Quality improvement in neurology: AAN epilepsy quality measures: Report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology.

OBJECTIVE: Epilepsy is a common neurologic condition with significant personal, societal, medical, and economic burdens. There are considerable gaps in the quality of care delivered. Measuring the quality of care delivered is the first step to its improvement. Performance measures are easily identified and quantitated ways to assess whether specific activities were carried out during a patient encounter. Therefore, epilepsy performance measures were derived through a standardized systematic process and may be the basis for pay-for-performance initiatives and maintenance of certification requirements. METHODS: Epilepsy measures were developed through the American Medical Association-convened Physician Consortium for Performance Improvement (PCPI) independent measure development process, which marked the first time a medical specialty society followed this process. Guidelines, measures, and consensus papers reviewed for the period 1998 to 2008 using the National Guidelines Clearinghouse, the National Quality Measures Clearinghouse, PubMed, MEDLINE, and the Cochrane Library were evaluated using a framework to determine the acceptability of each guideline or other evidence review document for measures development. Recommendation statements based on level of evidence, importance, validity, and gap in care were developed into candidate measures. A panel of experts from representative organizations vetted the measures. A period of public comment was followed by approval from the American Academy of Neurology and the PCPI. RESULTS: Literature search identified 160 relevant recommendation statements from 19 guidelines and 2 consensus papers. Systematic assessment resulted in 20 recommendation statements that were refined to 8 candidate measures by the expert panel. The measures are relevant to seizure type and frequency, etiology or epilepsy syndrome, EEG, neuroimaging, antiepileptic drug side effects, safety issues, referral for refractory epilepsy, and issues for women of childbearing potential. CONCLUSION: There is a reasonable evidence base, and consensus for, deriving performance measures for quality of epilepsy care. It is anticipated that implementation of these performance measures will improve care for patients with epilepsy if adopted by providers.

Quality improvement in neurology: AAN Parkinson disease quality measures: report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology.

BACKGROUND: Measuring the quality of health care is a fundamental step toward improving health care and is increasingly used in pay-for-performance initiatives and maintenance of certification requirements. Measure development to date has focused on primary care and common conditions such as diabetes; thus, the number of measures that apply to neurologic care is limited. The American Academy of Neurology (AAN) identified the need for neurologists to develop measures of neurologic care and to establish a process to accomplish this. OBJECTIVE: To adapt and test the feasibility of a process for independent development by the AAN of measures for neurologic conditions for national measurement programs. METHODS: A process that has been used nationally for measure development was adapted for use by the AAN. Topics for measure development are chosen based upon national priorities, available evidence base from a systematic literature search, gaps in care, and the potential impact for quality improvement. A panel composed of subject matter and measure development methodology experts oversees the development of the measures. Recommendation statements and their corresponding level of evidence are reviewed and considered for development into draft candidate measures. The candidate measures are refined by the expert panel during a 30-day public comment period and by review by the American Medical Association for Current Procedural Terminology (CPT) II codes. All final AAN measures are approved by the AAN Board of Directors. RESULTS: Parkinson disease (PD) was chosen for measure development. A review of the medical literature identified 258 relevant recommendation statements. A 28-member panel approved 10 quality measures for PD that included full specifications and CPT II codes. CONCLUSION: The AAN has adapted a measure development process that is suitable for national measurement programs and has demonstrated its capability to independently develop quality measures.

Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.

OBJECTIVE: To provide evidence-based recommendations on the treatment of nervous system Lyme disease and post-Lyme syndrome. Three questions were addressed: 1) Which antimicrobial agents are effective? 2) Are different regimens preferred for different manifestations of nervous system Lyme disease? 3) What duration of therapy is needed? METHODS: The authors analyzed published studies (1983-2003) using a structured review process to classify the evidence related to the questions posed. RESULTS: The panel reviewed 353 abstracts which yielded 112 potentially relevant articles that were reviewed, from which 37 articles were identified that were included in the analysis. CONCLUSIONS: There are sufficient data to conclude that, in both adults and children, this nervous system infection responds well to penicillin, ceftriaxone, cefotaxime, and doxycycline (Level B recommendation). Although most studies have used parenteral regimens for neuroborreliosis, several European studies support use of oral doxycycline in adults with meningitis, cranial neuritis, and radiculitis (Level B), reserving parenteral regimens for patients with parenchymal CNS involvement, other severe neurologic symptomatology, or failure to respond to oral regimens. The number of children (> or =8 years of age) enrolled in rigorous studies of oral vs parenteral regimens has been smaller, making conclusions less statistically compelling. However, all available data indicate results are comparable to those observed in adults. In contrast, there is no compelling evidence that prolonged treatment with antibiotics has any beneficial effect in post-Lyme syndrome (Level A).

