Evidence-based cognitive rehabilitation: recommendations for clinical practice.

OBJECTIVE: To establish evidence-based recommendations for the clinical practice of cognitive rehabilitation, derived from a methodical review of the scientific literature concerning the effectiveness of cognitive rehabilitation for persons with traumatic brain injury (TBI) or stroke. DATA SOURCES: A MEDLINE literature search using combinations of these key words as search terms: attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, reasoning, rehabilitation, remediation, and training. Reference lists from identified articles also were reviewed; a total bibliography of 655 published articles was compiled. STUDY SELECTION: Studies were initially reviewed according to the following exclusion criteria: nonintervention studies; theoretical, descriptive, or review papers; papers without adequate specification of interventions; subjects other than persons with TBI or stroke; pediatric subjects; pharmacologic interventions; and non-English language papers. After screening, 232 articles were eligible for inclusion. After detailed review, 61 of these were excluded as single case reports without data, subjects other than TBI and stroke, and nontreatment studies. This screening yielded 171 articles to be evaluated. DATA EXTRACTION: Articles were assigned to 1 of 7 categories according to their primary area of intervention: attention, visual perception and constructional abilities, language and communication, memory, problem solving and executive functioning, multi-modal interventions, and comprehensive-holistic cognitive rehabilitation. All articles were independently reviewed by at least 2 committee members and abstracted according to specified criteria. The 171 studies that passed initial review were classified according to the strength of their methods. Class I studies were defined as prospective, randomized controlled trials. Class II studies were defined as prospective cohort studies, retrospective case-control studies, or clinical series with well-designed controls. Class III studies were defined as clinical series without concurrent controls, or studies with appropriate single-subject methodology. DATA SYNTHESIS: Of the 171 studies evaluated, 29 were rated as Class I, 35 as Class II, and 107 as Class III. The overall evidence within each predefined area of intervention was then synthesized and recommendations were derived based on consideration of the relative strengths of the evidence. The resulting practice parameters were organized into 3 types of recommendations: Practice Standards, Practice Guidelines, and Practice Options. CONCLUSIONS: Overall, support exists for the effectiveness of several forms of cognitive rehabilitation for persons with stroke and TBI. Specific recommendations can be made for remediation of language and perception after left and right hemisphere stroke, respectively, and for the remediation of attention, memory, functional communication, and executive functioning after TBI. These recommendations may help to establish parameters of effective treatment, which should be of assistance to practicing clinicians.

Effect of Fas+ and Fas- target cells on the ability of NK cells to repeatedly fragment DNA and trigger lysis via the Fas lytic pathway.

We and others have recently shown that human NK cells express the Fas ligand (FasL) constitutively and that they can trigger the lysis of Fas positive (Fas+) target cells (TC) by apoptosis. We have also previously demonstrated that NK cells exposed to sensitive TC temporarily lose their ability to lyse sensitive TC via the granule-mediated pathway and that this loss is recovered when inactivated NK cells (NKi) are incubated in medium supplemented with IL-2, IL-12 or IL-15. In this study, we investigated the fate of the Fas-lytic pathway in NK cells exposed to either Fas+ or Fas- TC. To this end, we exposed NK cells to Jurkat (Fas-) or Jurkat (Fas+) TC for up to 6 h, separated NK cells from the TC and assessed the residual lytic activity against K562, a traditional human NK cell target, Jurkat Fas+ and Jurkat Fas- TC. Fas lytic activity was determined in calcium free medium, in the presence or absence of two distinct Fas-blocking monoclonal antibodies and a Fas.Fc fusion protein. In parallel experiments, the extent of DNA fragmentation in the three TCs was also assayed by the JAM test. Our results indicate that: (i) NK cells exposed to susceptible Fas+ TC temporarily lose most of their lytic potential due to the granule-mediated pathway, while only partially losing the Fas-lytic pathway. They also partially lose their ability to fragment DNA. (ii) NK cells exposed to Fas+ TC completely recover the Fas lytic pathway and the ability to fragment DNA via the Fas/Fas ligand when incubated in medium supplemented with IL-2 for 18 h.

Alcohol cue reactivity, negative-mood reactivity, and relapse in treated alcoholic men.

Relapsed alcoholic individuals frequently report that negative emotional states trigger their return to drinking. A parametric laboratory study was conducted to assess the separate and combined effects of exposure to alcohol-related stimuli and induced negative moods in abstinent alcoholic persons. The authors also sought to determine if reactivity to alcohol cues or reactivity to negative mood induction predicted relapse soon after treatment. Men with alcoholism (N = 50) undergoing inpatient treatment participated in a guided imagery procedure designed to induce negative moods and were then exposed to either their favorite alcoholic beverage or to spring water. Results indicated that both alcoholic beverage presentation and negative affect imagery led to increased subjective reporting of desire to drink. These effects were additive but not multiplicative (i.e., the interaction of mood state with beverage type was not significant). Reported urge to drink during the trial that combined negative mood imagery with alcoholic beverage exposure predicted time to relapse after inpatient discharge.