Poster No. 080 Relationship between triglyceride glucose index, MACE and nephropathy in type 2 diabetes

Background

The triglyceride glucose (TyG) index, a simple surrogate estimate of insulin resistance, has been demonstrated to predict cardiovascular disease morbidity and mortality in the general population. To explore the relationship between TyG index, MACE (major adverse cardiovascular events) and diabetic nephropathy in type 2 diabetes, we evaluated TyG index for 3 consecutive years.

Material and methods

This was a cross-sectional observational study that examined 172 subjects with T2DM. The mean age of the study participants was 61.71 ± 13.16 years, and 90 were female. The primary outcomes included the occurrence of MACE, defined as all-cause death, non-fatal myocardial infarction and non-fatal stroke. Subjects underwent a detailed standard evaluation to detect diabetic nephropathy (defined as urinary albumin excretion ≥ 30 mg/24 h). The TyG index was calculated as ln (fasting triglycerides × fasting glucose/2) and stratified into 4 quartiles (TyG-Q). The baseline characteristics of the study population in the four TyG-Q (Q1 (≤ 8.95) n = 43, Q2 (> 8.95 to ≤ 9.27) n = 43, Q3 (> 9.27 to ≤ 9.7) n = 43, and Q4 (> 9.7) n = 43) were analysed.

Results and conclusions

Higher TyG-Q correlated with the presence of nephropathy (p = 0.028), age (p = 0.0172), HbA1c levels (p = 0.001) and the presence of arterial hypertension (p = 0.032). The optimal TyG index cut-off for predicting MACE was 9.271 (sensitivity 54.0%; specificity 54%; area under the curve 0.532).The TyG index was significantly associated with MACE, suggesting that the TyG index may be a valid marker for risk stratification and prognosis in patients with T2DM.

The lack of influence of IVS5-91 G>A polymorphism of the SCN1A gene on efficacy of lamotrigine in patients with focal epilepsy

Background: IVS5-91G>A (rs3812718) polymorphism of the sodium voltage-gated channel alpha subunit 1 (SCN1A) gene has been associated with inadequate responsiveness to common antiepileptic drugs which act as sodium channel blockers. This study was performed to investigate the effect of IVS5-91G>A (rs3812718) polymorphism on lamotrigine (LTG) efficacy in a cohort of patients with non-lesional focal epilepsy taking LTG as monotherapy. Methods: A total of 100 of patients with non-lesional focal epilepsy on LTG monotherapy was included in this prospective interventional study. After reaching a stable dose of LTG patients were followed-up for 12 consecutive months. LTG responsiveness was defined as a 75% or more reduction in seizure frequency on a stable dose of LTG. Genotyping was performed at the end of the study using standard procedures and data were correlated with clinical data. Results: There were no significant differences in the prevalence of responsiveness to LTG between carriers of different genotypes. Average maintenance LTG doses in the responder group differed by genotype in the order AA>GA>GG, but these differences did not reach statistical significance. Conclusion: Our data suggest lack of association between SCN1A IVS5-91G>A (rs3812718) polymorphism and response to LTG.

Lack of association between polymorphism in ABCC2 gene and response to antiepileptic drug treatment in Croatian patients with epilepsy

Despite advances in antiepileptic drug (AED) therapy, about one-third of patients with epilepsy are resistant to drug treatment. Functional impact of polymorphisms in drug-efflux transporter genes may contribute to multidrug resistance theory. Studies on ABCB1 gene gave contradictory results and available data suggest that this polymorphism may not directly cause altered P-glycoprotein (Pgp) transport activity but may be associated with one or more causal variants in the stretch of linkage disequilibrium or is caused by multiple gene polymorphisms. Genetic polymorphisms also occur frequently in other transmembrane transport systems including the multidrug resistance proteins (MRPs, ABCC2). The aim of this research was to investigate the possible association of ABCC2 gene polymorphisms G1249A in exon 10 and C24T in exon 1 with the development of drug resistance. This cross-sectional study is a part of ongoing pharmacogenomic study of epilepsy in Croatian population. All patients enrolled in the study had an established diagnosis of partial complex epilepsy with or without secondary generalization with non lesional brain MRI with epilepsy protocol and have been suffering for more than two years. They were divided into two groups. The first group comprised 52 patients refractory to the current therapy, while the second group consisted of 45 patients with well-controlled seizures. Our data did not identify any significant association between genetic polymorphisms of exon 1 (24C > T) and exon 10 (1249G < A) of ABCC2 gene or any combined effect in response to AED treatment and development of drug resistance in patients with partial complex epilepsy. Statistical significant difference was not found in genotype based analysis, allele frequency, haplotype and combined genotype analysis.