Th1 cytokines stimulate RANTES chemokine secretion by human astroglial cells depending on de novo transcription.

Beta-chemokines induce the directional migration of monocytes and T lymphocytes that are implicated in the pathogenesis of multiple sclerosis (MS) lesions. RANTES is a member of the beta-chemokine family that has been detected in the lesions of MS patients. However, the cellular sources of RANTES message and the molecular basis for the regulation of its production in MS lesions are not well understood. Glial cells may be a major source of RANTES in vivo and have been shown to produce RANTES in vitro. Thus, the objective of this study was to establish a model system for studying the regulation of RANTES expression by cytokines in cultured human glial cells, and to determine the mechanism involved in the process. We show that the Th1 cytokines TNF-alpha and IL-1beta independently induce RANTES mRNA and chemokine levels in human U-251 MG astroglial cells, and that these effects are time- and concentration-dependent. In addition, we demonstrate that both cytokines increased the rate of transcription of the RANTES gene, as estimated by in vitro nuclear transcript elongation assays. The transcriptional activity in TNF-alpha-treated U-251 MG cells started to increase at 2 h and peaked at 8 h, with levels more than 14 times greater than controls. We further show that NF-kappaB may play a critical role in the up-regulation of human RANTES gene expression in this system. Gel shift assays revealed an induction of in vitro nuclear extract binding activity to the NF-kappaB element of RANTES in cells incubated with the Th1 cytokines. These observations suggest that human astroglia, within diseased brain, may be stimulated to produce RANTES chemokine in response to TNF-alpha and IL-1beta, and that this effect of the Th1 cytokines is attributed to increase of transcription.

Comparison of RANTES chemokine induction by Th1 cytokines in human astroglial cell lines.

Multiple sclerosis (MS) is a primary inflammatory demyelinating disease of the human central nervous system, characterized by accumulation of mononuclear cells of hematogenous origin. RANTES is a C-C (beta)-chemokine family member with strong chemoattractant activity for lymphocytes and monocytes that are implicated in the pathogenesis of MS lesions. However, the cellular sources of RANTES message and the regulation of its secretion within diseased brain are poorly understood. Therefore, we carried out this study to compare the effect of Th1 cytokines on the induction of RANTES in different human astrocytic cell lines. IFN-gamma alone had little effect on RANTES production in both U-373MG and U-105MG cells, while TNF-alpha or IL-1beta alone had differential effects in the two cell lines. Low levels of RANTES chemokine were detected in culture supernatants from U-373MG cells. By contrast, TNF-alpha or IL-1beta dramatically increased RANTES secretion in U-105MG cells. Interestingly, different combination treatments of cells with the three cytokines synergistically induced RANTES release from both U-373MG and U-105MG cells. Consistent with these results, we found similar expression patterns for RANTES at the comparable steady-state mRNA levels in both cell lines. Furthermore, we showed that U-105MG cells treated with TNF-alpha and IL-1beta alone or in combination markedly induced increases in the rate of transcription of the RANTES chemokine gene. Our results indicate that these cell lines may be good model systems for studying the regulation of RANTES expression by cytokines in human glial cells.

Glatiramer acetate inhibition of tumor necrosis factor-alpha-induced RANTES expression and release from U-251 MG human astrocytic cells.

Glatiramer acetate is an approved drug for the treatment of multiple sclerosis (MS). RANTES is a beta-family chemokine that manifests chemoattractant activity for T lymphocytes and monocytes/macrophages implicated in the pathogenesis of MS lesions. However, the effect of glatiramer acetate on the regulation of RANTES secretion in glial cells is unknown. In the present study, we demonstrate for the first time that treatment of human U-251 MG astrocytic cells with glatiramer acetate blocks tumor necrosis factor-alpha (TNF-alpha)-induced RANTES mRNA and protein in a dose- and time-dependent manner. This effect is attributed to inhibition of transcription and a 40% decrease in transcript stability. Furthermore, our electrophoretic mobility shift assays of nuclear extracts from TNF-alpha-treated cells reveal an increase in DNA-binding activity specific for the nuclear factor-kappa B (NF-kappaB) binding site, in the 5'-flanking promoter region of the human RANTES gene, and that this increase in NF-kappaB binding activity is prevented by pretreatment with glatiramer acetate or the NF-kappaB inhibitors. These findings suggest that glatiramer acetate may exert its therapeutic effect in MS partially through inhibiting NF-kappaB activation and chemokine production.

Induction of RANTES chemokine expression in human astrocytic cells is dependent upon activation of NF-kappaB transcription factor.

