A single-arm, open-label study of alemtuzumab in treatment-refractory patients with multiple sclerosis.

BACKGROUND: Alemtuzumab (CD52-specific humanized monoclonal antibody) was found to be an effective therapy for treatment-naive patients with relapsing-remitting multiple sclerosis. OBJECTIVE: Evaluate alemtuzumab's effects in patients with treatment-refractory relapsing-remitting multiple sclerosis. METHODS: Forty-five relapsing-remitting multiple sclerosis patients who experienced ≥2 relapses during 2 years prior to the study entry whilst receiving interferon therapy were administered 24 mg i.v. alemtuzumab/day for 5 days at baseline and 3 days 12 months later. Patients received premedication with 1 g i.v. methylprednisolone on days 1-3 at both times. RESULTS: After 2-year follow-up, the annualized relapse rate was reduced by 94% compared to pre-treatment levels, from 1.6 (2 years prior to treatment) to 0.17 for the 2 years following (P<0.0001). Moreover, 86% of patients showed stable or improved scores on the Expanded Disability Status Scale, and only 1 experienced an increase in disability lasting ≥6 months. The majority (70-88%) showed stable or improved leg, arm and cognitive function as measured by the Multiple Sclerosis Functional Composite. Serious adverse events observed in single patients were transient neutropenia and pneumonia, pulmonary emboli and deep vein thrombosis. Five patients developed clinical thyroid disorders but no opportunistic infections or cases of immune thrombocytopenic purpura were observed. CONCLUSIONS: Alemtuzumab effectively reduced relapse rates and improved clinical scores in patients with active relapsing-remitting multiple sclerosis not controlled by interferon therapy.

Assessment of pumped mercury vapour adsorption tubes as passive samplers using a micro-exposure chamber.

Mercury vapour adsorption tubes manufactured for pumped sampling and analysis have been evaluated for their performance as passive samplers. This has been done by exposing these tubes in a novel micro-exposure chamber. The uptake rates of these tubes have been found to be low (approximately 0.215 ml min(-1)) as compared to bespoke passive samplers for mercury vapour (typically in excess of 50 ml min(-1)). The measured uptake rates were shown to vary significantly between tubes and this was attributed to the variability in the air-sorbent interface and the proportion of the cross sectional area removed by the crimp in the quartz tubes used to secure the sorbent material. As a result of this variability the uptake rate of each tube must be determined using the micro-exposure chamber prior to deployment. Results have shown that the uptake rate determined in the micro-exposure chamber is invariant of concentration, and therefore these uptakes rates may be determined at a high mercury vapour concentration for many tubes at once in less than one hour. The uptake rate of the adsorption tubes under these conditions may be determined with a precision of 5%. Measurements made on a limited field trial in indoor and outdoor ambient air have shown that these tubes give results in acceptable agreement with more traditional pumped sampling methods, although longer sampling periods are required in order to reduce the uncertainty of the measurement, which is currently approximately 30%.

Chronic imipramine administration alters the activity and phosphorylation state of tyrosine hydroxylase in dopaminergic regions of rat brain.

In the present study the influence of imipramine, a tricyclic antidepressant, on the expression and function of tyrosine hydroxylase (TH) in dopaminergic rat brain regions was examined. Chronic administration of imipramine (18 days) decreased levels of TH enzyme activity in ventral tegmental area (VTA) and substantia nigra (SN), dopaminergic cell body regions, as well as in caudate-putamen (CP), nucleus accumbens (ACB), prefrontal cortex (PFC), and olfactory tubercle (OT), dopaminergic terminal fields. These effects were dependent on chronic drug treatment, as imipramine administration for 1 or 7 days did not significantly influence levels of TH activity in either SN or VTA. In contrast to drug regulation of enzyme activity, chronic imipramine treatment did not decrease levels of TH immunoreactivity in any of the dopaminergic cell body or terminal field regions studied, although levels of TH immunoreactivity were decreased in locus coeruleus (LC) as previously reported. However, imipramine treatment increased levels of TH back phosphorylation in VTA, suggesting that the antidepressant-induced decrease in levels of TH activity is a result of decreased phosphorylation of the enzyme. These results demonstrate that imipramine treatment regulates levels of TH enzyme activity in dopaminergic brain regions, and may account for some of the previously observed effects of these drugs on dopaminergic function. Finally, imipramine regulation of TH enzyme activity in VTA and immunoreactivity in LC was observed in Sprague Dawley, but not Wistar rats, demonstrating that different rat strains exhibit different biochemical responses to antidepressant treatment.

Hippocampal-dependent learning and experience-dependent activation of the hippocampus are preferentially disrupted by ethanol.

