Peering further into the mind's eye: combining visual evoked potential and optical coherence tomography measures enhances insight into the variance in cognitive functioning in multiple sclerosis

BACKGROUND

Spectral Optical Coherence Tomography (OCT) and Visual Evoked Potentials (VEPs) have both emerged as potentially useful biomarkers of cognitive decline in people with multiple sclerosis (PwMS). Their combined use may provide additional predictive value for identifying disease impact, progression, and remyelination capacity above-and-beyond what is captured using either approach alone.

OBJECTIVE

We examined the relationship between OCT/VEP measures and cognitive functioning in 205 PwMS. OCT measures included Retinal Nerve Fiber Layer Volume (RNFLV), Papillo-Macular Bundle Volume (PBMV), and Macular Volume (MV). VEP measures included latency of the P100, and inter-ocular latency. Cognitive performance was evaluated across seven separate domains of performance, and for overall cognition, using the NeuroTrax computerized testing battery.

RESULTS

Both OCT and VEP measures were significantly correlated with cognitive performance across several domains. Linear regression models that controlled for the influence of visual acuity revealed (1) that reduced MV was significantly predictive of poorer visual-spatial functioning, and (2) that delayed VEP latency was significantly predictive of performance in global cognitive functioning and visual-spatial functioning, after controlling for multiple comparisons. Among PwMS with normal visual acuity, PwMS with a combination of both relatively low MV and delayed VEP latency tended to have poorer performance in the domains of global, executive, and visual-spatial functioning compared to PwMS with both high MV and normal VEP latency.

CONCLUSION

Approaches that combine the use of OCT and VEP measures can enhance insight into underlying factors that contribute to variance in cognitive functioning in PwMS.

Multiple sclerosis and quality of life: The role of cognitive impairment on quality of life in people with multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS), a chronic disease of the central nervous system (CNS), affects functional ability and quality of life (QoL). Depression, fatigue, and disability status are among the many factors that have been shown to impact QoL in people with MS, but the extent to which MS-related cognitive impairment is related to QoL is understudied in the literature.

OBJECTIVE

The purpose of this study was to determine relevant predictors of QoL from a wide list of symptoms including physical disability, and a multi-dimensional computerized cognitive assessment battery (CAB), depression, fatigue, and demographic variables (including employment status). In addition, the unique predictive power of cognitive impairment on QoL was explored in relation to other common factors of disease impact.

METHODS

171 people with MS (PwMS) were evaluated with a computerized assessment battery (CAB), EDSS examination, and validated Patient Reported Outcome (PRO) measures (Multiple Sclerosis Impact Scale, MSIS-29; Beck Depression Inventory - Second Edition BDI-2; and the Modified Fatigue Impact Scale, MFIS).

RESULTS

171 PwMS were included [Age: 46.02 years ± 9.85, 124 (72.5%) female]. Depression and fatigue scores were highly correlated with MSIS-29. EDSS, unemployment, memory, executive functioning, and motor skills were moderately correlated with MSIS-29. Predictors of QoL were EDSS, depression, fatigue, executive functioning, and attention. Attention and executive functioning were predictive of QoL even after controlling for demographic variables, fatigue, depression, and physical disability status.

CONCLUSION

Findings indicate the need for comprehensive and quantified evaluation of all factors associated with disease burden, which will ultimately serve to improve the QoL in PwMS through more targeted and patient-centered care.

Risk of breakthrough COVID-19 after vaccination among people with multiple sclerosis on disease-modifying therapies

BACKGROUND

Disease-modifying therapies (DMTs) for people with multiple sclerosis (pwMS) may decrease vaccine effectiveness. We aimed to explore the association between various DMTs and the risk for breakthrough COVID-19.

METHODS

Population-based data from Clalit Health Services, Israel's largest healthcare organization, were used. PwMS treated with DMTs without prior COVID-19 were followed from the commencement of the mass vaccination campaign in December 2020. The end of follow-up was at the time of COVID-19 infection, the receipt of a third vaccine dose or until the end of August 2021. Time-dependent multivariate Cox proportional hazard models were used to estimate hazard ratios for COVID-19 according to vaccination, DMT, age, gender, disability and comorbidities.

RESULTS

2511 PwMS treated with DMTs were included (Age: 46.2 ± 14.6, 70% Female, EDSS: 3.0 ± 2.1). Of whom, 2123 (84.5%) received 2 vaccine doses. On multivariate models that included all pwMS, vaccination was protective (HR = 0.41, P < 0.001). On multivariate models that included only fully vaccinated pwMS cladribine, ocrelizumab, S1P receptor modulators and natalizumab were associated with breakthrough COVID-19 (HR = 6.1, 4.7, 3.7 and 3.3; P = 0.004, 0.008, 0.02 and 0.05, respectively). On multivariate models that included unvaccinated and fully vaccinated pwMS on each DMT separately, a protective trend was noted for vaccination on all DMTs (0.09 < HR < 0.65), except for cladribine (HR = 1.1). This protective trend was not statistically significant on ocrelizumab, S1P receptor modulators and natalizumab. COVID-19 among pwMS was generally mild. Only 2 vaccinated pwMS had a severe infection with eventual recovery.