RANTES is a C-C (beta)-family chemokine that is implicated in the migration of peripheral blood leukocytes to brain lesions in multiple sclerosis (MS), an inflammatory demyelinating disease of the central nervous system (CNS). Glial cells are active participants in the inflammatory response in the CNS, and they have been shown to respond to and produce a number of cytokines and chemokines in vivo and in vitro. Recently, we have shown inducibility of RANTES gene expression by TNF-alpha in human astrocytic cells. Therefore, the goal of the current study was to investigate the transcription activating factor involved in the process. We found that the induction of RANTES mRNA and protein by TNF-alpha in human astrocytic cells is associated with increased NF-kappaB DNA-binding activity. p65 and p50 were determined to be the components of the activated NF-kappaB transcription factor complex by supershift assay. In addition, the blockade of NF-kappaB activation by three known NF-kappaB inhibitors markedly reduced the TNF-alpha-induced RANTES expression at the mRNA and protein levels. Furthermore, the reduction in NF-kappaB binding activity to the promoter of the human RANTES gene caused by the NF-kappaB inhibitors parallels a decrease in RANTES expression in these cells. Our data suggest that NF-kappaB may mediate the induction of RANTES gene expression, in human glial cells, through its cognate cis-acting element.

Mechanisms underlying the synergistic effect of Th1 cytokines on RANTES chemokine production by human glial cells.

RANTES is a beta-family chemokine with potent chemoattractant activity for lymphocytes and monocytes that are implicated in the pathogenesis of multiple sclerosis (MS) lesions. Glial cells have been shown to produce RANTES in response to stimulation with Th1 cytokines (IFN-gamma, TNF-alpha, and IL-1beta) in vitro, and they may be a major source of RANTES production within diseased brain. This study was undertaken to investigate the mechanism underlying the effect of the Th1 cytokines on the induction of RANTES in a model system for human astroglia. We show that IFN-gamma has a synergistic effect with TNF-alpha or IL-1beta on RANTES mRNA and chemokine production in this system. We further show that the combination treatment of IFN-gamma and TNF-alpha, or IFN-gamma and IL-1beta induced 3-fold higher levels of RANTES gene transcription than seen with either TNF-alpha or IL-1beta alone, as measured by in vitro nuclear transcript elongation assays. In addition, we found that IFN-gamma decreased the rate of degradation of RANTES mRNA caused by TNF-alpha or IL-1beta. The t(1/2) of RANTES mRNA was 25+/-1 h in the presence of both IFN-gamma and TNF-alpha, as compared to a t(1/2) of 15+/-1 h in the presence of TNF-alpha alone. This 10 h difference represents an approximate 70% increment in RANTES mRNA half-life. Thus, these results suggest that both increased RANTES gene transcription and increased RANTES mRNA stability may account for the synergistic effect of Th1 cytokines on the up-regulation of RANTES expression in human astroglial cells.

Glatiramer acetate blocks interleukin-1-dependent nuclear factor-kappaB activation and RANTES expression in human U-251 MG astroglial cells.

RANTES is a basic 8-kDa polypeptide of the C-C chemokine subfamily with strong chemoattractant activity for T lymphocytes and monocytes/macrophages that are implicated in the pathogenesis of multiple sclerosis (MS) lesions. Glatiramer acetate is a drug recently approved for the treatment of MS. We therefore investigated the effect of glatiramer acetate on RANTES expression in glial cells in vitro. Treatment of human U-251 MG astroglial cells with glatiramer acetate blocks IL-1beta-induced RANTES chemokine production in a dose- and time-dependent manner. Glatiramer acetate also decreased steady-state levels of RANTES mRNA in these cells, which was attributable to reduced transcription, as assessed by nuclear run-on assays. In addition, we showed that NF-kappaB may be the transcriptional activator responsible for the IL-1beta-mediated RANTES gene expression in this system. Our data indicated that the IL-1beta-induced increase in RANTES was associated with an increase in in vitro nuclear extract binding activity specific for the NF-kappaB site in the promoter region of the RANTES gene. The increases in RANTES mRNA and protein expression were suppressed by the NF-kappaB inhibitors gliotoxin, isohelenin, and pyrrolidine dithiocarbamate (PDTC). Furthermore, we demonstrated that the increase in NF-kappaB DNA-binding activity was prevented by pretreatment with glatiramer acetate or the NF-kappaB inhibitors. Our results suggest that glatiramer acetate may inhibit IL-1beta-stimulated RANTES expression in human glial cells by blocking NF-kappaB activation, thus identifying part of the molecular basis for its anti-inflammatory and immunosuppressive effects in demyelinating diseases.

