Abnormal clinical presentation and surgical outcome of an intraventricular cavernoma of the third ventricle

We present a unique case of a man presenting with progressive short-term memory deficits over 10+ years who was found to have a large intraventricular cavernoma in the anterior wall of the third ventricle with invasion of medial limbic structures. Identifying intraventricular cavernomas early is crucial to prevent substantial growth and to increase the chance of successful patient outcomes.

Implementation and review of the care ecosystem in an integrated healthcare system

BACKGROUND AND OBJECTIVES

The University of California, San Francisco Memory and Aging Center (UCSF-MAC) led the development and tested a collaborative care model delivered by lay care team navigators (CTNs) with support from a multidisciplinary team known as the Care Ecosystem (CE). We evaluated outcomes related to the feasibility of the CE in a non-academic healthcare system, including acceptability, adoption, and fidelity to the original UCSF model.

RESEARCH DESIGN AND METHODS

The CE team at HealthPartners consisted of two CTNs, a social worker, an RN, a program coordinator, and a behavioral neurologist. Intake forms were developed to collect demographic, baseline, and annual data at one year related to dementia severity and caregiver status. Experience surveys were completed at 6 and 12 months by participating caregivers. All data was entered into REDCap.

RESULTS

A total of 570 PWD-caregiver dyads were recruited into the CE: 53% PWDs female, average age 75.2 ± 9.43, 19% living within rural communities. Of the 173 dyads assessed at one year, 30% responded to the annual intake forms and 58% of responded to experience surveys. At one year, PWDs progressed in disease severity and functional impairment, although caregiver burden and mood remained unchanged. We observed a significant reduction in caregiver reported emotional challenges associated with caregiving, sleep problems, and obtaining caregiver help at one year. 86% of caregivers reported feeling supported by their CTN nearly always or quite frequently, and 88% rated the CTN as highly responsive to what was important to them.

DISCUSSION AND IMPLICATIONS

The CE was feasible and well-received within a non-academic healthcare system.

Stroke Characteristics in a Cohort of Hmong American Patients

Background Prior studies have indicated high rates of vascular risk factors, but little is known about stroke in Hmong. Methods and Results The institutional Get With The Guidelines (GWTG) database was used to identify patients discharged with acute ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage between 2010 and 2019. Hmong patients were identified using clan names and primary language. Univariate analysis was used to compare Hmong and White patients. A subarachnoid hemorrhage comparison was not conducted because of the small sample size. We identified 128 Hmong patients and 3084 White patients. Hmong patients had more prevalent hemorrhagic stroke (31% versus 15%; P<0.0016). In the acute ischemic stroke cohort, compared with White patients, Hmong patients were younger (60±13 versus 71±15 years; P<0.0001), presented to the emergency department almost 4 hours later; and had a lower thrombolysis usage rate (6% versus 14%; P=0.03496), worse lipid profile, higher hemoglobin A1C, similar stroke severity, and less frequent discharge to rehabilitation facilities. The most common ischemic stroke mechanism for Hmong patients was small-vessel disease. In the intracerebral hemorrhage cohort, Hmong patients were younger (55±13 versus 70±15 years; P<0.0001), had higher blood pressure, and had a lower rate of independent ambulation on discharge (9% versus 30%; P=0.0041). Conclusions Hmong patients with stroke were younger and had poorer risk factor control compared with White patients. There was a significant delay in emergency department arrival and low use of acute therapies among the Hmong acute ischemic stroke cohort. Larger studies are needed to confirm these observations, but action is urgently needed to close gaps in primary care and stroke health literacy.

A Phase II, Single-Center, Randomized, Double-Blind, Placebo-Controlled Study of the Safety and Therapeutic Efficacy of Intranasal Glulisine in Amnestic Mild Cognitive Impairment and Probable Mild Alzheimer's Disease

BACKGROUND

Intranasal insulin is a potential treatment for neurodegenerative disease shown to increase cerebral glucose uptake, reduce amyloid plaques, and improve verbal memory in cognitively impaired as well as healthy adults. Investigations have suggested rapid-acting insulins such as glulisine may result in superior cognitive benefits compared with regular insulin.

