The effect of krill oil supplementation on skeletal muscle function and size in older adults: A randomised controlled trial.

BACKGROUND & AIMS: The aim of this study was to determine the effect of krill oil supplementation, on muscle function and size in healthy older adults. METHODS: Men and women, aged above 65 years, with a BMI less than 35kg/m2, who participated in less than 1h per week of structured self-reported exercise, were enrolled in the study (NCT04048096) between March 2018 and March 2020. Participants were randomised to either control or krill oil supplements (4g/day) for 6 months in this double blind randomised controlled trial. At baseline, 6 weeks and 6 months, knee extensor maximal torque was measured as the primary outcome of the study. Secondary outcomes measured were grip strength, vastus lateralis muscle thickness, short performance physical battery test, body fat, muscle mass, blood lipids, glucose, insulin, and C-Reactive Protein, neuromuscular (M-Wave, RMS and voluntary activation), and erythrocyte fatty acid composition. RESULTS: A total of 102 men and women were enrolled in the study. Ninety-four participants (krill group (26 women and 23 men) and placebo group (27 women and 18 men)) completed the study (mean (SD): age 71.2 (5.1) years and weight 71.8 (12.3) kg). Six months supplementation with krill oil resulted in, an increase in knee extensor maximal torque, grip strength and vastus lateralis muscle thickness, relative to control (p<0.05). The 6-month treatment effects were 9.3% (95%CI: 2.8, 15.8%), 10.9% (95%CI: 8.3, 13.6%) and 3.5% (95%CI: 2.1, 4.9%) respectively. Increases in erythrocyte fatty acid profile were seen with krill oil for EPA 214% (95%CI: 166, 262%), DHA 36% (95%CI: 24, 48%) and the omega-3 index 61% (95%CI: 49, 73%), relative to control (p < 0.05). Krill oil resulted in an increased, relative to control (p < 0.05), M-Wave of 17% (95%CI: 12.7, 38.1%) but there was no effect of krill oil on RMS, voluntary activation, or on any other secondary outcomes such as performance of the short performance physical battery test or quality of life. CONCLUSION: Krill oil supplementation for 6 months results in statistically and clinically significant increases in muscle function and size in healthy older adults. GOV IDENTIFIER: NCT04048096.

Cyclosporin, methotrexate and prednisolone for graft-versus-host disease prophylaxis in allogeneic peripheral blood progenitor cell transplants.

The utility of GVHD prophylaxis with cyclosporin, MTX and prednisolone (CSA/MTX/Pred) in allogeneic PBPC transplants is not well described although there are published data using this combination after bone marrow transplants. The effectiveness of this regimen on the prevention of GVHD was assessed in 107 consecutive sibling and less-than-ideal donor transplant recipients over a 5-year period and compared to that observed in 65 patients receiving standard CSA and short-course MTX without prednisolone. Oral prednisolone was commenced on day +14 at 0.5 mg/kg per day, increased to 1 mg/kg per day on day +21 to day +34 then gradually tapered and ceased by day +100. The cumulative incidence of acute GVHD (grades II-IV) to day 100 in those receiving prednisolone prophylaxis was lower (52 versus 76%, P<0.01). The onset of symptomatic GVHD requiring systemic treatment was delayed from a median of 41 days post transplant to 92 days. When assessment of the cumulative incidence of symptomatic GVHD continued to day +180 incidence became similar (74 versus 78%), there was no difference between the two groups in rates of relapse, transplant-related mortality, infections or chronic GVHD. We conclude that the addition of prednisolone to CSA/MTX delays the onset of early acute GVHD in PBPC recipients but has no impact on the overall incidence of GVHD.

Empiric antibiotic prescribing for patients with community-acquired pneumonia: where can we improve?

BACKGROUND: Community acquired pneumonia is one of the most common infections for which antibiotics are prescribed in Australia. METHODS: We audited empiric antibiotic prescribing for 392 adults with community-acquired pneumonia. RESULTS: Only 61.9% of patients received empiric antibiotic coverage for both typical and atypical pathogens. Of those who required intensive care unit management, 34.6% did not receive antibiotic cover for atypical pneumonia pathogens within the first 24 h. Approximately 21.9% of patients reporting antibiotic allergies were given antibiotics to which they had a documented allergy. CONCLUSION: Efforts to improve prescribing practices could be focused towards identifying patients with severe illness early and improving recognition of documented allergies.