A classical fear conditioning paradigm was used to examine the effect of acute ethanol on the acquisition of context conditioning, a hippocampal-dependent associative task, and tone conditioning, a hippocampal-independent task. Administration of ethanol before the presentation of seven tone-shock pairings severely disrupted the acquisition of context conditioning, but had only a slight effect on tone conditioning, when conditioned fear was measured 48 h later. This effect was dose dependent: a dose of 0.5 g/kg had no effect on either context or tone conditioning, while doses of 1.0 and 1.5 g/kg disrupted context conditioning by 78-86%, and tone conditioning by 9-17%. Subsequent experiments indicated that ethanol's preferential effect on context conditioning could not be attributed to the fact that context conditioning is weaker than tone conditioning, ethanol-induced changes in motivational state or state-dependent learning. The effect of ethanol on stimulus-induced increases in hippocampal and neocortical expression of c-fos mRNA, a marker for changes in metabolic neuronal activity, was also examined. Ethanol completely blocked the induction of hippocampal c-fos mRNA by exposure to the conditioning context alone or seven tone-shock pairings, but only attenuated neocortical responses to these stimuli. Together, these results suggest that ethanol disrupts hippocampal-dependent learning by preferentially impairing stimulus processing at the level of the hippocampus.

Chronic ethanol intake decreases vasopressin mRNA content in the rat hypothalamus: a PCR study.

Vasopressin mRNA content was studied by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) in the hypothalami of rats chronically treated with ethanol (EtOH). Quantitative RT-PCR allows for the accurate measurement of peptide mRNA levels in discrete regions of the brain of individual animals. EtOH markedly reduced the level of vasopressin mRNA. Furthermore, salt loading was ineffective in inducing a significant increase in vasopressin mRNA level in EtOH-treated rats, unlike in controls. The present results suggest that EtOH not only decreases vasopressin mRNA content in the rat hypothalamus, but also impairs its capacity to respond to salt loading.

Ethanol effects on delayed spatial matching as modeled by a negative exponential forgetting function.

Performance on delayed matching-to-position as a function of ethanol was investigated in rats and dose effects assessed by fitting an exponential decay model of forgetting to signal detection sensitivity scores. Three ethanol doses (0.25, 0.50, and 0.75 g/kg) and one isovolume saline control were examined. For further comparison, one dose of chlordiazepoxide (CDP; 5 mg/kg) and its saline control were also given. Forgetting functions were reasonably well described by the decay model under all treatment conditions. In addition, the functions's decay constant (-b) proved to be differentially sensitive to both drug and dose effects. Reduced decay estimates were obtained following the two lowest ethanol doses, the reduction being statistically significant for the 0.25 g/kg dose. In contrast, the function estimate of initial sensitivity, the intercept parameter (SI0), was not significantly affected by ethanol. Consistent with the low-dose ethanol effects, CDP significantly decreased the value of the decay parameter while leaving the intercept parameter unaffected. But unlike ethanol, the variance accounted for by the model for the individual data was less following CDP administration. Drug effects were interpreted using the exponential decay model of forgetting, and the results suggest independent discriminative control over SI0 and b. The significant effect of the low-dose sedative-hypnotics upon b, with no attendant effects upon SI0, is suggested to result from enhanced, spontaneous, delay interval mediation.

Chronic imipramine treatment normalizes levels of tyrosine hydroxylase in the locus coeruleus of chronically stressed rats.

Previous studies have demonstrated that chronic stress increases and antidepressant treatments decrease levels of tyrosine hydroxylase (TH) in locus coeruleus (LC). In the present study, the influence of chronic antidepressant treatment on the induction of TH immunoreactivity in response to cold stress is examined. It was found that chronic imipramine pretreatment (18 days) attenuated the induction of TH in response to cold stress, resulting in levels of TH immunoreactivity not different from control. In contrast, imipramine pretreatment for 1 or 7 days was not sufficient to normalize the stress-induced elevation of TH immunoreactivity. These findings raise the possibility that the therapeutic action of antidepressants may be derived, in part, from the ability of these treatments to normalize levels of TH and thereby the function of the NE neurotransmitter system under conditions of stress.

Involvement of pertussis toxin sensitive G-proteins in conditioned fear-potentiated startle: possible involvement of the amygdala.