CONCLUSIONS

Vaccination effectively protects pwMS from COVID-19. An increased risk of breakthrough infection was noted on high-efficacy DMTs, however COVID-19 after vaccination was usually mild.

Effect of Radiographic Contrast Media Shortage on Stroke Evaluation in the United States

BACKGROUND AND PURPOSE

We performed this study to identify the effect of the nationwide iodinated contrast media shortage due to reduction in GE Healthcare production, initiated on April 19, 2022, on the evaluation of patients with stroke.

MATERIALS AND METHODS

We analyzed the data on 72,514 patients who underwent imaging processed with commercial software in a sample of 399 hospitals in United States from February 28, 2022, through July 10, 2022. We quantified the percentage change in the daily number of CTAs and CTPs performed before and after April 19, 2022.

RESULTS

The daily counts of individual patients who underwent CTAs decreased (a 9.6% reduction, P = .002) from 1.584 studies per day per hospital to 1.433 studies per day per hospital. The daily counts of individual patients who underwent CTPs decreased (a 25.9% reduction, P = .003) from 0.484 studies per day per hospital to 0.358 studies per day per hospital. A significant reduction in CTPs using GE Healthcare contrast media (43.06%, P < .001) was seen but not in CTPs using non-GE Healthcare contrast media (increase by 2.93%, P = .29). The daily counts of individual patients with large-vessel occlusion decreased (a 7.69% reduction) from 0.124 per day per hospital to 0.114 per day per hospital.

CONCLUSIONS

Our analysis reported changes in the use of CTA and CTP in patients with acute ischemic stroke during the contrast media shortage. Further research needs to identify effective strategies to reduce the reliance on contrast media-based studies such as CTA and CTP without compromising patient outcomes.

Cognitive impairment, fatigue and depression in multiple sclerosis: Is there a difference between benign and non-benign MS?

INTRODUCTION

Multiple Sclerosis (MS) is a chronic inflammatory and degenerative disease of the central nervous system (CNS). The severity of disability in people with MS (PwMS) is generally measured with the Expanded Disability Status Scale (EDSS). A variant of MS known as 'benign MS' (BMS) has been defined as an EDSS score of 3 or lower, combined with a disease duration of 10 years or longer; however, there is disagreement in the field about whether BMS really exists. Given that the EDSS does not capture cognitive issues, communication dysfunction, fatigue, depression, or anxiety properly, its ability to accurately represent disability in all PwMS, including BMS, remains questionable.

METHODS

In this study, 141 persons with BMS (PwBMS) were included, consisting of 115 females (82%) and 26 males (18%) with a mean age of 50.8 (±8.68). A computerized test battery (NeuroTrax®) was used to assess cognition, covering seven cognitive domains (memory, executive function, visual-spatial processing, verbal function, attention, information processing, and motor skills). Fatigue was measured using the Fatigue Severity Scale (FSS). The Beck Depression Inventory (BDI) was used to assess symptoms of depression. Cognitive impairment was defined for this study as when someone has a score lower than 85 in at least two subdomains of the cognitive test battery. Rates of impairment were compared to 158 persons with non-benign MS (PwNBMS; with a disease duration of 10 years and longer and an EDSS score higher than 3) and 487 PwMS with a disease duration of fewer than 10 years.

RESULTS

Cognitive impairment was found in 38% of PwBMS and in 66% of PwNBMS (p<0.001). In PwBMS, the lowest rate of impairment was found in the verbal function domain (18%) and the highest rate of impairment in the domain of information processing (32%). Fatigue and depression were found in 78% and 55% of all PwBMS, with no difference in these rates between PwBMS and PwNBMS (p = 0.787 and p = 0.316 resp.) CONCLUSION: Cognitive impairment, fatigue and depression are common among people with an EDSS-based definition of benign MS. These aspects should be incorporated into a new and better definition of truly benign MS.

Cognitive impairment in people with multiple sclerosis: Perception vs. performance - factors that drive perception of impairment differ for patients and clinicians

BACKGROUND

Neurologists' perceptions of the presence of cognitive impairment (CI) in people with multiple sclerosis (PwMS) may not always align with findings of objective cognitive assessment. The accuracy of self-reported CI in PwMS can also be highly variable across individuals, and may not align with objective measurement of cognitive disturbances. Research suggests that additional factors impact perceived cognitive ability, such as depression and fatigue. Objective cognitive screening regardless of patient or neurologist perception has been recommended but still is often limited in routine care. Moreover, comprehensive neuropsychological assessment is even less routinely done.

OBJECTIVE

To explore how neurologists' perceptions of PwMS' CI compare to the perception of the patient by determining whether PwMS and their clinicians are accurate in detecting the presence and degree of CI as defined by a multi-domain validated computerized test battery in PwMS, as well as investigate what factors influence perception of CI in each group.