Treatment with aldose reductase inhibitor or with myo-inositol arrests deterioration of the electroretinogram of diabetic rats.

Biochemical abnormalities in the retinal pigment epithelium of experimentally diabetic animals include increased sorbitol and decreased myo-inositol. Diabetes also causes a progressive reduction in the amplitude of the c-wave of the electroretinogram of the pigmented rat. The c-wave is generated by the retinal pigmented epithelium. Myo-inositol administration or treatment with sorbinil, an inhibitor of aldose reductase, arrested the decline in the c-wave. Therefore, hyperglycemia-associated defects in myo-inositol or sorbitol metabolism may be involved in the pathogenesis of the electrophysiological deficit of the diabetic retina. The homogeneous cell layer of the pigment epithelium may be a useful tissue model for studying the pathogenesis of the complications of diabetes.

Differential regulation of protein kinase C and (Na,K)-adenosine triphosphatase activities by elevated glucose levels in retinal capillary endothelial cells.

Elevated cellular sorbitol levels resulting from conversion of increased glucose by aldose reductase might deplete cellular myoinositol content, which could then lower inositol phosphates (InsPs) and diacylglycerol levels, key regulators of protein kinase C (PKC). Secondary to altered PKC activity, other cellular enzymes such as (Na,K)-ATPase could be affected. To test this hypothesis we examined the association between PKC activity, (Na,K)-ATPase activity, and sorbitol, myoinositol, and InsP levels in cultured bovine retinal capillary endothelial cells, a cell type prominently involved in diabetic retinopathy. Elevating glucose concentration in culture media from 100 to 400 mg/dl led to a 100% increase in sorbitol levels, which could be inhibited completely by sorbinil, an aldose reductase inhibitor. In contrast, no changes were observed in myoinositol or InsP levels. Subfractionated PKC activities showed a 100% increase in the membranous pool with a parallel decrease in the cytosolic fraction. Adding sorbinil did not affect PKC activity, whereas the PKC agonist, phorbol myristate acetate (PMA), stimulated translocation of PKC. Ouabain-inhibitable (Na,K)-ATPase activity was decreased 70% by elevated glucose levels. This decrease could be prevented by adding either PMA or sorbinil. Thus, in retinal capillary endothelial cells elevated glucose concentration can affect PKC and (Na,K)-ATPase activities, probably via different mechanisms.

"Magnetic resonance imaging negative positron emission tomography positive" temporal lobe epilepsy: FDG-PET pattern differs from mesial temporal lobe epilepsy.

PURPOSE: Some patients with temporal lobe epilepsy (TLE) lack evidence of hippocampal sclerosis (HS) on MRI (HS-ve). We hypothesized that this group would have a different pattern of 2-deoxy-2-[F-18]fluoro-D-glucose (FDG)-positron emission tomography (PET) hypometabolism than typical mesial TLE/HS patients with evidence of hippocampal atrophy on magnetic resonance imaging (MRI) (HS+ve), with a lateral temporal neocortical rather than mesial focus. PROCEDURES: Thirty consecutive HS-ve patients and 30 age- and sex-matched HS+ve patients with well-lateralized EEG were identified. FDG-PET was performed on 28 HS-ve patients and 24 HS+ve patients. Both groups were compared using statistical parametric mapping (SPM), directly and with FDG-PET from 20 healthy controls. RESULTS: Both groups showed lateralized temporal hypometabolism compared to controls. In HS+ve, this was antero-infero-mesial (T = 17.13); in HS-ve the main clustering was inferolateral (T = 17.63). When directly compared, HS+ve had greater hypometabolism inmesial temporal/hippocampal regions (T = 4.86); HS-ve had greater inferolateral temporal hypometabolism (T = 4.18). CONCLUSIONS: These data support the hypothesis that focal hypometabolism involves primarily lateal neocortical rather than mesial temporal structures in 'MRI-negative PET-positive TLE.'

Non-invasive computed tomography angiography in the assessment of coronary stent patency: an Australian experience.