The present study evaluated the effects of intraventricular or intracerebral administration of pertussis toxin on fear-potentiated startle (a measure of conditioned fear) and shock sensitization (a measure of unconditioned fear). In Experiment 1 all animals were unilaterally implanted with cannulae into the lateral ventricle 1 week prior to 2 days of fear conditioning (ten light-shock pairings on each of 2 days). Five days later, animals were infused with either 1 microgram pertussis toxin or saline and tested for fear-potentiated startle 24 h after infusion and tested for shock sensitization 26 or 50 h after infusion. Pertussis toxin blocked the ability of a light conditioned stimulus to facilitate startle but did not alter the ability of acute footshock to increase startle amplitude in the same animals. In Experiment 2 bilateral infusion of 1 microgram pertussis toxin into the basolateral nuclei of the amygdala, but not the interpositus nuclei of the cerebellum, also blocked fear-potentiated startle when animals were tested 6 h after infusion. These findings suggest a role for pertussis toxin sensitive G-proteins, perhaps within the amygdala, in the expression of conditioned but not unconditioned fear.

Sodium valproate alters GnRH-GABA interactions during development in seizure-prone mice.

During reproductive maturation, characteristic changes occur in the morphology of the gonadotropin releasing hormone (GnRH) cell population within the hypothalamus. In the early stages of development, GnRH neurons are bipolar cells; however, just before pubertal onset, the majority of these neurons transform into unipolar cells. Our laboratory has reported that valproic acid (VPA), an antiepileptic medication that has previously been shown to slow the velocity of pubertal development in both humans and seizure-prone mice, is capable of delaying the normal process of GnRH morphological differentiation. As VPA is primarily believed to act via a GABAergic mechanism, the present study investigated potential influences of VPA on GnRH-GABA interactions within the medial preoptic area (mPOA) across pubertal development (experiment 1), as well as in adult animals (experiment 2). The results from experiment 1 revealed the expected drug effects on GnRH cell morphology. For VPA animals, there was a greater percentage of bipolar neurons at every time period except for the 24-day sample. Additionally, VPA animals had greater numbers of bipolar and unipolar GnRH neurons with GABA associations across all ages. However, experiment 2 showed a lack of drug effects on GnRH-GABA interactions in adulthood. These results suggest that VPA may delay GnRH cell morphological maturation by altering the density of GABAergic inputs to GnRH neurons. These inputs may normally play a role in timing the activation of the GnRH pulse generator. However, any neuroendocrine effects of VPA in adulthood are most likely due to the actions of VPA at another level of the hypothalamic-pituitary-gonadal axis.

Stress-induced activation of prefrontal cortex dopamine turnover: blockade by lesions of the amygdala.

Stress consistently has been found to activate peripheral and central catecholamine systems. Dopamine (DA) turnover in the prefrontal cortex is especially sensitive to stress produced by relatively mild footshock, conditioned fear, or exposure to a novel cage. Because lesions of the central nucleus of the amygdala block the effects of both stress and fear in many experimental paradigms, the present study evaluated whether such lesions would block stress-induced increases in prefrontal dopamine turnover using either mild footshock or novelty as stressors. In Experiment 1 electrolytic lesions of the central nucleus of the amygdala attenuated the increase in the dopamine metabolite homovanillic acid (HVA) in the prefrontal cortex evaluated in post-mortem tissue normally produced by footshock. In Experiment 2 similar lesions attenuated the increase in dopamine turnover in the prefrontal cortex using a different stressor, novelty, and a different measure of dopamine turnover, DOPAC/DA ratios. These data provide further evidence for the critical role of the amygdala in stress.

Effects of septal lesions on fear-potentiated startle, and on the anxiolytic effects of buspirone and diazepam.

The present study evaluated the effect of septal lesions on baseline startle amplitude, potentiated startle (a measure of conditioned fear), and the ability of either buspirone or diazepam to block potentiated startle. Baseline responding to an acoustic stimulus was obtained for all rats, followed by potentiated startle training (ten light-shock pairings on each of two days). Rats were then given bilateral electrolytic lesions of the septum or sham surgery. Four and seven days following surgery all rats were tested again for baseline startle amplitude. Ten days postsurgery, rats were injected with either 5.0 mg/kg buspirone or vehicle and tested for potentiated startle (increased acoustic startle in the presence of a light previously paired with shock). Five days later septal-lesioned animals were injected with either 5.0 mg/kg of diazepam or vehicle and again tested for potentiated startle. Septal lesions increased baseline startle amplitude significantly, but did not alter the magnitude of potentiated startle or impair the ability of buspirone or diazepam to block potentiated startle. In Experiment 2 rats were trained using the above procedures, and were subsequently given discrete bilateral lesions of the lateral septum or sham surgery. Lateral septal lesions again had no effect on the magnitude of potentiated startle. These findings do not support an involvement of the septum in the inhibition of fear, or in the mediation of the anxiolytic effects of buspirone or diazepam.

Lesions of the central nucleus of the amygdala block the excitatory effects of septal ablation on the acoustic startle reflex.