METHODS

PwMS completed a computerized multi-domain cognitive testing battery, and self-reported measures of disease impact (MSIS-29), fatigue (MFIS), and depression (BDI-II). Disability was assessed by the clinician using the Expanded Disability Status Scale (EDSS). Clinicians and patients also provided an estimation of cognitive deficits along a Likert scale.

RESULTS

In this cohort of PwMS (N=202, age range: 20 to 88, gender: 71% female), their level of accuracy in detecting attention deficits (k = -.028, p = .010) was low but statistically significant. In contrast, clinicians' accuracy in detecting global CI (k = -.037, p < .001) and a number of specific domain deficits was moderate. Fatigue (p < .001) and cognitive performance (p = .012) significantly predicted patient perceived cognitive deficits. Clinician perceived cognitive performance was significantly predicted by multiple factors: cognitive scores (p < .001), physical disability (p = .011), age (p = .021), and depression (p = .038).

CONCLUSION

The need to objectively screen for CI in PwMS, regardless of perception, can be aided by a better understanding of the agreement and discrepancies between the patient and clinician regarding perceived cognitive disturbances and the presence of CI defined by a multi-dimensional objective screening battery.

Mobile-phone-based e-diary derived patient reported outcomes: Association with clinical disease activity, psychological status and quality of life of patients with multiple sclerosis

BACKGROUND

The applicability of mobile digital technology to promote clinical care of people with multiple sclerosis (pwMS) is gaining increased interest as part of the implementation of patient-centered approaches. We aimed at assessing adherence to a smartphone-based e-diary, which was designed to collect patient-reported outcomes (PROs). Secondary objectives were to evaluate the construct and predictive validity of e-diary derived PROs and to explore the various factors that were associated with changes in PROs over time.

MATERIALS AND METHODS

In this observational cohort study patients downloaded an MS tailored e-diary into their personal smartphones. Report of PROs was enquired once monthly for a period of one year through a smartphone-based application, using previously validated tools. An e-diary derived bodily function summary score (eBF) was defined as the sum of scores depicting vision, limbs function, pain, bowl/ bladder dysfunction, pseudobulbar affect and spasticity. Multiple linear regression and analysis of covariance were used to determine the association between PROs, clinician-reported outcomes (ClinROs) of disease activity and quality of life (QoL). Regression coefficient analysis was used to compare the slope of change in eBF before and after a relapse.

RESULTS

97 pwMS downloaded the e-diary [Female: 64 (66%), EDSS 3.4±2.1]. 76 patients (78%) completed the 12-month study period. 53 patients (55%) submitted ≥75% of requested surveys. Anxiety was negatively associated with adherence to periodic PROs assessments by the e-diary. E-diary derived PROs were significantly correlated with corresponding functional system scores (0.38< r <0.8, P<0.001). eBF score significantly predicted QoL (β = -0.36, P = 0.001) while EDSS did not. Change in eBF score over time was independently associated with the occurrence of an MS relapse (F = 4.4, P = 0.04), anxiety (F = 6.4, P = 0.01) and depression (F = 5.1, P = 0.03). Individual regression slopes of eBF scores were significantly higher pre-relapse than post-relapse (3.0±3.3 vs. -0.8±2.0, P = 0.007).

CONCLUSION

Adherence of pwMS to recording in an e-diary collecting PROs was high. Changes in e-diary derived PROs over time predict clinical MS relapses on the group level and thus carry the potential of usage in clinical research as well as for improved MS care in real world setting.

Visual evoked potential latency predicts cognitive function in people with multiple sclerosis

Prior studies have reported an association between visual evoked potentials (VEPs) and cognitive performance in people with multiple sclerosis (PwMS), but the specific mechanisms that account for this relationship remain unclear. We examined the relationship between VEP latency and cognitive performance in a large sample of PwMS, hypothesizing that VEP latency indexes not only visual system functioning but also general neural efficiency. Standardized performance index scores were obtained for the domains of memory, executive function, visual-spatial processing, verbal function, attention, information processing speed, and motor skills, as well as global cognitive performance (NeuroTrax battery). VEP P100 component latency was obtained using a standard checkerboard pattern-reversal paradigm. Prolonged VEP latency was significantly associated with poorer performance in multiple cognitive domains, and with the number of cognitive domains in which performance was ≥ 1 SD below the normative mean. Relationships between VEP latency and cognitive performance were significant for information processing speed, executive function, attention, motor skills, and global cognitive performance after controlling for disease duration, visual acuity, and inter-ocular latency differences. This study provides evidence that VEP latency delays index general neural inefficiency that is associated with cognitive disturbances in PwMS.

The association between MRI brain volumes and computerized cognitive scores of people with multiple sclerosis

BACKGROUND

Computerized cognitive assessment facilitates the incorporation of multi-domain cognitive monitoring into routine clinical care. The predictive validity of computerized cognitive assessment among people with multiple sclerosis (PwMS) has scarcely been investigated.