BACKGROUND: This study aimed to evaluate the feasibility and accuracy of 16-slice computed tomography (CT) in the assessment of coronary stent patency. CT coronary angiography (CA) has a high degree of accuracy in the assessment of coronary artery disease compared with invasive selective CA. However, its accuracy in the evaluation of stent patency is not well investigated. METHODS: We conducted a retrospective observational study of paired CT coronary angiography (CT-CA) and invasive fluoroscopic coronary angiography (FCA) in 37 patients with 47 coronary stents. CT-CA was carried out with an electrocardiogram-gated 16-slice CT (LightSpeed-16, General Electric (GE), WI, USA). Two CT reporters, blinded to the FCA findings, assessed CT images for stent patency. A cardiologist blinded to CT findings reported FCA. FCA was regarded as the reference standard. RESULTS: A CT-CA could assess 45 of 47 coronary stents (96%). Non-assessable stents on CT-CA were due to motion artefacts and stent-blooming effects. Of those 45 assessable stents, CT-CA correctly identified five out of seven stents with binary in-stent restenosis (ISR) and 37 of 38 stents without binary ISR. The sensitivity and specificity of 16-slice CT in the evaluation of coronary stents for binary ISR were 71% (95% confidence interval (CI) (29%, 96%)) and 97% (95%CI (86%, 100%)), respectively, exclusive of non-assessable stents. The positive and negative predictive values of 16-slice CT were 83% (95%CI (36%, 100%)) and 95% (95%CI (83%, 99%)), respectively. CONCLUSION: Sixteen-slice CT has a low sensitivity, but very a high specificity when compared with FCA in the evaluation of coronary stents for ISR.

Female genital tract graft-versus-host disease: incidence, risk factors and recommendations for management.

Female genital tract graft-versus-host disease (GVHD) is an under-recognized complication of allogeneic stem cell transplantation impacting on quality of life. We describe a prospective surveillance programme for female genital GVHD to better characterize incidence, risk factors and clinical features and the impact of a structured intervention policy. A retrospective audit was conducted on the medical records of all female transplant recipients surviving at least 6 months at a single centre over a 5-year period. Patients commenced topical vaginal oestrogen early post transplant with hormone replacement as appropriate for age, prior menopausal status and co-morbidities. A genital tract management programme included regular gynaecological review and self-maintenance of vaginal capacity by dilator or intercourse. The incidence of genital GVHD was 35% (95% confidence interval (CI) (25, 50%)) at 1 year and 49% (95% CI (36, 63%)) at 2 years. Topical therapy was effective in most cases; no patient required surgical intervention to divide vaginal adhesions. The main risk factor was stem cell source with peripheral blood progenitor cells posing a higher risk than marrow (hazard ratio=3.07 (1.22, 7.73), P=0.017). Extensive GVHD in other organs was a common association. We conclude that female genital GVHD is common, and early detection and commencement of topical immunosuppression with dilator use appears to be highly effective at preventing progression.

Donor methylenetetrahydrofolate reductase genotype is associated with graft-versus-host disease in hematopoietic stem cell transplant patients treated with methotrexate.

Methotrexate (MTX), used as a graft-versus-host disease (GvHD) prophylactic agent in hematopoietic stem cell transplantation (HSCT), exerts its effect via folate cycle inhibition. A critical enzyme involved in folate metabolism is 5,10-methylenetetrahydrofolate reductase (MTHFR). We examined the association of a single nucleotide polymorphism (SNP) at position 677 in the MTHFR gene on GvHD outcomes in allogeneic HSCT patients administered MTX. MTHFR genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) on 193 HSCT patients and donors. A total of 140 patients were transplanted with an HLA-matched related donor and 53 with an unrelated donor. GvHD outcomes were compared between genotypes by univariate and multivariate analysis. The combined donor 677CT and TT genotypes were associated with a decreased incidence of GvHD (acute and chronic combined) in HSCT recipients with an HLA-matched related donor (75% at 1 year in the CT and TT group compared with 91% in the wild type CC group, P=0.01), increased time to onset of first GvHD (P=0.001) and time to first GvHD treated with systemic therapy (P=0.022). Unrelated donor MTHFR genotype was not associated with outcome parameters and no associations of recipient genotype in either related or unrelated donor cohorts were observed.

Short-term effects of methylprednisolone on cerebral volume in multiple sclerosis relapses.

We prospectively investigated the short-term effects of intravenous methyl-prednisolone (IVMP) on cerebral volume in patients suffering a multiple sclerosis (MS) relapse. Ten patients underwent MRI brain studies immediately before and after IVMP treatment, and 4 and 8 weeks later. Whole brain volumes decreased significantly over the 8-week period. The greatest change occurred during IVMP administration. This has implications for MS treatment trials using cerebral atrophy as an endpoint.

