Cognitive impairment is a negative short-term and long-term prognostic factor in elderly patients with hip fracture

BACKGROUND

Subjects with severe cognitive impairment (CI) have a high-risk of hip fractures with increased rate of adverse postoperative functional outcomes and mortality.

AIM

To evaluate the impact of different degrees of CI on functional recovery and mortality after hip fracture.

DESIGN

Prospective observational study.

SETTING

Two orthopedic surgery units.

POPULATION

Two hundred twenty-eight consecutive patients after a hip surgery.

METHODS

Patients were assessed at baseline through the Short Portable Mental Status Questionnaire (SPMSQ), an instrument that allows to categorize subjects as follows: cognitively intact (SPMSQ≥8) or with mild (SPMSQ=6-7), moderate (SPMSQ=3-5) and severe CI (SPMSQ<3). Barthel Index (BI) was used to assess functional disability. All patients underwent rehabilitation from the day after surgery to discharge (mean length of stay =10.2±3.4). Outcome measures were: (1) overall mortality up to 12 months after surgery; (2) motor ability achieved at discharge from the orthopedic ward (sitting, standing, walking); (3) BI and SPMSQ at 1, 3, 6 and 12 months postoperatively.

RESULTS

All degrees of severity of CI were inversely correlated to the ability to walk at hospital discharge. At one year from surgery, the majority of patients with CI were functionally severely dependent, whereas about half of the cognitively intact ones gained a functional independence status. CI and the level of premorbid disability influenced the risk of death.

CONCLUSION

CI for all degrees of severity is a negative prognostic factor in elderly patients with hip fracture.

CLINICAL REHABILITATION IMPACT

We suggest evaluating the cognitive status of patients with hip fracture as it affects both the short and long-term functional recovery at any degree of severity.

General cognition predicts post-stroke recovery defined through minimal clinically important difference (MCID): a cohort study in an Italian rehabilitation clinic

BACKGROUND

In the field of rehabilitation it is crucial to define if changes in functional scores correspond to relevant clinical improvements.

AIM

To assess whether cognition affects motor recovery in post-stroke patients using a clinical meaningful criterion: the minimal clinically important difference (MCID).

DESIGN

Retrospective cohort study.

SETTING

Inpatient rehabilitation clinic

POPULATION

Two hundred nine first-ever stroke patients undergoing a post-acute inpatient rehabilitation.

METHODS

Cognitive status was assessed with the cognitive FIM and the Mini-Mental State Examination (MMSE). The response to the rehabilitation was defined as the achievement of the MCID between admission and discharge in the motor FIM (responder) and both in the motor and in the cognitive FIM (best-responder).

RESULTS

Subjects with a baseline higher MMSE>24.9 had a near four-fold higher probability of being responder (OR 3.91; 95% CI 1.72-8.89) and a two-fold higher probability of being best-responder (OR 2.69; 95% CI 1.24-5.84) on motor FIM as compared to those with a MMSE≤24.9. A duration of the rehabilitation of 55-61 days implies a three-fold higher probability (OR 3.17; 95% CI 1.15-8.72) to be responder as compared to shorter period of treatment; a treatment >61 days does not involve a greater probability of response.

CONCLUSIONS

This is the first study that examined post-stroke motor recovery mainly in terms of clinical relevance (MCID). Subjects with a higher cognitive level are more likely to achieve a clinically meaningful recovery.

CLINICAL REHABILITATION IMPACT

MCID can be applied extensively to post-stroke patients undergoing to an inpatient rehabilitation in order to have a clinically useful instrument that assess the recovery.

The NOS3 G894T (Glu298Asp) polymorphism is a risk factor for frontotemporal lobar degeneration

BACKGROUND AND AIMS

Neuronal nitric oxide synthase (NOS)1 C276T polymorphism was shown to increase the risk for frontotemporal lobar degeneration (FTLD). In the brain, both NOS1 and NOS3 (endothelial isoform) have been detected. The distribution of NOS3 G894T (Glu298Asp) and T-786C single nucleotide polymorphisms (SNPs) was analyzed in a population of 222 patients with FTLD compared with 218 age-matched controls to determine whether they could influence the susceptibility to develop the disease.