Inactivation gating and 4-AP sensitivity in human brain Kv1.4 potassium channel.

Voltage-gated K(+) channels vary in sensitivity to block by 4-aminopyridine (4-AP) over a 1000-fold range. Most K(+) channel phenotypes with leucine at the fourth position (L4) in the leucine heptad repeat region, spanning the S4-S5 linker, exhibit low 4-AP sensitivity, while channels with phenylalanine exhibit high sensitivity. Mutational analysis on delayed rectifier type K(+) channels demonstrate increased 4-AP sensitivity upon mutation of the L4 heptad leucine to phenylalanine. This mutation can also influence inactivation gating, which is known to compete with 4-AP in rapidly inactivating A-type K(+) channels. Here, in a rapidly inactivating human brain Kv1.4 channel, we demonstrate a 400-fold increase in 4-AP sensitivity following substitution of L4 with phenylalanine. Accompanying this mutation is a slowing of inactivation, an acceleration of deactivation, and depolarizing shifts in the voltage dependence of activation and steady-state inactivation. To test the relative role of fast inactivation in modulating 4-AP block, N-terminal deletions of the fast inactivation gate were carried out in both channels. These deletions produced no change in 4-AP sensitivity in the mutant channel and approximately a six-fold increase in the wild type channel. These results support the view that changes at L4 which increase 4-AP sensitivity are largely due to 4-AP binding and may, in part, arise from alterations in channel conformation. Primarily, this study demonstrates that the fast inactivation gate is not a critical determinant of 4-AP sensitivity in Kv1.4 channels.

Multiple Sclerosis: Symptomatic Treatment.

Therapy for multiple sclerosis (MS) that prevents exacerbation of the disease and slows the progression of disability has not diminished the importance of treating symptoms. Because the new agents are not curative and rarely reverse existing deficits, many patients under treatment have or will have persistent symptoms. Many neurologic symptoms are seen in patients with MS, but it is important to recognize that some nonneurologic symptoms, such as pain, fatigue, and mood disturbance, are common and may cause significant disability. The first and most important step in the management of symptoms is to discuss the symptoms with the patient on an ongoing basis. The second step is to recognize treatable symptoms and to apply the appropriate strategies for management. There have been promising results with experimental agents, primarily potassium channel blockers, that may improve function in demyelin-ated fiber pathways and that offer the possibility of treatment for a range of symptoms. At present, the management of symptoms varies, depending on the symptom, and it involves the coordinated application of a range of treatment approaches including medication, lifestyle changes, rehabilitation, and, in some cases, surgery.

Modulation of interferon gamma induced increases in cathepsin B in THP-1 cells by adrenergic agonists and antagonists.

In order to investigate the possible modulation of macrophage function by the autonomic nervous system, the effect of adrenergic agonists and antagonists on interferon (IFN)-gamma-induced increases in cathepsin B (CB) in a macrophage-like cell line was studied. It has been shown previously that IFN-gamma induces increased CB activity in phorbol myristate acetate (PMA)-primed THP-1 cells. Isoproterenol (ISO) (10 micrometers), a mixed beta-receptor agonist, increased the induction of CB activity in the cells but norepinephrine (10 micrometers) and epinephrine (10 micrometers), the alpha and beta receptor agonists, had little effect. The addition of the mixed alpha-receptor antagonist phentolamine (10 micrometers) had no effect on ISO induced increases but the mixed beta-receptor antagonist propranolol (10 micrometers) and the selective beta1-receptor antagonist atenolol produced significant inhibition. These results suggest that the activation of beta-receptors could be involved in the induction of CB activity in macrophages and provide a possible mechanism for the regulation of macrophage effector function by the autonomic nervous system. Dibutyryl cAMP (1 mm) alone also induced increases in CB in THP-1 cells, and H-89 or HA1004 abrogated the effect of dibutyryl cAMP, suggesting that the effect of ISO on CB could be through the elevation of cAMP and the activation of cAMP-dependent protein kinases.

Effects of IFN-beta on human cerebral blood flow distribution.

The effect of interferon-beta1b (IFN-beta) on human cerebral blood flow distribution was examined in five multiple sclerosis patients using functional brain single-photon emission tomography (SPECT). Of nine regions of interest studied, only the basal ganglia exhibited a significant change (increase) in relative photon emission intensity (i.e., relative blood flow) when comparing SPECT scans obtained 6 h after s.c. IFN-beta injection with scans obtained at the same time of day (noon) 30 h after IFN-beta injection (IFN-beta-free day). The increase in relative blood flow to the basal ganglia following IFN-beta injection correlated positively with changes in mean arterial pressure (MAP). Additional studies will be required to determine the relevance of these observations for IFN-beta-induced central nervous system side effects.