Refining the perfusion-diffusion mismatch hypothesis.

BACKGROUND AND PURPOSE: The Echoplanar Imaging Thrombolysis Evaluation Trial (EPITHET) tests the hypothesis that perfusion-weighted imaging (PWI)-diffusion-weighted imaging (DWI) mismatch predicts the response to thrombolysis. There is no accepted standardized definition of PWI-DWI mismatch. We compared common mismatch definitions in the initial 40 EPITHET patients. METHODS: Raw perfusion images were used to generate maps of time to peak (TTP), mean transit time (MTT), time to peak of the impulse response (Tmax) and first moment transit time (FMT). DWI, apparent diffusion coefficient (ADC), and PWI volumes were measured with planimetric and thresholding techniques. Correlations between mismatch volume (PWIvol-DWIvol) and DWI expansion (T2(Day 90-vol)-DWI(Acute-vol)) were also assessed. RESULTS: Mean age was 68+/-11, time to MRI 4.5+/-0.7 hours, and median National Institutes of Health Stroke Scale (NIHSS) score 11 (range 4 to 23). Tmax and MTT hypoperfusion volumes were significantly lower than those calculated with TTP and FMT maps (P<0.001). Mismatch > or =20% was observed in 89% (Tmax) to 92% (TTP/FMT/MTT) of patients. Application of a +4s (relative to the contralateral hemisphere) PWI threshold reduced the frequency of positive mismatch volumes (TTP 73%/FMT 68%/Tmax 54%/MTT 43%). Mismatch was not significantly different when assessed with ADC maps. Mismatch volume, calculated with all parameters and thresholds, was not significantly correlated with DWI expansion. In contrast, reperfusion was correlated inversely with infarct growth (R=-0.51; P=0.009). CONCLUSIONS: Deconvolution and application of PWI thresholds provide more conservative estimates of tissue at risk and decrease the frequency of mismatch accordingly. The precise definition may not be critical; however, because reperfusion alters tissue fate irrespective of mismatch.

Diabetes and the myo-inositol paradox.

To test the general applicability of the hypothesis that diabetes mellitus causes increased polyol pathway activity, decreased tissue free myo-inositol, and resultant pathological changes in tissues susceptible to the ravages of diabetes, we measured glucose, sorbitol, and myo-inositol with quantitative histochemical techniques in layers of the cornea, the aortic myointima, the cardiac left ventricle and atrioventricular node (AVN), and retina and kidney after 19 days or 2 mo (mildly diabetic non-insulin-treated [MD] and severely diabetic insulin-treated [SD] groups) in the alloxan-induced diabetes model. In the aqueous humor, glucose rose linearly with increased serum glucose, sorbitol was markedly increased in the MD and SD groups, and myo-inositol did not change in any diabetic group. There was no change in glucose or sorbitol in aortic myointima in any group, but myoinositol was decreased in 19-day diabetic rabbits by 26%, unchanged in MD rabbits but paradoxically increased by 60% in SD rabbits. Glucose, sorbitol, and myo-inositol increased in all three corneal layers in SD rabbits but only in epithelium and stroma in 19-day and MD rabbits. AVN glucose and sorbitol did not change in 19-day diabetic, MD, or SD diabetic rabbits. AVN myo-inositol was three times higher than ventricular myo-inositol and did not appear to change in SD rabbits. Retinal pigmented epithelium myo-inositol was decreased 30% in SD rabbits. Glomerular myo-inositol was also decreased, but not significantly, in SD rabbits. We conclude that the paradoxical increase in corneal and aortal myo-inositol raises fundamental questions about the general applicability of the myo-inositol-depletion hypothesis.

MRI-negative PET-positive temporal lobe epilepsy: a distinct surgically remediable syndrome.