Predictive factors for early identification of pharmacoresistant epilepsy

Epilepsy is one of the most common neurologic diseases. Despite improved diagnostic and therapeutic possibilities seizures remain refractory in more than 30% of patients with epilepsy. The aim of this study was to analyze the possible predictive factors for the development of pharmacoresistance in cryptogenic partial complex epilepsy. Patients were divided into two groups based on the number of seizures, clinical response to antiepileptic drugs and duration of the disease. One group consisted of patients resistant to anticonvulsant drugs and the other group of patients with well controlled seizures. Disease onset, electroencephalographic (EEG) findings and frequency of secondary generalization of partial complex seizures were analyzed in both groups. The results obtained showed a statistically significantly earlier occurrence of first epileptic seizure in the group of patients with pharmacoresistant epilepsy. The group of pharmacoresistant patients also had a statistically significantly higher proportion of secondary generalization of complex partial seizures as well as a higher proportion of patients with focal changes in EEG. These findings suggest that the onset of the disease at an earlier age, focal changes in EEG and secondary generalization of partial seizures may be early predictive factors for the development of pharmacoresistance in patients with cryptogenic partial complex epilepsy.

Report of the Croatian Society for Neurovascular Disorders, Croatian Medical Association. Evidence based guidelines for treatment of primary headaches--2012 update

These guidelines have been developed to assist the physician in making appropriate choices in work-up and treatment of patients with headaches. The specific aim of the Evidence Based Guidelines for Treatment of Primary Headaches--2012 Update is to provide recommendations for establishing an accurate diagnosis and choose the most appropriate therapy in the group of patients with primary headaches, based on a comprehensive review and meta-analysis of scientific evidence with regard to treatment possibilities in Croatia. These data are based on our previous Evidence Based Guidelines for Treatment of Primary Headaches published in 2005 and other recommendations and guidelines for headache treatment.

Impaired cerebral vasoreactivity in type 2 diabetes mellitus

The aim of our study was to assess cerebral vasoreactivity (CVR) in type 2 diabetes mellitus (DM2) and factors which may influence on it. According to previous studies, evaluating CVR in DM2 on the similar way, the results were dubious. For the evaluation CVR we used breath holding index (BHI) and transcranial Doppler ultrasound (TCD) in 50 patients with DM2 and 50 sex- and age-matched healthy controls. We observed epidemiologic and clinic data, other vascular risk factors and laboratory parameters. We found statistically significant difference in BHI between patients with DM2 (BHI = 0.69 +/- 0.31) and age- and sex-matched healthy controls (BHI = 1.33+/-0.28) (p < 0.05 ). Because of a significant correlation between BHI and age (p < 0.001) in healthy controls we made an adjustment of BHI for age before further analyses (BHIadj). In DM2 group we found a significant correlation between BHIadj and age (p = 0.0004), fasting glycemia (p = 0.04), and albuminuria (p = 0.04) (creatinine clearance in multivariate analysis (p = 0.007)). Our study has shown that CVR is impaired in DM2 patients and that it's severity was associated with age, fasting glycemia and renal function. Functional TCD is a very good screening method for detection and monitoring of cerebral microangiopathic changes in DM2 patients.

Arterial hypertension - prevalence of risk factors and morbide associations that increase cardiovascular risk

Hypertension represents a serious problem in Romania, as there are over 3 million hypertensive people in our country. There is a high incidence of deaths caused by hypertension.WE PERFORMED AN ANALYTICAL PROSPECTIVE STUDY THAT AIMS TO DETERMINE: prevalence of arterial hypertension in a population from Cluj county, distribution on age and gender, arterial hypertension severity, association of hypertension with other cardiovascular risk factors. Our study included 2266 patients, age 14 years old up to over 90 years old, both masculine and feminine gender, known with hypertension and new-diagnosed ones. Each subject was submitted to an interview based on a questionnaire. Diagnosis of arterial hypertension was established according to ESH criteria that consider as hypertension: values over 140/90 mmHg. Out of all subjects submitted to the study 647 (29.74%) were diagnosed with arterial hypertension and, from these, 102 (15.13%) were new-diagnosed patients.We found out a predominance of arterial hypertension at the age of 51-60 and over 60, an increased involvement of feminine sex; an association of hypertension with other major cardiovascular risk factors: obesity, diabetes, dislypidemia.Arterial hypertension represents an important health problem in Romania due to an increased prevalence, major impact on morbidity and mortality by cardiovascular and cerebro-vascular disease. These facts accentuate the necessity of an early diagnosis, of making people aware of the severity of the disease and it's impact on their lifestyle.

Patient with neuromyelitis optica and inflammatory demyelinating lesions comprising whole spinal cord from C2 level till conus: case report

BACKGROUND

Neuromyelitis optica (NMO) is an idiopathic, severe, inflammatory demyelinating disease of the central nervous system, that causes severe optic neuritis and myelitis attacks. Early discrimination between multiple sclerosis (MS) and NMO is important, as optimum treatment for both diseases may differ considerably.

