/- 1.8. The average score for the vehicle-treated controls was 1.8 +/- 0.8. These findings demonstrate that U74006F can significantly protect locomotor function in our model of compression spinal cord injury if administered as late as 4 hours postinjury. Delaying administration of the compound to 8 hours after injury results in considerable loss of its protective capabilities even if the dose is increased threefold.

Stimulation of mono- and diacylglycerol lipase activities by bradykinin in neural cultures.

Neural cultures of fetal mouse spinal cord, mouse neuroblastoma (N1E-115) and mixed primary glial cell cultures from neonatal rat brain display measurable activities of mono- and diacylglycerol lipases. Treatment of fetal mouse spinal cord cultures with bradykinin (10 nM) for 1-4 min resulted in a marked increase in specific activities of mono- and diacylglycerol lipases. This is the first direct demonstration that bradykinin can act through the lipase pathway. The increase in activities of lipases was dose and time dependent. The bradykinin response was blocked by [Thi5,8, D-Phe7]bradykinin, a bradykinin B-2 receptor antagonist, indicating that the bradykinin induced stimulation of lipase activities involves bradykinin receptors.

Thyrotropin-releasing hormone has profound presynaptic action on cultured spinal cord neurons.

Thyrotropin-releasing hormone (TRH) receptors are widely distributed throughout the nervous system. In particular, both the dorsal and the ventral horn (VH) neurons contain a rich distribution of TRH receptors, and TRH application to these sites has profound physiological effects. Currently the mechanism of action of TRH is not known. We examined the effect of TRH on ventral horn neurons using intracellular and patch-clamp techniques. Our results indicate that TRH application profoundly increases the firing rate of VH cells by decreasing membrane conductance. More importantly, TRH causes a significant increase in frequency and amplitude of postsynaptic potentials. Under voltage-clamp condition, TRH reduces holding current and causes a significant increase in the rate of occurrence and the amplitude of excitatory postsynaptic currents (EPSCs), an effect that lasts for more than 5 minutes. This effect of TRH is not observed in cultured neurons pretreated with tetanus toxin. TRH also fails to alter the characteristics of the EPSCs when it is applied to a region of the cell that is sparsely innervated. These results provide strong evidence that presynaptic mechanisms have a significant role in the excitatory effect of TRH on the VH neurons. Because there is evidence that trophic factors are released from presynaptic terminals, by increasing synaptic activity, TRH can have a trophic influence on the spinal cord neurons. In addition, because there are a significant number of TRH containing neurons within the spinal cord, it is likely that TRH has a major role in information processing within the spinal cord.

Effects of treatment with U-74006F on neurological outcome following experimental spinal cord injury.

The compound U-74006F is one of a series of 21-aminosteroids that lack glucocorticoid or mineralocorticoid activity. These potent inhibitors of lipid peroxidation have been specifically developed for the acute treatment of central nervous system trauma and ischemia. This study evaluated the dose-response characteristics and capability of U-74006F to promote functional recovery in cats subjected to compression trauma of the upper lumbar (L-2) spinal cord. Thirty minutes following injury, randomized and investigator-blinded treatment was initiated with the intravenous administration of either vehicle (citrate-buffered saline) or one of eight doses of U-74006F. Initial doses of U-74006F ranged from 0.01 to 30 mg/kg. Subsequent doses consisted of intravenous bolus injections followed by a continuous 42-hour intravenous infusion. Over the 48-hour treatment period, cats received total U-74006F doses ranging from 0.048 to 160 mg/kg. The animals were evaluated weekly for neurological recovery based upon an 11-point behavioral scale. With the exception of two cats in one group, the animals receiving accumulated doses of U-74006F (ranging from 1.6 to 160.0 mg/kg/48 hrs) exhibited nearly 75% of normal neurological function by 4 weeks after injury. Lower total doses of 0.16 and 0.48 mg/kg/48 hrs were associated with approximately 50% return of normal function, which was not significantly better than the recovery in the vehicle-treated control group. The lowest total dose tested (0.048 mg/kg/48 hrs) gave results indistinguishable from those in vehicle-treated cats, which had recovered only 20% of their preinjury neurological function by 4 weeks. These findings demonstrate that over a 100-fold range of doses, U-74006F has a remarkable capacity to promote functional recovery in spinal cord-injured cats.