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of rapid-acting intranasal glulisine in subjects with amnestic mild cognitive impairment (MCI) or mild probable Alzheimer's disease (AD).

METHODS

We performed a single-center, randomized, double-blind, placebo-controlled study to evaluate the efficacy of intranasal glulisine 20 IU twice daily versus saline placebo in 35 memory-impaired (MCI/AD) subjects using the Impel NeuroPharma I109 Precision Olfactory Delivery (POD^®) device. The 13-item Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog13), Clinical Dementia Rating (CDR) global score, and Functional Assessment Questionnaire (FAQ) were measured at baseline and 3 and 6 months. Secondary outcome measures included digit span forward/backwards, Trail Making Test Parts A/B, Controlled Oral Word Association Test (COWAT), and Weschler Memory Scale (WMS)-IV logical memory. Adverse effects (AEs) and serious adverse effects (SAEs) were measured along with blood glucose/insulin levels.

RESULTS

No significant difference in ADAS-Cog13, CDR Sum of Boxes (CDR-SOB), or FAQ scores were found between treatment groups at 3 and 6 months. Subjects in the saline group were significantly older than those in the glulisine group (p = 0.022). No significant differences in sex, education, apolipoprotein E4 (ApoE4) status, and Montreal Cognitive Assessment (MoCA) score existed between treatment groups. Overall, the number of adverse events per person was similar between groups (2.32 vs. 2.24; p = 0.824), although subjects receiving intranasal glulisine had higher rates of nasal irritation (25.0% vs. 13.9%) and respiratory symptoms (15.9% vs. 8.3%) compared with placebo. There were no differences in blood sugar or rate of hypoglycemia between the treatment and placebo groups.

CONCLUSIONS

Intranasal glulisine was relatively safe and well-tolerated and did not consistently impact peripheral glucose or insulin levels. There were no enhancing effects of intranasal glulisine on cognition, function, or mood, but the ability to detect significance was limited by the number of subjects successfully enrolled and the study duration. CLINICALTRIALS.

GOV REGISTRATION

NCT02503501.

Intranasal Insulin: a Treatment Strategy for Addiction

Addiction to substances such as alcohol, cocaine, opioids, and methamphetamine poses a continuing clinical and public challenge globally. Despite progress in understanding substance use disorders, challenges remain in their treatment. Some of these challenges include limited ability of therapeutics to reach the brain (blood-brain barrier), adverse systemic side effects of current medications, and importantly key aspects of addiction not addressed by currently available treatments (such as cognitive impairment). Inability to sustain abstinence or seek treatment due to cognitive deficits such as poor decision-making and impulsivity is known to cause poor treatment outcomes. In this review, we provide an evidenced-based rationale for intranasal drug delivery as a viable and safe treatment modality to bypass the blood-brain barrier and target insulin to the brain to improve the treatment of addiction. Intranasal insulin with improvement of brain cell energy and glucose metabolism, stress hormone reduction, and improved monoamine transmission may be an ideal approach for treating multiple domains of addiction including memory and impulsivity. This may provide additional benefits to enhance current treatment approaches.

IMPLEMENTATION OF A MINDFULNESS BASED DEMENTIA-CARE PROGRAM WITHIN A HEALTHCARE SYSTEM

The stress associated with caring for a loved one with Alzheimer’s disease or a related dementia can negatively affect mental and physical health. Mindfulness-based stress reduction (MBSR), teaching caregivers to focus on the present moment with non-judgmental awareness, has been shown to improve overall mental health, reduce perceived stress, and decrease depression. At HealthPartners, we implemented the Mindfulness Based Dementia-Care (MBDC) program, an 8-week program designed for family caregivers for those living with dementia. MBDC combines teaching of MBSR skills along with essential education for this chronic disease. Participants attend a 1-hour orientation session, 2-hour classes each week for 8 weeks, at-home practice between classes, and a 6-hour Saturday retreat. Secure electronic surveys are administered at baseline, program completion and follow-up for evaluation of the program. We will discuss barriers and learnings of implementation as well as preliminary results from the evaluation.

