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Two articles and an editorial consider the genetics of MS. Mann et al. (p. 552) studied the genetic markers of glutathione S-transferase in a large population of MS patients in England. Certain GST phenotypes were more likely to be disabled by MS. Conversely, Steckley et al. (p. 729) found no relationship between vitamin D-related genes and MS. The accompanying editorial by Weinshenker and Kantarci (p. 542) examines the strategies that the two papers use and consider how the genetics of MS will finally be unraveled.
Alzheimer’s disease: anti- inflammatory drugs
In epidemiologic studies, antiinflammatory drugs appear to have a protective effect against AD. Aisen et al. (p. 588) conducted a one-year controlled trial of low dose prednisone in AD. It was not of benefit. Mackenzie (p. 732) studied AD neuropathology in nondemented subjects who had taken nonsteroidal antiinflammatory drugs (NSAIDs). There was no effect of NSAIDs on senile plaques or neurofibrillary tangles. This paper complements the previous one and suggests that NSAIDs may be more effective than corticosteroids because NSAIDs are considered likely to affect microglial activation.
Treatment of Lambert-Eaton myasthenic syndrome
A randomized controlled trial by Sanders et al. (p. 603) compared 3,4-DAP with placebo in LEMS. 3,4-DAP resulted in significant improvement by clinical and EMG measures. The only side effects were perioral and digital paresthesias.
Seizures, Epilepsy
Berg et al. (p. 625) investigated the proportion of patients with uncontrolled epilepsy who continued to drive against advice despite the risks, and examined what factors predicted that a given patient would persist in driving. Over 30% of 367 patients had driven, most at least weekly. Women and patients who were unemployed were less likely to drive. Nearly 40% had auto accidents. Gilbert and Buncher (p. 635) analyzed the value of EEG in the diagnostic evaluation of a first childhood seizure in published studies. Only four studies (831 children) were suitable for analysis. Quantification of sensitivity, specificity, and the probability of recurrence indicated that routine EEG provides too little information to alter treatment. Two studies consider the outcome of epilepsy surgery. Paolicchi et al. (p. 642) followed 75 children under 12 years of age for at least one year following surgery. A good outcome was seen with 77% (seizure-free 59%). Complete resection of the focus improved outcome (92% seizure-free). Otherwise, it was not possible to predict outcome. Foldvary et al. (p. 630) analyzed seizure out- come in 79 subjects with follow-up of at least 2 years after surgery (mean 14 years). Seizure-free status at two years was predictive of long-term outcome. Of the 55% who had at least one post-surgery seizure, 86% occurred within 2 years.
Stroke
Buchan et al. (p. 679) examined t-PA use by neurologists in 68 consecutive acute strokes seen in a teaching hospital. Using control data from the NINDS t-PA study, their experience showed t-PA to be effective with a number needed to treat of six. The risk of hemorrhage and death was significantly increased (and the benefits less) in patients who were treated in violation of the appropriate protocol. Toni et al. (for the ECASS I group) (p. 684) studied whether it was possible to identify lacunar infarcts by either clinical presentation or early CT. A 7-day CT was used to define lacunar infarcts. Neither clinical picture nor initial, early CT were able to predict that a stroke was lacunar. Inzitari et al. (p. 660) categorized strokes in the NASCET study as nonlacunar, possible-lacunar, and probable-lacunar. They examined risk factors as well as outcome with surgery. Diabetes and hyperlipidemia were more important than hypertension as risk factors for lacunar strokes. Lacunar strokes were more often seen with lesser degrees of carotid stenosis. Endarterectomy was of less benefit for patients with evidence of lacunar strokes.
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