Pretreatment with alpha tocopherol enhances neurologic recovery after experimental spinal cord compression injury.

Lipid hydrolysis with subsequent production of eicosanoids and lipid peroxidation are two of the earliest potentially pathochemical events induced in spinal cord tissue by mechanical trauma. Although these membrane lipid disturbances are thought to contribute to the paralysis that occur subsequent to spinal cord injury, such a correlation has not been demonstrated directly. Consequently, the purpose of this study was to test the capacity of alpha tocopherol, the major lipid antioxidant in cellular membranes and a compound that limits the injury-induced lipid hydrolysis and peroxidation in spinal cord tissue, to promote functional recovery in a static loading model of spinal cord injury. After laminectomy, the L2 spinal cord of cats was compressed with 180 g for 5 min. For 5 days before injury and for 5 days postinjury, treated cats received orally 1000 IUD-alpha tocopherol acetate daily. Control cats were similarly injured but untreated. All cats were blindly evaluated weekly for 4 weeks for their neurologic recovery based on an 11 point behavioral scale that assessed walking, running, and stair climbing. By the second postinjury week, alpha tocopherol-pretreated cats demonstrated significantly better recovery than untreated controls. By 4 weeks, treated cats had recovered 72% of their preinjury function as compared with 20% for untreated controls, i.e., a 3.5-fold difference. These results strongly suggest that lipid peroxidation and/or hydrolysis is primarily involved in the genesis of posttraumatic paralysis and that alpha tocopherol exerts its protection of injured spinal cord tissue, at least in part, by its antioxidant and/or antilipolytic activity.

Early membrane lipid changes in laminectomized and traumatized cat spinal cord.

The effects of surgical exposure (laminectomy) and compression trauma on various aspects of membrane lipid metabolism in the feline spinal cord were determined in this study. Tissue samples were frozen in situ and grossly dissected into gray and white portions prior to lipid analyses. Laminectomy alone resulted in measurable changes in spinal cord lipid metabolism, including increases in gray matter free fatty acids, diacylglycerols, and eicosanoids. A 90-min recovery period greatly reduced the levels of these compounds. Compression of the spinal cord with a 170-g weight (following a 90-min recovery period) caused very large increases in gray matter free fatty acids, diacylglycerols, and eicosanoids, and decreases in cholesterol and ethanolamine plasmalogens. Similar, but time delayed changes in these compounds were also observed in white matter.

Evaluation of an intensive methylprednisolone sodium succinate dosing regimen in experimental spinal cord injury.

Beginning 30 minutes after compression trauma of the upper lumbar (L-2) spinal cord, cats were treated with either a high-dose regimen of methylprednisolone (MP) administered as the sodium salt of the 21-succinate ester (Solu-Medrol sterile powder) or the MP vehicle. Animals were randomly assigned to either treatment group (10 cats per group), and all personnel were blind as to which animals received vehicle or drug. The intensive 48-hour dosing regimen was designed to maintain therapeutic tissue levels of MP and consisted of an initial 30 mg/kg intravenous bolus of MP; 2 and 6 hours later additional 15 mg/kg MP doses were administered by intravenous bolus. Immediately following the bolus given at 6 hours, a continuous MP infusion of 2.5 mg/kg/hr was started. The infusion was stopped abruptly at 48 hours with no dose tapering. Animals in the vehicle group received an equivalent volume of MP vehicle. The total MP dose administered over 48 hours was 165 mg/kg. Animals were evaluated weekly for neurological recovery based upon a 12-point functional scale which assessed general mobility, running, and stair-climbing. Mean recovery scores at 1 month after injury (+/- standard error of the mean) were: vehicle group (seven cats) 3.7 +/- 0.9, and MP group (10 cats) 8.7 +/- 0.2; (p less than 0.001). Histological evaluation of the spinal cords revealed a strong negative correlation between neurological recovery and size of the spinal cord cavity at 1 month (r = -0.88). Three of 10 animals in the vehicle group became ill and had to be dropped from the study, whereas all of the 10 MP-treated animals survived in excellent health. The results demonstrate the therapeutic effectiveness and low incidence of side effects associated with an intensive MP dose regimen for treatment of experimental spinal cord injury.

Effects of methylprednisolone and the combination of alpha-tocopherol and selenium on arachidonic acid metabolism and lipid peroxidation in traumatized spinal cord tissue.