Abstract TP370: Performance of a New “Code Stroke” Process in Hospitalized Patients in a Comprehensive Stroke Center in Minnesota

Background and Purpose: Literature suggests that recognition and management of stroke of hospitalized patients is difficult, and the morbidity and mortality rates of in-patient strokes exceed those of out of hospital stroke. Timely treatment is an important factor for a favorable prognosis for hospitalized patients suspected of having a stroke. A new protocol for in-patient stroke was implemented as a quality improvement project at our comprehensive stroke center starting January 2017.

Methods: The new protocol included focused nursing education, replacement of 2-step activation process with 1-step process whereby the bedside nurse activates ‘Code Stroke’ using same criteria as used by EMS and ED triage nurses. Code Stroke activates a specialized stroke team (neurologist, ICU physicians, ICU nurses, pharmacy) and clears the CT scanner. Accurate documentation was encouraged and template notes were provided. Expectations were put forth regarding the relevant quality metrics. Feedback was provided in real-time as well as in writing, to participating care team. This analysis was done utilizing data from a prospectively maintained database of inpatient stroke, feedback communications, and chart review. The following metrics were used to examine the performance of the new process: rate of stroke symptoms identification, errors in paging, errors in documentation, time to CT, and outcome of code activation.

Results: In the 6 months prior to the new protocol, a ‘Code Stroke’ was activated 5 times, only one was a true stroke and was treated with thrombectomy. In the 6 months after the new protocol, ‘Code Stroke’ was activated 46 times, with 15 confirmed strokes (14 ischemic, 1 hemorrhagic). A change in care occurred for 13 patients, including IV alteplase (n=2), thrombectomy (n=1), change in medical management (n=9), and decompressive hemicraniectomy (n=1). Mean time for Code Stroke to CT was 26 minutes despite errors in pages (wrong call back number, incorrect code designation).

Conclusion: Our new process increases detection and treatment of in-patient strokes. Elements of success include system-wide organization, simplifying the process, mirroring ED process, and availability of stroke response team.

Abstract WP228: Clinical Characteristics of Hmong Patients Presenting with Acute Ischemic Stroke

Introduction: Hmong people are originally from the mountainous areas of Southeastern China, Northern Vietnam, Laos, and Thailand. Large numbers have migrated to the USA. In response to a request from leaders of the Hmong community and given the lack of literature, this study was conducted to describe ischemic stroke in the Hmong patients at our comprehensive stroke center.

Methods: Institutional GWTG database and charts for years 2010-2015 were retrospectively reviewed. Hmong patients were identified by their last names (18 clans) provided by the Hmong community leaders. Different demographic, social, and clinical aspects were reported and compared to white patients in a univariate analysis.

Results: Forty-one Hmong and 1510 White were included in the analysis. Compared to Whites, Hmong patients were significantly younger (60±2.16 vs. 70±0.39 years # ), predominantly women (66% vs. 48%; p=0.03), less frequently covered by medical insurance (68% vs. 87% # ) and less frequently brought by ambulance (44% vs. 54% # ). Onset-to-door time, door-to-needle time, NIHSS at admission, and incidence of vascular risk factors was similar between the two groups; however, Hmong patients seemed to have poorly controlled risk factors with mean A1C 11±0.9% in diabetics (n=13) and mean LDL 116±6.4 mg/dL in hyperlipidemics (n=16). The most common stroke mechanisms were small vessel (31%) and intracranial atherosclerotic diseases (27%). Based on imaging in Hmong patients; 56% had intracranial arterial calcification, 53% had microaniopathic disease, 46% had intracranial stenosis, and 18% extracranial stenosis. On echocardiogram, 68% of Hmong had left ventricular hypertrophy, 54% had dilated left atrium, one patient had hypokinesis, and none had low ejection fraction. The length of stay and the rate of independent ambulation on discharge were not different between Hmong and Whites, however, a larger proportion of Hmong were discharged home (59% vs. 46%; p=0.05). # p≤0.0005

Conclusion: In this study population, Hmong patients suffered from poorly controlled risk factors, had high incidence of small vessel and intracranial atherosclerotic disease, low incidence of carotid disease and heart failure and utilized fewer resources than Whites.