OBJECTIVE

To explore the associations between brain volumes and cognitive scores from a computerized cognitive assessment battery (CAB, NeuroTrax) among PwMS.

METHODS

PwMS were evaluated with the CAB and underwent brain MRI within 40 days. Cognitive assessment yielded age- and education-adjusted scores in 9 cognitive domains: memory, executive function, attention, information processing speed, visual spatial, verbal function, motor skills, problem solving, and working memory. The global cognitive score (GCS) is the average of all domain scores. MRI brain and lesion volumes were assessed with icobrain ms, a fully automated tissue and lesion segmentation and quantification software.

RESULTS

91 PwMS were included [Age: 52.1 ± 11.7 years, 64 (70%) female, EDSS: 3.4 ± 2.0, 79 (87%) with a relapsing remitting course]. Significant correlations were found between the GCS and whole brain, white matter, grey matter, thalamic, lateral ventricles, hippocampal and lesion volumes (Correlation coefficients: 0.46, 0.40, 0.25, 0.42, -0.36, 0.21, -0.3, respectively). Regression analysis revealed that lateral ventricles and thalamic volumes were the most consistent predictors of all cognitive domain scores.

CONCLUSION

Computerized cognitive scores were significantly associated with quantified MRI. These findings support the predictive validity of multi-domain computerized cognitive assessment for people with multiple sclerosis.

Mobile phone-based e-diary for assessment and enhancement of medications adherence among patients with multiple sclerosis

Background

Adherence to multiple sclerosis (MS) disease-modifying drugs (DMDs) is essential for realization of their optimal effectiveness and benefits.

Objective

To evaluate the usefulness and validity of a smartphone-based e-diary as a tool for adherence assessment as well as its effectiveness as a promoter of adherence to DMDs.

Methods

An MS tailored e-diary (MyMS&Me) reminded patients to take their DMDs on time. DMD intake was self-recorded in the e-diary by the participants. Three methods of adherence evaluation were compared: e-diary derived, retrospective self-reported, and the medication possession rate (MPR). The proportion of patients with poor adherence to DMDs (defined as MPR <80%) among e-diary users was compared with a control group without intervention.

Results

Sixty-two patients downloaded the e-diary (Female: 41 (66%), Expanded Disability Status Scale 3.2 ± 2.2) and 55 controls were enrolled. The median difference between e-diary-derived adherence and the MPR was –3% (95% limits of agreement: −53% to 12%). The median difference between retrospective self-reported adherence and the MPR was 0.3% (95% limits of agreement: −20% to 42%). The proportion of participants with poor adherence to DMDs was similar in the e-diary and control groups (10% vs. 13%, p = 0.6).

Conclusions

Substantial and clinically important disagreement between methods of medication adherence evaluation was noted. Smartphone reminders did not significantly improve the MPR of DMDs.

HDL-cholesterol elevation associated with fingolimod and dimethyl fumarate therapies in multiple sclerosis

Background

Patients with Multiple Sclerosis (PwMS) display altered lipoproteins levels and function, which seem to affect disease risk and progress. Whether disease-modifying therapies affect the lipoprotein profile in PwMS has scarcely been studied.

Objective

The study aims to assess whether fingolimod and dimethyl fumarate (DMF) affect lipoproteins in PwMS.

Methods

We compared retrospectively the blood lipoprotein levels of 29 fingolimod-treated and 41 DMF-treated patients before and after 3 and 12 months of therapy. Patients treated with cholesterol-reducing medications were not included. Data on weight change and disease activity during 1-year follow-up were obtained.

Results

HDL level, HDL/LDL ratio and HDL/total cholesterol ratio were increased in both treatment groups after 3 months’ therapy and sustained, with no change in LDL or triglycerides. While at baseline only 26% of patients met the recommended minimum of HDL 60 mg/dl, after 3 months’ therapy, 43% of fingolimod-treated and 47% of DMF-treated patients reached the recommended level. The majority of patients had no weight reduction.

Conclusions

Fingolimod and DMF therapies are associated with a specific increase in HDL in PwMS. Further studies are required to validate these findings and their potential implication as biomarker of reduced inflammatory state and/or reduced risk of neurodegeneration or cardiovascular comorbidity.

The impact of subjective cognitive fatigue and depression on cognitive function in patients with multiple sclerosis

BACKGROUND

The association between subjective cognitive fatigue and objective cognitive dysfunction in patients with multiple sclerosis (PwMS) has been studied, with conflicting results.

OBJECTIVE

To explore the impact of fatigue on cognitive function, while controlling for the influence of depression, disability, comorbidities, and psychotropic medications.

METHODS

PwMS completed a computerized cognitive testing battery with age- and education-adjusted cognitive domain scores. Disability (Expanded Disability Status Scale (EDSS)), cognitive fatigue, and depression were concurrently evaluated.