Many studies have investigated the role of the septum and the amygdala in emotional behavior. While the literature is somewhat inconsistent, most studies suggest a role for the septal nuclei in the inhibition of fear and stress responses (at the behavioral, autonomic and hormonal levels) while the central nucleus of the amygdala is involved in the production of such responses. The present study examined the ability of lesions of the central nucleus of the amygdala to block the excitatory effects of complete septal ablation on the acoustic startle reflex. Septal ablation produced a significant increase in startle amplitude which was blocked by concomitant lesions of the central nucleus of the amygdala. These results suggest that the increase in startle amplitude resulting from septal damage might be due to a disinhibition of neuronal activity in the central nucleus of the amygdala, a structure known to mediate the increase in startle associated with conditioned and unconditioned fear, or from antagonistic interactions at other target sites which themselves modulate startle.

Ethical issues and the importance of consensus for the intensive care team.

This paper draws upon an empirical study and combines moral philosophical insights and sociological analysis to shed light on the ethical issues in intensive care. It is argued that moral philosophical debate often leaves aside the social context in which ethical decisions are taken and carried through. In order to gain an understanding of how intensive care is accomplished and specifically how ethical issues are handled, the study focused primarily on nurses' accounts of and views on the practices which form the everyday work of intensive care. A qualitative approach was adopted involving theoretical sampling and the constant comparative method of analysis. The paper argues that the most difficult ethical issue in intensive care, namely the withholding or withdrawal of treatment, is an area in which nursing and medical perspectives are often at odds. However, when the social context of clinical practice is taken into account, this paper argues. there is common ground between the two professions. It was found that the period during which the decision to withdraw treatment is being made, the members of the intensive care team closest to the bedside, nursing and medical staff. become impatient for some resolution of the situation. The differences of opinion which arise over the decision to withdraw are not simply to do with the way in which the situation is experienced by each professional group, proximity to the patient had a part to play in shaping their views rather than, as it is sometimes presumed. a simple rift between medicine and nursing. The data suggest that intensive care has to be a team effort. Even though there is no legal requirement for nurses to agree with the ICU decisions, there seems to be a strong desire within the intensive care team that moral consensus should be achieved in the interests of good patient care. Intensive care relies on the integrity of the team and the unfailing functioning of teamwork. Consequently, achieving this, it seems, is more important than other temporary lapses in interprofessional relations and disagreements over treatment in individual cases. Consensus is important and its achievement is a central, day to day working arrangement for insuring the solidarity of the team.

Signal detection analysis of ethanol effects on a complex conditional discrimination.

The effects of ethanol on a conditional object identification task were investigated using an operant analog of Signal Detection Analysis. Water and three doses of ethanol (0.40, 0.75 and 1.5 g/kg) were orally administered on three separate occasions to three adult squirrel monkeys. Significant discrimination impairment as a function of increasing ethanol dose was observed. At the 1.5 g/kg dose, impairment extended to nonspecific effects, with subjects ceasing to respond early into the session. Subsequent signal detection analyses revealed that the reduction in performance resulted from losses in discriminability. Response bias was found to change unpredictably and independently of ethanol administration. Reaction time measures also showed no changes except a moderate, nonsignificant, facilitation in speed at the lowest (0.40 g/kg) dose. Taken together, these data suggest that ethanol acts to impair complex, or cognitive, performance by disrupting current sources of stimulus control within the range of doses tested.

Post-learning ethanol effects on a water-finding task in rats.

Ethanol's post-training facilitation of memory was examined using a latent learning paradigm known as the "water-finding task." Rats were assigned to one of two ethanol groups (E0.75 g/kg or E1.5 g/kg) or to a control group (saline) and individually placed in a novel open field containing a drinking tube. Following this exposure, subjects were immediately administered intraperitoneal (IP) injections of either the saline or ethanol and 48 hours later, re-introduced to the field. Initial latencies to contact the tube each time were recorded. A linear regression analysis of trial 2 latencies regressed onto trial 1 latencies indicated a statistically significant effect of ethanol on the relation between initial and subsequent latencies. Though the control rats' trial 2 latencies were completely random with respect to their previous speeds (rSAL = -0.07), the ethanol rats' trial 2 latencies were positively correlated with initial speeds (rE0.75 = 0.35, rE1.5 = 0.67). These results suggest that under conditions of post-training ethanol, trial 2 behavior is more similar to, or controlled by, trial 1 behavior and are consistent with the argument that, under certain training and testing contexts, ethanol can come to exert control over a response's recurrence.

Conducting an interview.

The traditional guidance to researchers conducting interviews in the field is that the researcher should say as little as possible and encourage the respondents to talk in an untramelled way about the issues under discussion. But is this approach appropriate in all circumstances? Keith Melia examines the issues by focusing on research carried out in an intensive care unit.