Expression of Podoplanin in Different Grades of Oral Squamous Cell Carcinoma

Background:

The expression of podoplanin is up-regulated in a number of different human cancers, including squamous cell carcinoma of the oral cavity and its relationship with tumor invasion raises the possibility that podoplanin expression could be used as a biomarker for diagnosis and prognosis.

Aim:

The aim of the present study is to evaluate the expression of podoplanin in different grades of squamous cell carcinoma (SCC) and to correlate the expression of podoplanin with relevant clinical features such as age, sex, site and associated habits.

Materials and Methods:

Retrospective study was carried on formalin fixed, paraffin embedded blocks of oral SCC (OSCC) from the archives of Department of Oral and Maxillofacial Pathology, Vishnu Dental College, Bhimavaram. Thirty diagnosed cases were included, of which 10 were well-differentiated SCC (WDSCC) (n = 10), 10 moderately DSCC and 10 poorly DSCC. Demographics including age, sex, gender and associated habit history, were recorded. Immunohistochemical staining was done with podoplanin anti D2–40 antibody, for all the cases of OSCC and assessed qualitatively. The data obtained were tabulated and subjected to statistical analysis.

Results:

In the present study, 27 cases of SCC showed podoplanin expression and remaining three cases showed no expression. The scoring criterion suggested by Yuan et al. was followed for semi-quantitative assessment. OSCC, seven cases presented weak expression (Immunoreactive score [IRS] 0–3), 15 presented moderate expression (IRS Score 4–7) and 5 presented high expression (IRS Score > 8). The assessment of podoplanin expression in the cytoplasm, the membrane and the cytoplasm and membrane (both) of tumor cells showed overall high positivity in the cytoplasmic followed by both and the membrane.

Conclusion:

Podoplanin could be a potent biomarker in assessing the cytoplasm/membrane staining of tumor cells. Furthermore, a high level of podoplanin expression is suggestive of high frequency of lymph node metastasis and immature status in the differentiation process of OSCC.

Current status of multidrug resistant tuberculosis in a tertiary care hospital of East Delhi

BACKGROUND AND OBJECTIVE

Multidrug resistant tuberculosis (MDR-TB) is caused by infection due to Mycobacterium tuberculosis which is resistant to both isoniazid (INH) and rifampicin (RIF). It is caused by selection of resistant mutant strains due to inadequate treatment and poor compliance. MDR-TB is a major public health problem as the treatment is complicated, cure rates are well below those for drug susceptible tuberculosis and patient remains infectious for months despite receiving the best available therapy. The drug susceptibility pattern of M. tuberculosis is essential for proper control of MDR-TB in every health care setting, hence the study was initiated with the aim of studying the prevalence of MDR-TB in patients attending a tertiary care hospital in east Delhi.

MATERIALS AND METHODS

Five hundred and forty-three pulmonary and extrapulmonary samples from suspected cases of tuberculosis received in the mycobacteriology laboratory from November 2009 through October 2010 were investigated for M. tuberculosis. All the samples were subjected to direct microscopic examination for demonstration of acid fast bacilli followed by culture on Lowenstein-Jensen (LJ) medium to isolate M. tuberculosis. Identification was done by conventional biochemical methods. Drug susceptibility of isolated M. tuberculosis strains was done by conventional 1% proportion method followed by sequencing of RIF resistant isolates to detect mutations to confirm resistance.

RESULTS AND CONCLUSIONS

M. tuberculosis was isolated from 75 out of 543 suspected cases of pulmonary/extrapulmonary TB. Three of the total 75 M. tuberculosis isolates (4%) showed resistance to any one of the first line drugs. Prevalence of MDR-TB was 1.3%. The sequencing of single MDR strain showed mutations at codons 516, 517, and 518. Amplification of rpoB and sequential analysis of the amplicon is a better way of detection of mutation and the evidence of new mutation in this study indicate that mutations continue to arise, probably due to the ability of M. tuberculosis to adapt to drug exposure.