Most patients with non-lesional temporal lobe epilepsy (NLTLE) will have the findings of hippocampal sclerosis (HS) on a high resolution MRI. However, a significant minority of patients with NLTLE and electroclinically well-lateralized temporal lobe seizures have no evidence of HS on MRI. Many of these patients have concordant hypometabolism on fluorodeoxyglucose-PET ([18F]FDG-PET). The pathophysiological basis of this latter group remains uncertain. We aimed to determine whether NLTLE without HS on MRI represents a variant of or a different clinicopathological syndrome from that of NLTLE with HS on MRI. The clinical, EEG, [18F]FDG-PET, histopathological and surgical outcomes of 30 consecutive NLTLE patients with well-lateralized EEG but without HS on MRI (HS-ve TLE) were compared with 30 consecutive age- and sex-matched NLTLE patients with well-lateralized EEG with HS on MRI (HS+ve TLE). Both the HS+ve TLE group and the HS-ve TLE patients had a high degree of [18F]FDG-PET concordant lateralization (26 out of 30 HS-ve TLE versus 27 out of 27 HS+ve TLE). HS-ve TLE patients had more widespread hypometabolism on [18F]FDG-PET by blinded visual analysis [odds ratio (OR = + infinity (2.51, -), P = 0.001]. The HS-ve TLE group less frequently had a history of febrile convulsions [OR = 0.077 (0.002-0.512), P = 0.002], more commonly had a delta rhythm at ictal onset [OR = 3.67 (0.97-20.47), P = 0.057], and less frequently had histopathological evidence of HS [OR = 0 (0-0.85), P = 0.031]. There was no significant difference in surgical outcome despite half of those without HS having a hippocampal-sparing procedure. Based on the findings outlined, HS-ve PET-positive TLE may be a surgically remediable syndrome distinct from HS+ve TLE, with a pathophysiological basis that primarily involves lateral temporal neocortical rather than mesial temporal structures.

Quantitative histochemical determination of Na+ and K+ in microscopic samples using carbon furnace atomic absorption spectrometry.

Carbon furnace atomic absorption spectrometry was used to measure the Na and K content of freeze-dried microscopic tissue samples. This method was sufficiently sensitive to measure pmol amounts of Na and K from tissue weighing 10-60 ng. Within the spatial resolution of the microdissection procedure, ion diffusion that might occur during cryosectioning, freeze-drying, and dissection of the tissue did not seem to be a problem. Data obtained with this methodology were in agreement with previously reported values of the Na and K content of various tissues, thus supporting the usefulness of this quantitative histochemical technique.

Experimental diabetes mellitus impairs the function of the retinal pigmented epithelium.

The retinal pigmented epithelium (RPE), which influences the composition of the retinal extracellular fluid, is significantly affected in diabetes. Changes in RPE morphology, permeability, and electrophysiology in experimentally diabetic animals have been described. To facilitate the study of diabetes-related changes in RPE metabolism, we applied the techniques of quantitative histochemistry to pure samples of RPE and individual retinal layers from eyes of normal and alloxan-diabetic rabbits. Glucose within the RPE approximated serum levels in both normal and diabetic animals. Other changes in diabetics included increased sorbitol, decreased myo-inositol, elevated total Na, and loss of measurable Na+-K+-ATPase activity within the RPE. The altered ion metabolism was associated with a progressive decrease in the amplitude of the RPE-generated c-wave of the electroretinogram. The deterioration of the c-wave was arrested by treatment of the diabetic animals with either myo-inositol supplementation or with sorbinil, an inhibitor of aldose reduction. Diabetic alterations in the RPE might impair the ability of the tissue to maintain normal transport functions. The subsequently altered composition of the extracellular environment of the retina may play an important role in the pathogenesis of diabetic retinopathy.

Effect of myo-inositol on renal Na-K-ATPase in experimental diabetes.

The activity of Na-K-ATPase in the kidney is increased by experimental diabetes. Because the kidney is rich in myo-inositol and abnormal inositol metabolism has been implicated in early neural complications of diabetes, we studied the effect of myo-inositol supplementation on Na-K-ATPase activity in renal medullary and cortical homogenates of Sprague-Dawley rats made diabetic with streptozotocin. Myo-inositol (650 mg/kg) was administered by gavage daily for 1 and 2 weeks after induction of diabetes. Medullary Na-K-ATPase (mumol/mg protein/h) was increased at 1 week by approximately 60% in diabetic rats versus control (25.9 +/- 0.07 vs 16.3 +/- 0.7; P less than .01). This increase was completely prevented by myo-inositol supplementation, despite persistent hyperglycemia. At 2 weeks, similar results were seen; medullary Na-K-ATPase activity was increased by 50% in diabetic rats compared with control, and once again myo-inositol prevented this increase. Sorbinil, the aldose reductase inhibitor, was also administered by gavage (20 mg/kg) for 2 weeks and partially prevented the increase in medullary Na-K-ATPase activity (20.0 +/- 0.9; P less than .05). At both 7 and 14 days, Na-K-ATPase activity in the cortex of untreated diabetic rats was also significantly increased compared with nondiabetic control rats and the increase was prevented by myo-inositol or Sorbinil. Myo-inositol or Sorbinil did not reduce Na-K-ATPase activity of nondiabetic control rats, nor did they prevent the increase in medullary Na-K-ATPase in compensatory hypertrophy following uninephrectomy. Myo-inositol content of outer medulla was about five to six times that of cortex, but was unaltered by the diabetic state.(ABSTRACT TRUNCATED AT 250 WORDS)