CASE PRESENTATION

We report a case of a patient who initially presented as longitudinally extensive transverse myelitis (LETM), having spastic upper extremities diparesis and spastic paraplegia, C2/C3 sensory level and urinary incontinence, as well as extensive inflammatory spinal cord lesions from C2 level to conus. After 5 months the patient had another attack of transverse myelitis, had electrophysiological findings consistent with optic neuritis, was seropositive for NMO-IgG (aquaporin-4 IgG) and thus fulfilled NMO diagnostic criteria. Following treatment of disease attacks with pulse corticosteroid therapy and intravenous immunoglobulins, we included oral azathioprine in a combination with oral prednisone in the therapy. Since there was no significant clinical improvement, we decided to use cyclophosphamide therapy, which resulted in good clinical improvement and gradual decrease of cord swelling.

CONCLUSION

In this NMO case report we wanted to emphasize the extensiveness of inflammatory spinal cord changes in our patient, from C2 level to conus. In the conclusion it is important to say that accurate, early diagnosis and distinction from MS is critical to facilitate initiation of immunosuppressive therapy for attack prevention.

Epilepsy due to malformations of cortical development--correlation of clinical, MRI and Tc-99mECD SPECT findings

Malformations of cortical development (MCD) have been increasingly recognized as an important cause of intractable epilepsy. The aim of our study was to define epileptogenicity of MCDs by correlating MRI, EEG and semiology of epileptic attacks, and to determine the effect of MCD on drug resistant epilepsy. We also intended to reveal the utility of interictal single photo emission computed tomography (SPECT) in verification of MCD lesions and relative prevalence of different MCDs. Based on interictal EEG finding, semiology of the epileptic attacks and brain magnetic resonance imaging (MRI) "electroclinical epileptogenicity" of MCD was defined. Brain MRI revealed cortical dysplasia (CD) in nine patients, polymicrogyria in four patients, lissencephaly and schizencephaly in one patient each. Three patients had a combination of malformations. The localization of SPECT hypoperfusion corresponded to MCD lesion in ten (66.67%) patients. Electroclinically confirmed epileptogenicity of MCD overlapped with MR and interictal SPECT findings in fourteen (93.3%) and nine (60.0%) patients, respectively. Our study results demonstrated the MCD lesions to be highly epileptogenic and a frequent cause of intractability.

Psychosis and EEG Abnormalities as Manifestations of Hashimoto Encephalopathy

Hashimoto encephalopathy (HE) is a distinct form of encephalopathy, which can manifest itself with purely psychiatric symptoms. A 38-year-old female with history of rheumatoid arthritis was treated with psychotropic drugs for a couple of years in psychiatric structures because of the onset of depressive symptoms, psychoticlike manifestations, and impairment of cognitive functions. The electroencephalography (EEG) was characterized by general slowing with high voltage (2 to 3 Hz) delta biphasic and triphasic waves. Once a firm diagnosis of HE was made, corticosteroid treatment resulted in resolution of her psychiatric symptoms, marked EEG improvement, and partial improvement in her cognitive functions. HE should be suspected in young females with history of autoimmune disorders and EEG abnormalities.

Association of refractory complex partial seizures with a polymorphism of ApoE genotype

Apolipoprotein E (ApoE) is a constituent of many types of lipoproteins that play a role in metabolism of cholesterol and lipids in the body as well as in the brain. ApoE is synthesised in astrocytes and microglia and enter to neurons through LDL, LRP and VLDL receptors. Recently it was shown that ApoE is also produced in neurons. ApoE has a role in modulating learning and memory, structural plasticity, mobilization of cholesterol in repair, growth and maintenance of myelin and neuronal membranes during development and aging, and cell death after ischemic, convulsive, or other type of brain injury. The aim of this research was to investigate the possible association of ApoE gene polymorphism with the development of resistance to pharmacological therapy in patients with partial complex seizures with or without secondary generalization. In this prospective matched-pair controlled study, 60 patients with cryptogenic epilepsy with complex partial seizures, with or without secondary generalization, who have been suffering for five or more years, were studied. The first group comprised 30 patients refractory to the current therapy, while the second group consisted of patients with well-controlled seizures. The refractory and non-refractory groups of patients differed significantly in their phenotypes. Phenotype E3/4 was six times more frequent in refractory group than among non-refractory group. The lack of response was shown to be significantly associated with the presence of epsilon4 allele. This study provided evidence that the presence of epsilon4 allele is more often associated with a lack of response to current antiepileptic drugs as compared to epsilon2 and epsilon3 alleles.