Eye-specific gene expression following embryonic ethanol exposure in zebrafish: roles for heat shock factor 1

The mechanisms through which ethanol exposure results in developmental defects remain unclear. We used the zebrafish model to elucidate eye-specific mechanisms that underlie ethanol-mediated microphthalmia (reduced eye size), through time-series microarray analysis of gene expression within eyes of embryos exposed to 1.5% ethanol. 62 genes were differentially expressed (DE) in ethanol-treated as compared to control eyes sampled during retinal neurogenesis (24-48 h post-fertilization). The EDGE (extraction of differential gene expression) algorithm identified >3000 genes DE over developmental time in ethanol-exposed eyes as compared to controls. The DE lists included several genes indicating a mis-regulated cellular stress response due to ethanol exposure. Combined treatment with sub-threshold levels of ethanol and a morpholino targeting heat shock factor 1 mRNA resulted in microphthalmia, suggesting convergent molecular pathways. Thermal preconditioning partially prevented ethanol-mediated microphthalmia while maintaining Hsf-1 expression. These data suggest roles for reduced Hsf-1 in mediating microphthalmic effects of embryonic ethanol exposure.

Ethanol-induced microphthalmia is not mediated by changes in retinoic acid or sonic hedgehog signaling during retinal neurogenesis

BACKGROUND

Microphthalmia (reduced eye size), generally accompanied by vision defects, is a hallmark of fetal alcohol spectrum disorder (FASD) in humans. In zebrafish, embryonic ethanol exposure over the time of retinal neurogenesis also results in microphthalmia. This microphthalmia is in part the consequence of reduced retinal cell differentiation, including photoreceptors. Here we pursue 2 signaling pathways implicated in other aspects of FASD pathogenesis: retinoic acid (RA) and Sonic hedgehog (Shh).

METHODS

We evaluated markers for RA and Shh signaling within the eyes of embryos treated with ethanol during the period of retinal neurogenesis. We also performed rescue experiments using administration of exogenous RA and microinjection of cholesterol, which augments Shh signaling.

RESULTS

Using sequential or co-treatments, RA did not rescue ethanol-induced microphthalmia at any concentration tested. In addition, RA itself caused microphthalmia, although the underlying mechanisms were distinct from those of ethanol. Interestingly, RA treatment appeared to recover photoreceptor differentiation in a concentration-dependent manner. This may be an independent effect of exogenous RA, as ethanol treatment alone did not alter RA signaling in the eye. Cholesterol injection also did not rescue ethanol-induced microphthalmia at any concentration tested, and ethanol treatments did not alter expression of shh, or of ptc-2, which is normally regulated by Shh signaling.

CONCLUSIONS

Together these findings indicate that, during the time of retinal neurogenesis, effects of ethanol on eye development are likely independent of the RA and Shh signaling pathways. These studies suggest that FASD intervention strategies based upon augmentation of RA or Shh signaling may not prevent ethanol-induced microphthalmia.

Profile of direct walk-in and referred clients attending Integrated Counselling and Testing Centre

The HIV pandemic has had a profound impact on the health and economic conditions of individuals, and people living with HIV/AIDS are faced with the task of maintaining optimal health status despite an increasing insult to their immune status. The aim of the present study was to study the profile of direct walk-in and referred patients attending the Integrated Counselling and Testing Centre (ICTC) of a tertiary care hospital, which may provide important clues to understanding the epidemiology of the disease in a particular region. The study included all the attendees of the ICTC referred from the hospital or direct walk-in from January 2007 to December 2007. Three rapid HIV tests were used and the samples showing positive results in all the three tests were declared HIV positive. The results were analysed to correlate between HIV positivity, age, sex, route of transmission and direct walk-in/referred patients. A low proportion of ICTC attendees (27%) in our study were direct walk-ins. As regards HIV positivity, 312 (8.3%) out of 2440 males and 164 (4.3%) out of 1315 females were HIV positive. Among the referred HIV-positive patients 162 were males and 62 females, whereas among the direct walk-in HIV-positive patients, 150 were males and 102 females. Integrated counselling and testing is now seen as a key entry point for HIV prevention. In addition to scaling up ICTC services, it is also important to raise awareness by aggressive health education programmes and integration of ICTC into various community organizations.