Planum temporale asymmetries in great apes as revealed by magnetic resonance imaging (MRI).

The planum temporale (PT), a portion of Wernicke's area, is important for linguistic functions in humans and is larger in the left compared to the right hemisphere. In this study, we assessed the presence and size of the PT in a sample of non-human primates including 21 great apes, four lesser apes, 11 Old World monkeys and eight New World monkeys using magnetic resonance imaging. The PT was measured in both the sagittal and coronal planes by use of multiplanar reformatting software. The PT could only be identified in the sample of great apes and not in the remaining non-human primate species. Within the great ape sample, the PT was larger in the left hemisphere than in the right in a statistical majority of the subjects. These results are consistent with the notion that the PT evolved as a definable structure about 15 million years ago and may have arisen as a result for selection for greater cortical folding which in turn led to greater gyrification in larger brains.

Intracardiac operation in seven pregnant women.

The outcome of open heart operations on pregnant women is not well documented. Between March 1985 and October 1988, 7 pregnant patients underwent valve replacement at Tygerberg Hospital. This included three redo operations and one double-valve replacement. The range of perfusion temperatures used during cardiopulmonary bypass was 28 degrees to 33 degrees C with aortic cross-clamp times of 53 to 121 minutes. One baby was stillborn, but the others were normally delivered at full term, and all the mothers survived. The stillborn baby was lost after the shortest procedure at the highest temperature during cardiopulmonary bypass.

Regulation of cholesterol acquisition and utilization in the corpus luteum.

In this report we have focused on two aspects of control of corpus luteum function; the regulation of lipoprotein uptake and the modulation of cholesterol side chain cleavage through alterations in the phospholipid milieu. Until recently, a role of gonadotropins in the acquisition of lipoprotein-carried cholesterol had not been generally appreciated. However, it is likely that the regulation expression of cell surface lipoprotein receptors will prove to be an important function of tropic hormones, particularly LH, since luteal cells generate progestins at a substantial rate and must, therefore, have an equally substantial supply of cholesterol. Factors other than gonadotropins may have a function in control of lipoprotein receptors and it would not be surprising if luteolytic factors, such as prostaglandin F2 alpha, are found to diminish lipoprotein-uptake as part of their action in reducing steroidogenesis. The control of mitochondrial pregnenolone synthesis by gonadotropin-induced alterations in phospholipid composition of mitochondrial membranes represents a novel concept. Whether certain polar lipids will emerge with the status of intracellular messengers remains to be seen. In any event, our observations clearly demonstrate the possibility for such a mechanism of control.

Serial MRI in multiple sclerosis: a prospective pilot study of lesion load, whole brain volume and thalamic atrophy.

Using serial magnetic resonance imaging (MRI), we investigated the relationship between diffuse cerebral atrophy, T1 and T2 lesion volumes, mean thalamic volumes and clinical progression in patients with established multiple sclerosis (MS). Eleven patients were included in this prospective serial study. Cerebral volumes, T1 hypointense lesion volumes, and T2 hyperintense lesion volumes at baseline and at up to 3 years follow-up were assessed on MRI brain scans. As a putative measure of cerebral atrophy mean thalamic volumes were also obtained. The outcome measures were the MRI parameters and disability on Kurtzke's expanded disability status scale (EDSS). Of the 11 patients 6 worsened clinically as measured by an increase of 0.5 or more on the EDSS. Cerebral atrophy occurred in 91% of patients and was independent of changes in lesion volumes and was not associated with disease progression as determined by the EDSS.