RESULTS

In all, 699 PwMS were included. Both cognitive fatigue and depression were significantly and negatively correlated with the same cognitive domains: information processing speed, executive function, attention, motor function, and memory (-0.15 ⩽ r ⩽ -0.14 for cognitive fatigue; -0.24 ⩽ r ⩽ -0.19 for depression). Multivariate analysis revealed significant but small independent correlations only between depression and neuropsychological test results, while cognitive fatigue had no independent correlation with objective cognitive function except for a trend toward impaired motor function in highly fatigued PwMS. Depression and cognitive fatigue accounted for no more than 6% of the variance in objective cognitive domain scores.

CONCLUSION

Cognitive fatigue is not independently related to objective cognitive impairment. Depression may influence cognitive function of PwMS primarily when it is severe. Cognitive impairment in PwMS should not be ascribed to fatigue or mild depression.

[FROM STATISTICAL ASSOCIATIONS TO SCIENTIFIC CAUSALITY]

The pathogenesis of most chronic diseases is complex and probably involves the interaction of multiple genetic and environmental risk factors. One way to learn about disease triggers is from statistically significant associations in epidemiological studies. However, associations do not necessarily prove causation. Associations can commonly result from bias, confounding and reverse causation. Several paradigms for causality inference have been developed. Henle-Koch postulates are mainly applied for infectious diseases. Austin Bradford Hill's criteria may serve as a practical tool to weigh the evidence regarding the probability that a single new risk factor for a given disease is indeed causal. These criteria are irrelevant for estimating the causal relationship between exposure to a risk factor and disease whenever biological causality has been previously established. Thus, it is highly probable that past exposure of an individual to definite carcinogens is related to his cancer, even without proving an association between this exposure and cancer in his group. For multifactorial diseases, Rothman's model of interacting sets of component causes can be applied.

Vitamin D supplementation for patients with multiple sclerosis treated with interferon-beta: a randomized controlled trial assessing the effect on flu-like symptoms and immunomodulatory properties

BACKGROUND

Flu-like symptoms (FLS) are common side effects of interferon beta (IFN-β) treatment in patients with Multiple Sclerosis (PwMS) and are associated with post-injection cytokine surge. We hypothesized that vitamin D3 supplementation would ameliorate FLS by decreasing related serum cytokines' levels.

METHODS

In a randomized, double blind study of 45 IFNβ-treated PwMS, 21 patients were assigned to 800 IU of vitamin D3 per day (low dose), while 24 patients received 4,370 IU per day (high dose) for one year. FLS were assessed monthly by telephonic interviews. Serum levels of 25-hydroxy-D (25-OH-D), calcium, PTH, IL-17, IL-10 and IFN-γ were measured periodically. EDSS, relapses, adverse events and quality of life (QoL) were documented.

RESULTS

25-OH-D levels increased to a significantly higher levels and PTH levels decreased in the high dose group. There was no significant change in FLS. IL-17 levels were significantly increased in the low dose group, while patients receiving high dose vitamin D had a heterogeneous IL-17 response. No significant differences in relapse rate, EDSS, QoL, serum IL-10 and IFNγ were found. Hypercalcemia or other potential major adverse events were not observed.

CONCLUSION

Vitamin D supplementation to IFN-β treated PwMS, at the doses used, seems safe and associated with dose-dependent changes in IL-17 serum levels, while not affecting IFN-β related FLS.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT01005095.

Patients with multiple sclerosis in a war zone: coping strategies associated with reduced risk for relapse

The objective of this article is to examine the role of coping strategies in multiple sclerosis outcomes among civilians under a military attack during the 2006 war between Hezbollah and Israel. Participants were 156 patients with relapsing—remitting multiple sclerosis. We analysed the relationships between coping and emotional distress and between coping and multiple sclerosis exacerbation. We also assessed a model of the relationship between perceived stress, event-related stress, and coping with increased risk of multiple sclerosis exacerbations using multivariate logistic regression. Ways of coping and subjective stress were evaluated by means of structured interviews using questionnaires previously validated. The more distressed our respondents were during the war, the more likely they were to employ a variety of ways of coping. Correlation coefficients between coping scores and perceived war stress ranged from 0.2 to 0.44 ( p < 0.001—0.01). Correlation coefficients between the various coping scores and broader indices of distress ranged from 0.28 to 0.5 ( p < 0.001). Of the remitting patients during and following the war, 47.1% reported the use of ‘direct coping and planning’, compared to 16.7% of patients who relapsed during the same period ( p = 0.014). ‘Direct coping and planning’ was negatively related to exacerbation of multiple sclerosis symptoms (OR = 0.1, 95% CI = 0.02—0.5). The Nagelkerke R2 was 0.26. Our findings point to an association between ‘direct coping and planning’ and reduced multiple sclerosis relapse rate during wartime. Further research should explore whether the employment of specific ways of coping can reduce the risk for relapse among patients with multiple sclerosis during periods of distress.