Cytomegalovirus infection: an Indian perspective

Human cytomegalovirus (CMV) poses an important public health problem as it may cause serious morbidity and mortality in congenitally infected newborns and immunocompromised patients, most notably transplant recipients and HIV-infected persons. It is probably one of the most common infections known to humans and is characterized by a self-limiting infection in healthy individuals. CMV infection is the single most frequent cause of infectious complications in the early period following kidney transplantation Post-transfusion cytomegalovirus infection is of concern in the immunocompetent as well as in certain categories of immunocompromised individuals such as neonates, pregnant women, recipients of bone marrow and other organ transplants and individuals with immunodeficiency disorders. The emergence of AIDS in India has necessitated the establishment of reliable tests for diagnosis of cytomegalovirus infection as a damaged immune system permits cytomegalovirus reactivation. The magnitude of this problem in India and the various diagnostic modalities used have not been adequately investigated and, hence, CMV infection is still a major health problem warranting strong preventive measures. The ultimate goal of the prevention program is to develop a vaccine that can be administered to seronegative women of childbearing age to prevent primary infection during pregnancy.

Onychomycosis--epidemiology, diagnosis and management

Onychomycosis is a fungal infection of nails caused by dermatophytes, yeasts or nondermatophyte molds and represents about 30% of mycotic cutaneous infections. Increasingly onychomycosis is being viewed as more than a mere cosmetic problem. In spite of improved personal hygiene and living environment, onychomycosis continues to spread and persist. The prevalence rate of onychomycosis is determined by age, predisposing factor, social class, occupation, climate, living environment and frequency of travel. Onychomycosis in immunocompromised patients can pose a more serious health problem. Dermatophytes are the most frequently implicated causative agents in onychomycosis. Previously regarded as contaminants, yeasts are now increasingly recognised as pathogens in fingernail infections, as are some moulds. Clinical diagnosis of onychomycosis is based on the patients' history; a physical examination, microscopy and culture of nail specimens. The treatment of onychomycosis has been attempted throughout the ages, but only in the last two decades have safe, effective systemic treatments been available for this chronic superficial fungal disease. Oral Griseofulvin and Ketoconazole; once the agents of choice for the treatment of onychomycosis, have been superseded by newer systemic compounds that have a higher cure and lower relapse rates, cause fewer side effects and are suitable for short-term dosing.

Mechanisms for persistent microphthalmia following ethanol exposure during retinal neurogenesis in zebrafish embryos

The exposure of the developing human embryo to ethanol results in a spectrum of disorders involving multiple organ systems, including the visual system. One common phenotype seen in humans exposed to ethanol in utero is microphthalmia. The objective of this study was to describe the effects of ethanol during retinal neurogenesis in a model organism, the zebrafish, and to pursue the potential mechanisms by which ethanol causes microphthalmia. Zebrafish embryos were exposed to 1% or 1.5% ethanol from 24 to 48 h after fertilization, a period during which the retinal neuroepithelium undergoes rapid proliferation and differentiation to form a laminated structure composed of different retinal cell types. Ethanol exposure resulted in significantly reduced eye size immediately following the treatment, and this microphthalmia persisted through larval development. This reduced eye size could not entirely be accounted for by the accompanying general delay in embryonic development. Retinal cell death was only slightly higher in ethanol-exposed embryos, although cell death in the lens was extensive in some of these embryos, and lenses were significantly reduced in size as compared to those of control embryos. The initiation of retinal neurogenesis was not affected, but the subsequent waves of cell differentiation were markedly reduced. Even cells that were likely generated after ethanol exposure--rod and cone photoreceptors and Müller glia--were delayed in their expression of cell-specific markers by at least 24 h. We conclude that ethanol exposure over the time of retinal neurogenesis resulted in persistent microphthalmia due to a combination of an overall developmental delay, lens abnormalities, and reduced retinal cell differentiation.