[Minimally invasive neurosurgical methods in treatment of pharmacoresistant epilepsy]

The first clinical attempts at neuromodulation in the form of applying functional electrostimulations started some thirty years ago. Nowadays, it is obvious that the approach to neuromodulation and functional electrostimulation has changed significantly. Neuromodulation tends to affect the disturbed function either by the modulation of neuronal signals or by abolition of dysfunction, preserving the intact central nervous system. The mechanism of activity is connected through direct afferent projections, neurotransmitter modulation and neuronal network regulation. NeuroCybernetic Prosthesis (NCP; Cyberonics) is a vagal nerve stimulator consisting of a pulse generator, bipolar VNS lead, programming wand with accompanying software for IBM-compatible computer, a tunneling tool and handheld magnets. NCP is placed on the left vagal nerve (middle cervical part). In 1988, Penry JK et al. inserted the first human implant. The Food and Drug Association indicated VNS as add-on therapy for diminishing the number of seizures in the adults and adolescents over 12 years of age with partial seizures, who are resistant to pharmacological therapy.

[Changes in autonomic control of heart rate after ischemic cerebral stroke]

BACKGROUND AND PURPOSE

Heart rate variability (HRV) is a physiological phenomenon which reflects the influence of the autonomic nervous system on the heart work. The research in HRV has not been limited to the domain of basic and clinical cardiology, mostly with the aim of stratifying the risks of sudden death from malignant arrhythmias among patients with myocardial infarction (MI), but over the past few years the research has been done and studies have been published also in the area of neurology. Likewise acute MI, acute ischemic stroke leads to autonomic dysbalance and lowered HRV. However, literature lacks relevant data on autonomic dysbalance after the acute phase of ischemic stroke. The aim of this study was to assess the level of autonomic dysbalance in patients after the acute phase of ischemic stroke.

PATIENTS AND METHODS

This prospective study included 86 consecutive patients who had suffered ischemic stroke (59 men and 27 women, mean age 56 +/- 13 years) and 86 age-matched healthy control subjects (62 men and 24 women, mean age 53 +/- 9 year). In the acute phase of the disease, along with clinically manifest neurologic deficit, there is ischemic hemispheric lesion verified by computed tomography (CT) scan. Lesion of the left and right cerebral hemisphere was detected in 56% and 44% of patients, respectively. After the acute phase of the disease, patients were hospitalized at one of the neurologic departments of the Hospital for Medical Rehabilitation in Krapinske Toplice, Croatia, where rehabilitation was carried out (mean duration 20 +/- 9 days) in the 1999-2002 period. Inclusion criteria were: age under 70 years, first ischemic stroke verified by CT scan within 2-12 weeks of the acute phase of the disease, Barthel index 30-50, and stable sinus rhythm in ECG. Exclusion criteria were: a history of previous ischemic stroke, intracerebral hemorrhage, MI, percutaneous coronary intervention or surgical revascularization of the myocardium, clinical signs of coronary artery disease, acute heart failure, diabetes mellitus, chronic atrial fibrillation, sinus node disease, AV block grade II or III, and the use of beta adrenergic blockers or antiarrhythmic agents class Ic or III in medication. Twenty-four hour Holter ECG was performed 58 +/- 23 days after the stroke (14 +/- 5 days from the beginning of rehabilitation). HRV was analyzed from the Holter ECG data. The values of the HRV parameters in stroke patients were compared with those recorded in the control group. Most of the variables proposed by the Task Force on HRV were analyzed. Time domain analysis included: mean RR, mean of R-R intervals for normal beats; SDNN, standard deviation of all normal R-R intervals; SDNN-i, mean of 5-minute standard deviations of RR intervals; SDANN-I, standard deviation of the 5-minute means of R-R intervals; rMSSD, square root of the mean of the squared successive differences in R-R intervals; and pNN50, percentage of R-R intervals that are by at least 50 ms different from the previous interval. Frequency domain analysis included: TP, total power (0.0-0.5 Hz); VLF, very low (0.0033-0.04 Hz); LF, low (0.04-0.15 Hz); HF, high (0.15-0.40 Hz) frequency components; and LF/HF, low to high frequency ratio. Statistical analysis was performed using the commercial software package, Microsoft SPSS for Windows, Version 8.0.

RESULTS

Patients who had suffered an ischemic stroke had a significantly lower overall HRV and shorter mean RR interval than healthy subjects from the control group: SDNN 96 +/- 27 vs. 136 +/- 31 ms, p < 0.001; TP 1962 +/- 1338 vs. 3968 +/- 2857 ms2, p < 0.001; and mean RR 869 +/- 104 vs. 892 +/- 117 ms, p = 0.02.

CONCLUSION

As in MI, the values of HRV stay significantly lower after the acute phase of the disease in patients who have suffered ischemic stroke compared to healthy persons of the same age.