Pertussis is under diagnosed in infants hospitalized with lower respiratory tract infection in the pediatric intensive care unit

BACKGROUND

To determine the rate of pertussis in infants aged <1 year hospitalized at the pediatric intensive care unit (PICU) with lower respiratory tract infection (LRTI) and to characterize the clinical aspects of these patients.

MATERIAL/METHODS

Infants <12 months hospitalized with LRTI in the PICU were identified retrospectively. Demographic, clinical and laboratory data were obtained. Stored nasopharyngeal washes (NPW) were tested by polymerase chain reaction (PCR) for the pertussis toxin gene (ptxA) and insertion element IS481 sequences.

RESULTS

Eleven of seventy-four (15%) NPW were positive for pertussis, none of them was clinically suspected. Of the positive patients, 82% suffered from paroxysmal cough vs. 32% of the negative patients and from prolonged cough, 45.5% vs. 8%, respectively (P<0.01). Thirty (41%) patients needed mechanical ventilation with no differences between positive and negative pertussis patients. Infiltrates in x-rays were more common among pertussis negative than among pertussis positive patients, 29% vs. 0% (P=0.05).

CONCLUSIONS

Lower respiratory tract infections caused by pertussis are a more frequent cause of admission to the PICU than generally recognized. Patient's history with paroxysmal cough suggests the possibility of pertussis and the lack of whooping cough does not rule out pertussis. Pediatricians should be aware of the limitations of their diagnostic tools when ruling out pertussis especially in infants with a diagnosis of bronchiolitis. Using new diagnostic methods add considerably to the sensitivity of pertussis diagnosis in PICU and PCR techniques should be used routinely, at least in a PICU setting.

Helicobacter pyloriInfection and Seasickness Susceptibility among Naval Sailors: Is There Any Association?

BACKGROUND

Vomiting is a very common and bothersome expression of seasickness. Previous works have shown that Helicobacter pylori infection may be related to vomiting resulting from nongastrointestinal causes, and physiological research has revealed that H. pylori may alter gastric motility. These findings, along with anecdotal case histories, led us to suspect that H. pylori infection may be related to the vomiting of seasickness. The objective of this study was to evaluate the association between H. pylori infection and seasickness susceptibility.

METHODS

Participants were 90 healthy, male, naval crew members 19.5 to 25 years of age. Forty-five were susceptible to seasickness, and 45 were nonsusceptible control subjects. Quantitative analysis of IgG levels for H. pylori was performed with an enzyme-linked immunosorbent assay.

RESULTS

The rate of H. pylori infection was 38% in the susceptible group, compared with 31% in the nonsusceptible group (p = 0.5). The titer of antibodies to H. pylori among case subjects was 81.2 U/mL (95% confidence interval, 11.5-151.1 U/mL), compared with 31.1 U/mL (95% confidence interval, 0.1-65.1 U/mL) for control subjects (p = 0.2).

CONCLUSION

The current study does not support an association between H. pylori infection and seasickness susceptibility among sailors.

Subdivision of essential tremor patients according to physiologic characteristics

OBJECTIVE

To test the effect of different forearm postures on tremor characteristics. We hypothesized that changes in tremor characteristics in relation to posture can subclassify essential tremor (ET) patients.

METHODS

Fourteen ET patients were tested while seated and holding a full cup in three well-defined arm postures: 15 cm above the armrest, elbow at 90 degrees flexion and when the cup was near the mouth. Hand movements were recorded using a triaxial accelerometer. Concomitantly, we recorded surface electromyogram (EMG) signals from the wrist extensor muscles. Hand acceleration and the primary tremor frequency from the power spectrum were calculated for each posture in two independent trials. The coherence at the primary tremor frequency between the EMG and the accelerometry signals was calculated.

RESULTS

ET patients could be classified into two groups: ET-1 (nine patients) had position-dependent peak frequencies while ET-2 (five patients) had position-independent peak frequencies. The latter group had significantly higher coherencies between EMG and accelerometry of tremor and insignificantly higher tremor amplitudes compared with ET-1. In both groups tremor amplitude increased when the hand was near the mouth.

CONCLUSION

The results suggest that ET patients can be classified based on the position dependence of frequency and other physiologic properties.

Breast-fed and formula-fed infants do not differ in immunocompetent cell cytokine production despite differences in cell membrane fatty acid composition

BACKGROUND

Breast-fed and formula-fed infants differ in the amount and type of polyunsaturated fatty acids consumed. The fatty acid composition of cell membranes is related to dietary fatty acids and, in adults, changes in membrane fatty acid composition are accompanied by changes in monocyte cytokine production and hence a modification of the immunologic response.

OBJECTIVE

Our objective was to determine whether production by immunocompetent cells of the proinflammatory cytokines interleukin 1 (IL-1) and tumor necrosis factor (TNF) differs between breast-fed and formula-fed infants.

