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Cognitive dysfunction occurs in up to 65% of patients with multiple sclerosis (MS), but there is no effective treatment for the symptoms. The authors conducted a 12-week, open-pilot study to assess the efficacy and tolerability of donepezil HCl administered in patients with MS and cognitive impairment. Seventeen patients at a long-term care facility with Mini-Mental State Examination scores of < or = 25 received 5 mg of donepezil HCl for a 4-week period, followed by 8 weeks of 10 mg of donepezil HCl. Cognitive, neurologic, functional, and behavioral assessments were conducted at baseline and at 4 and 12 weeks. Statistically significant improvement was observed in several cognitive domains including attention, memory, and executive functioning, as well as different aspects of behavior. These data suggest that donepezil HCl merits further study as a potentially viable treatment option for patients with cognitive impairment associated with MS.

CapitationSir: William M. Glazer says that "capitation should bring an end to reviewers as we have known them" (Supplement 2).

The balance between the risks and benefits of mass vaccination in prevention of an epidemic is not clear. The Centers for Disease Control and Prevention has established a guideline for appropriate use of smallpox vaccine in the civilian population.

Background. The use of sodium polystyrene sulfonate in decreasing serum potassium has recently been questioned due to the lack of documented effectiveness. Methods. A retrospective cohort analysis of all hospitalized patients who received sodium polystyrene sulfonate over four months was performed. The change in serum potassium was noted over a period of 24 hours. Patients who received any other form of potassium-altering drug or treatment were excluded. Results. The administration of sodium polystyrene sulfonate reduced serum potassium by 16.7% (P < 0.001) as compared to the baseline serum potassium over a period of 24 hours. During this same time, no change in serum creatinine was identified (P = 0.73). In addition, there was no correlation between potassium and creatinine change (r2 = 0.0004 and P = 0.99). Patients with higher initial serum potassium (≥5.6 mEq/L) reduced their potassium concentration 4% more than those with initial serum potassium of <5.6 mEq/L; however, this reduction did not reach statistical significance (P = 0.32). There was no significant difference in the effectiveness of 15 gm and 30 gm resin preparation (P = 0.54). Thirteen deaths were noted in our cohort, of which one death was due to ischemic colitis. Conclusion. We conclude that sodium polystyrene sulfonate is effective in lowering serum potassium.