No abstract

Previous studies reported that a 2- to 3-week course of IV cyclophosphamide plus adrenocorticotropic hormone (ACTH) induction can temporarily halt progressive MS for a period of 12 months in the majority of patients treated, after which reprogression occurs. The Northeast Cooperative Multiple Sclerosis Treatment Group was formed to determine whether outpatient pulse cyclophosphamide therapy could affect reprogression and whether there were differences between a modified induction regimen and the previously published regimen. Two hundred fifty-six progressive MS patients were randomized into four groups to receive IV cyclophosphamide/ACTH via the previously published versus a modified induction regimen, with or without outpatient IV cyclophosphamide boosters (700 mg/m2 every other month for 2 years). There were blinded evaluations performed every 6 months. Results demonstrate that (1) there were no differences between the modified and the published induction regimens either in terms of initial stabilization or subsequent progression; (2) without boosters, the majority of patients continued to progress; and (3) in patients receiving boosters, there was a statistically significant benefit at 24 months and 30 months (p = 0.04). Time to treatment failure after 1 year was also significantly prolonged in the booster versus the nonbooster group (p = 0.03). Age was the most important variable that correlated with response to therapy in that amelioration of disease progression occurred primarily in patients 40 years of age or younger. Boosters had a significant benefit on time to treatment failure in patients ages 18 to 40, p = 0.003, but not in patients ages 41 to 55, p = 0.97.(ABSTRACT TRUNCATED AT 250 WORDS)

The prevalence of burnout is higher in physicians than in other professions and is especially high in neurologists. Physician burnout encompasses 3 domains: (1) emotional exhaustion: the loss of interest and enthusiasm for practice; (2) depersonalization: a poor attitude with cynicism and treating patients as objects; and (3) career dissatisfaction: a diminished sense of personal accomplishment and low self-value. Burnout results in reduced work hours, relocation, depression, and suicide. Burned-out physicians harm patients because they lack empathy and make errors. Studies of motivational factors in the workplace suggest several preventive interventions: (1) Provide counseling for physicians either individually or in groups with a goal of improving adaptive skills to the stress and rapid changes in the health care environment. (2) Identify and eliminate meaningless required hassle factors such as electronic health record "clicks" or insurance mandates. (3) Redesign practice to remove pressure to see patients in limited time slots and shift to team-based care. (4) Create a culture that promotes career advancement, mentoring, and recognition of accomplishments.

Seven patients with cancer complicated by nonmetastatic sagittal sinus thrombosis were encountered in a 7-year period. Five had hematologic malignancies and two had solid tumors. There were two different presentations. In the first, neurologic signs and symptoms (e.g., headaches, seizures, hemiparesis, lethargy) occurred suddenly in five patients shortly after initiation of cancer therapy. Four of these five patients recovered with minimal residua; the fifth died as a direct result of the sinus thrombosis. The second presentation occurred in the two patients with terminal cancer who declined gradually without focal signs; both patients died. Only arteriography can reliably establish the diagnosis of sagittal sinus occlusion. In patients with cancer, sagittal sinus occlusion probably results from a "hypercoagulable state" associated with the systemic neoplasm.