DESIGN

Twenty-six healthy infants (13 breast-fed and 13 fed modified cow-milk formula) aged 2-4 mo were studied. The fatty acid composition of red blood cell (RBC) membrane phospholipids was measured by gas-liquid chromatography and IL-1 and TNF release were measured in whole blood culture in bacterial-endotoxin-stimulated and unstimulated cells.

RESULTS

The infants' ages, weights, hemoglobin concentrations, and white blood cell counts did not differ significantly between groups. The percentage of n-3 fatty acids of total RBC phospholipid fatty acids was significantly higher in breast-fed than in formula-fed infants (6.31 +/- 2.5% compared with 2.98 +/- 0.97%); docosahexaenoic acid (22:6n-3) concentrations were also markedly higher in breast-fed infants (5.1 +/- 1.2% compared with 2.2 +/- 0.9%, P: < 0.001), but eicosapentaenoic acid (20:5n-3) and docosapentaenoic acid (22:5n-3) concentrations did not differ significantly between groups. The percentage of n-6 fatty acids was not significantly different between groups. The percentage of oleic acid (18:1) was higher in formula-fed than in breast-fed infants (16.2 +/- 0.7% compared with 20.6 +/- 1.1%; P: < 0.001). IL-1 and TNF release in whole blood culture did not differ significantly between groups.

CONCLUSION

The release of proinflammatory cytokines by immunocompetent cells does not differ significantly in breast-fed and formula-fed infants despite differences in cell membrane fatty acid composition.

Comment on 'Health aspects of cannabis: revisited' (Hollister)

Twelve years ago Leo Hollister (1986) published a review on health aspects of cannabis which can truly be called a 'classic'. In a field where emotions, prejudices and personal preferences frequently supplant objectivity, Hollister drew a picture not only solidly based on clinical studies - some of which came from his laboratory - but also on his thorough knowledge of drug dependence and medicine and on his common sense. For over a decade, at meetings, 'Hollister says' meant his 1986 review. He has now revisited the field, again demonstrating his mastery of the topic. In the 1986 review a portion was devoted to therapeutic uses. This aspect has not been revisited now, which we can only regret. I certainly would have liked to hear what he has to say on the debate on 'medical marijuana', on the clinical advantages of marijuana versus THC (or vice versa), and on specific issues such as the use of marijuana in multiple sclerosis, which is widely used by patients. Such a use is not supported in the US by the National Multiple Sclerosis Society, while in the UK, the British Medical Association strongly recommends 'carefully controlled trials of cannabinoids in patients with chronic spastic disorders which have not responded to other drugs'. Such trials merit a high priority (British Medical Association, 1997).

High association of anticardiolipin antibodies with psychosis

BACKGROUND

Lupus anticoagulant (LA) and anticardiolipin antibodies (aCL) are autoantibodies that can be detected in plasma or serum of patients with autoimmune-related diseases. The presence of these autoantibodies has been associated with recurrent arterial and/or venous thromboembolism as well as with recurrent fetal loss and thrombocytopenia. In recent years, other medical conditions such as dementia, chorea, psychosis, migraine, and peripheral neuropathy have been associated with these autoantibodies. An adverse response to neuroleptic treatment was reported to be associated with the presence of autoantibodies, but these patients rarely developed clinical vascular manifestations.

METHOD

We conducted a study of 34 unmedicated patients admitted to the hospital with acute psychosis in whom aCL and LA were examined before and after neuroleptic treatment to determine the presence of antibodies relative to the treatment condition.

RESULTS

32% (11/34) of the unmedicated psychotic patients had antiphospholipid antibodies: we detected elevated titers of IgG-aCL isotype in 24% (8/34) of unmedicated patients (p < .02 compared with 20 normal controls, none of whom tested positive), and 9% (3/34) had LA. Twenty-two patients were followed up after medication; 31.8% (7/22) of these patients showed moderate titers of IgG-aCL (p < .28), and 18.2% (4/22) were LA positive. Altogether, antiphospholipid antibodies were detected in 40.9% (9/22) of the medicated patients.

CONCLUSION

This study shows the increased incidence of LA and aCL antibodies in neuroleptic-treated psychotic patients and the possible association between psychosis and antiphospholipid antibodies.

Prolactin response to electroconvulsive shock in anesthetized rats

Serum prolactin level (SPL) of anesthetized rats was measured in response to electroconvulsive shock (ECS). This measurement served as an indicator of dopaminergic and serotonergic activity. Such neurotransmitter activity was modulated by pretreatment with cyproheptadine, parachlorophenylalanine (PCPA), pimozide, bromocriptine or L-dopa. A statistically significant lowered SPL was found in rats given ECS plus antiserotonergic agents, in comparison with animals receiving antiserotonergic agent or ECS alone. When ECS was administered to rats pretreated with the dopaminergic blocker, pimozide, there was a significant decrease in SPL, compared with animals receiving pimozide alone. When the dopaminergic system was stimulated by dopamine agonists, there was no elevation of SPL in response to ECS. Thus, there may be a balance between serotonergic and dopaminergic systems. The agents used in the experiment may upset this balance and produce a change in prolactin response to a given ECT stimulus.