Neurologic symptoms following Pfiesteria exposure: case report and literature review.

Although the recently identified dinoflagellate, Pfiesteria piscicida, may have neurotoxic effects on humans, the precise nature of the neurologic symptoms associated with varying levels of exposure is unknown. Toward this end, we review the neurologic symptoms of three Pfiesteria-exposed laboratory workers reported to data and compare them to the evaluation of an exposed waterman from Maryland. The occupational exposure of a Maryland waterman appears to produce a mild, reversible encephalopathy which predominantly affects functions associated with the frontal and temporal lobes. A comprehensive neurologic examination is recommended for all Pfiesteria piscicida and morphologically related organism-exposed, symptomatic persons.

Effect of protein kinase modulators on the regulation of cathepsin B activity in THP-1 human monocytic leukemia cells.

Cathepsin B (CB), a lysosomal cysteine proteinase, is implicated in cancer metastasis and inflammatory tissue injury. We examined the effects of the protein kinase agonists and inhibitors on the regulation of CB activity in THP-1 human monocytic cells by two macrophage activators, lipopolysaccharide (LPS) and interferon- (IFN- ). CB elevation induced by LPS alone or LPS followed by IFN- was blocked by protein kinase C (PKC) inhibitors staurosporine, H-7, phloretin and bisindolylmaleimide, and by cyclic nucleotide-dependent protein kinase inhibitors HA 1004, H-8, H-89 and cAMP-dependent protein kinase (PKA) inhibitor. The CB activity by LPS and IFN- were augmented by diacylglycerol kinase inhibitor. PKC activator, phorbol 12-myristate 13-acetate (PMA) and PKA activator, dibutyryl cAMP could replace LPS in priming the cells for IFN- stimulation but 8-bromo-cGMP did not. These findings suggest that the activation of PKC and PKA appears to be involved at least in part in the induction of CB activity in THP-1 cells.

Glatiramer acetate blocks the activation of THP-1 cells by interferon-gamma.

Glatiramer acetate (previously known as copolymer 1) is a synthetic copolymer of four amino acids that has been approved for use in the treatment of multiple sclerosis. It has been shown to suppress myelin antigen specific T cell activation by competing with these antigens at the major histocompatibility complex class II binding site and by inducing antigen specific suppressor T cells. In this study we investigated the effects of glatiramer acetate on the human monocytic cell line, THP-1, activated by lipopolysaccharide and interferon-gamma as a model for macrophages. At non-toxic concentrations of glatiramer acetate there were dose dependent reductions in the percentage of cells expressing human leukocyte DR and DQ antigen as well as in mean fluorescence intensity by flow cytometry. Production of tumor necrosis factor-alpha and the lysosomal cysteine proteinase cathepsin B were markedly inhibited, but production of interleukin-1 increased. These results suggest that glatiramer acetate might alter macrophage effector function and suggest that further studies in human monocytes and macrophages are warranted.

Effect of propranolol and IFN-beta on the induction of MHC class II expression and cytokine production by IFN-gamma IN THP-1 human monocytic cells.

This study was undertaken to investigate the effects of propranolol, IFN-beta, and the protein kinase modulators on IFN-gamma induction of MHC class II antigen expression and cytokine production in THP-1 human monocytic cells. IFN-gamma induced expression of HLA-DR and DQ molecules and secretion of the monokines IL-1 beta and TNF-alpha in THP-1 cells in a time and dose-dependent manner. The effect of INF-gamma on class II HLA antigens was dose-dependently inhibited by IFN-beta. H-7, phloretin, staurosporine as well as GF 109203X are selective enzyme inhibitors of protein kinase C (PKC), down-regulating IFN-gamma induced MHC class II expression and cytokine production. Stimulators of PKC, like PMA, replaced IFN-gamma in the induction of monokines in THP-1 cells, whereas the addition of HA 1004 or arachidonic acid to the culture had no effect on IFN-gamma mediated changes. Blocking of phospholipase D (PLD)-derived diacylglycerol (DAG) formation by propranolol abrogated IFN-gamma increased HLA class II expression and IL-1 beta secretion, but had little effect on IFN-gamma induced TNF-alpha production. These findings appear to suggest that PLD-derived phosphatidate is not the primary source of DAG production in IFN-gamma-induced TNF-alpha secretion, but may be necessary for IFN-gamma-mediated MHC class II induction and IL-1 beta production in human monocytes, whereas phospholipase A2 may not be required for IFN-gamma activation of PKC in the process.