Traumatic injury of the spinal cord leads to a series of pathological events that result in tissue necrosis and paralysis. Among the earliest biochemical reactions are hydrolysis of fatty acids from membrane phospholipids, production of biologically active eicosanoids, and peroxidation of lipids. This study examines the effect of agents purported to improve recovery following spinal cord trauma, methylprednisolone sodium succinate (MPSS) and the combination of alpha-tocopherol and selenium (Se), on the posttraumatic alterations of membrane lipid metabolism. Pretreatment with either MPSS or alpha-tocopherol and Se reduced the trauma-induced release of total FFA including arachidonate in the injured spinal cord tissue. In addition, these agents decreased the postinjury levels of prostanoids. Pretreatment with either MPSS or alpha-tocopherol and Se also completely prevented the trauma-induced loss of cholesterol while inhibiting the increase of a cholesterol peroxidation product, 25-hydroxycholesterol. These data suggest that: perturbation of membrane lipid metabolism may contribute to the tissue necrosis and functional deficit of spinal cord injury and MPSS or the combination of alpha-tocopherol and Se may protect injured spinal cord tissue, at least in part, by limiting these posttraumatic membrane lipid changes.

Bromocriptine treatment of neuroleptic malignant syndrome.

Five patients with neuroleptic malignant syndrome were treated with bromocriptine mesylate 7.5-45 mg/day in three divided doses for at least 10 days. Response to therapy was assessed by monitoring vital signs and serum creatine kinase (CK) levels. In addition, a disability score was determined using a scale based on variables assessed on neurologic examinations. In all five patients, significant improvement was noted 24-72 hours after initiation of bromocriptine treatment and was accompanied in four patients by a rapid drop in serum CK levels. Resolution of confusion and mutism was noted within 24-48 hours after treatment. Normalization of vital signs occurred within 48 hours to 4 days, and resolution of extrapyramidal rigidity occurred within 1 week. In two patients, early discontinuation of bromocriptine resulted in relapse of neuroleptic malignant syndrome, which responded to reinstitution of the drug. The results suggest a therapeutic role for bromocriptine in the treatment of neuroleptic malignant syndrome.

Thrombin interactions with central nervous system tissue and implications of these interactions.

A monospecific antibody was developed to human alpha-thrombin. This antibody stained neurons but not astrocytes in murine spinal cord cultures incubated with 1-10 nM alpha-thrombin using the avidin-biotin-peroxidase technique. Staining did not occur when the primary or linking antibodies were eliminated, and staining was blocked with hirudin. Preliminary studies showed release of arachidonic acid from the cultures when exposed to thrombin. It was proposed that arachidonate release from the membranes of neurons upon exposure to thrombin was similar to that observed in platelets, for example, by activation of phospholipases. Moreover, prostanoids were formed that could have a deleterious effect on cellular elements in the central nervous system. The potential role of thrombin receptors on neurons was discussed.

Delay in the absolute latency of auditory brainstem response (ABR) component P1 in acute inflammatory demyelinating disease.

A patient with an acute inflammatory demyelinating disease and bilateral involvement of the peripheral (i.e. extracranial) portion of the VIII n. is described. The diagnosis of VIII n. involvement was made on the basis of grossly prolonged Auditory Brainstem Response (ABR) component P1 latencies which resolved to normal latencies in one year. It is suggested that involvement of the peripheral myelin is not uncommon in central demyelinating disease even in the absence of auditory system complaints.

Mechanical damage to murine neuronal-enriched cultures during harvesting: effects on free fatty acids, diglycerides, Na+,K+-ATPase, and lipid peroxidation.

The most commonly used procedure to harvest cultured cells from petri dishes is to scrape the cells off the plates with a rubber or Teflon policeman. However, the results reported herein demonstrate that this technique, with its associated mechanical trauma, significantly perturbed cell membranes in neuronal-enriched cultures derived from the ventral half of fetal murine spinal cords. This is evidenced by liberation of free fatty acids and diglycerides, partial inhibition of Na+,K+-ATPase activity, and increased malondialdehyde production. Harvesting the cells by freezing, either on liquid nitrogen or dry ice, significantly attenuated these effects. This important observation indicates that mechanical manipulation of cultured cells during harvesting significantly affects subsequent biochemical analyses, particularly those associated with the cell membrane (e.g., membrane lipid metabolism and assay of intrinsic membrane enzymes).