Premature ovarian failure--the prognostic application of autoimmunity on conception after ovulation induction

OBJECTIVE

To assess whether the presence of autoimmune activity in patients with premature ovarian failure (POF) can predict the response to ovulation induction and conception.

DESIGN

Assessment of autoimmune activity in patients with POF, correlating the response to ovulation induction with this autoreactivity.

SETTING

Tertiary care academic center.

PATIENTS

Forty women with POF, 15 of them treated by ovulation induction because of infertility.

INTERVENTIONS

All patients were tested for the presence of autoimmune activity, antibodies against various tissues, and 15 of them were treated with combinations of hMG/hCG, glucocorticosteroids as immunosuppressant, and some of them also with a long-acting GnRH agonist. Those patients not interested in infertility were put on hormone replacement therapy (HRT).

MAIN OUTCOME MEASURES

Serum E2 and P were measured during ovulation induction as well as follicular diameter monitoring by transvaginal sonography. Achievement of gestations and their outcome were monitored in the group in which ovulation induction was accomplished.

RESULTS

Antibodies against thyroglobulin, nuclear antigens, heart, tissue gluten, or increased levels of immunoglobulin (Ig)M, or decreased levels of complement C3 and C4 were significantly different in the patients with POF than in the control population. Autoreactivity of at least one class of the tested antibodies was found in 31 of 40 patients (77%). In 15 patients with autoimmune activity who have undergone ovulation induction using hMG/hCG, 14 pregnancies were achieved in 8 patients. Two of the pregnancies were spontaneous, and 12 were generated by hMG/hCG and fluocortolone, with or without pretreatment with GnRH-a. Twelve healthy babies were generated by 10 gestations, 3 ended in spontaneous abortions (23%), and 1 is ongoing. All the nonspontaneous pregnancies were achieved in the first three cycles of ovulation induction.

CONCLUSIONS

Patients with POF and autoimmune activity, suggesting an autoimmune etiology to the ovarian failure, may respond to ovulation induction and have a conception rate of approximately 40% in three cycles. Those who do not conceive in three treatment cycles have a very low probability to conceive; therefore, further attempts of ovulation induction should be discouraged. However, some patients may spontaneously conceive in association with HRT.

Mononeuritis multiplex associated with prolonged vancomycin treatment

Images

Postpartum maternal group B streptococcal meningitis

Maternal group B streptococcal (GBS) meningitis is rare, with only four cases previously reported in the literature. In this review a fifth case of postpartum GBS meningitis is presented. The five cases are compared with 34 cases of GBS meningitis in nonparturient adults. All cases of maternal GBS meningitis followed a vaginal delivery. The mean age of patients who had GBS meningitis outside the perinatal setting was 55 years, and most of these individuals had associated illnesses or frank immunosuppression; the mortality rate in this group was 23%. In contrast, all five patients with maternal GBS meningitis recovered. The case presented herein, like the four previous cases, illustrates the point that when patients with maternal GBS meningitis are treated immediately and have been healthy before the infection, the prognosis is good.

Early spontaneous rupture of the post myomectomy gravid uterus

Rupture of a pregnant uterus is a serious threat to the mother's life and her fetus. Most of these cases have predisposing factors of which a post myomectomy scar is rare. Rupture of a post myomectomy gravid uterus usually occurs in the third trimester of pregnancy or during labor. We present a case of a very early spontaneous rupture which occurred at the 20th week of gestation in a post myomectomy uterus. To the best of our knowledge no previous report of a ruptured myomectomy scarred uterus has been described at such an early stage.

Patterns of growth of uterine leiomyomas during pregnancy. A prospective longitudinal study

In a prospective study 32 leiomyomas (fibroids) in 29 pregnant women were examined with ultrasound every 3-8 weeks. Each patient had between 3 and 6 scans (mean 4.4) during the course of pregnancy, and 13 patients had a final scan at 6 weeks postpartum. An individual growth curve was established for each tumour and the patterns of growth were analysed. No increase in size during the pregnancy was observed in 25 fibroids (78%). Only 7 (22%) increased in size but by no more than 25% of the initial volume. At 6 weeks postpartum the size of the fibroids did not differ significantly from the size during pregnancy.

Recurrent acute otitis media--prophylactic penicillin treatment: a prospective study. Part I

Recurrent acute otitis media (RAOM) is a distressing clinical manifestation of middle ear pathology, mainly expressed in the first two years of life. In this controlled study, prophylactic treatment by phenoxymethyl penicillin reduced significantly the frequency of RAOM in 60 children, as compared to 48 children who received a short ampicillin course only on the occasion of an acute otitis media episode. The importance of breastfeeding, age at initial episode, the type of treatment given and the pertinent literature is discussed. A working hypothesis of this prophylactic treatment is suggested.