RESULTS

A statistically significant increased frequency of the NOS3 G894T SNP was observed in patients as compared with controls (40.0 vs. 31.4%, P = 0.011, OR: 1.65, CI: 1.13-2.42). Conversely, the distribution of the T-786C SNP was similar in patients and controls. No differences were observed stratifying according to gender.

DISCUSSION

The NOS3 G894T polymorphism likely acts as risk factor for sporadic FTLD, but studies in larger populations are needed to confirm these preliminary findings.

Free and Cued Selective Reminding Test: an Italian normative study

The presence of episodic memory impairment is required for the diagnosis of Alzheimer's dementia by all current diagnostic criteria. The new research criteria proposed by Dubois et al. (Lancet Neurol 6:734-746, 2007) require that the impairment should not improve significantly with cueing, recognition testing nor after the control of effective encoding. This is considered to be the core deficit of "prodromal Alzheimer's disease". The Free and Cued Selective Reminding Test (FCSRT) is a memory test that allows in assessing these specific features of memory impairment. Here, we report normative data for an Italian version of the FCSRT. The test is based on the 12 pictorial stimuli, 6 belonging to the living domain, and 6 to the non-living domain. Six scores were derived from the performance of 227 healthy Italian adults, with age, sex and education homogenously distributed across subgroups: immediate free recall (IFR), immediate total recall (ITR), delayed-free recall (DFR), delayed total recall (DTR), Index of Sensitivity of Cueing (ISC), number of intrusions. In multiple regression analyses, age emerged as an influencing factor for both IFR and DFR, with older people obtaining lower scores. Education and gender appear to influence only IFR, with better performance by more educated subjects and females. Adjusted scores were used to determine inferential cutoff scores and to compute equivalent scores.

Differences in hippocampal metabolism between amnestic and non-amnestic MCI subjects: automated FDG-PET image analysis

AIM

The aim of this study was to assess whether 18F-fluorodeoxyglucose positron emission tomography differentiates amnestic (aMCI) from single-non-amnestic mild cognitive impairment (snaMCI) with executive dysfunction.

METHODS

Sixteen aMCI subjects (62% females, age 75+/-8 years) and 14 snaMCI subjects (71% females, age 74+/-6 years) underwent [18F]FDG-PET and clinical follow-up. Comparisons between MCI subgroups and with seven cognitively normal elderly subjects were performed using SPM2.

RESULTS

At baseline aMCI and snaMCI exhibited a similar pattern of hypometabolism, mostly in the posterior cingulate gyrus, as compared with controls. In the comparison between the MCI subtypes, the aMCI subjects showed reduced metabolism in the medial temporal lobes (MTL) (hippocampus, fusiform gyrus and amygdala). At follow-up 12 aMCI developed Alzheimer's disease (AD), while snaMCI had a heterogeneous course, including five subjects who developed Lewy body dementia.

CONCLUSIONS

The patterns of altered brain metabolism in aMCI and snaMCI subjects compared to controls are similar and do not provide evidence for making clinical distinctions between them. Comparison between the two MCI subtypes showed MTL hypometabolism in aMCI subjects, possibly reflecting the fact that most had prodromal AD.

DCUN1D1 is a risk factor for frontotemporal lobar degeneration

BACKGROUND AND PURPOSE

Frontotemporal lobar degeneration (FTLD) is considered as a proteinopathy; therefore, it is conceivable that genes encoding for factors involved in protein misfolding and/or degradation could play a role in its pathogenesis.

METHODS

An association study of defective in cullin neddylation 1 (DCN-1)-domain containing 1 (DCUN1D1), which is involved in protein degradation, was carried out in a population of 220 patients with FTLD as compared with 229 age-matched controls.

RESULTS

A statistically significant increased frequency of the GG genotype of the DCUN1D1 rs4859146 single nucleotide polymorphism (SNP) was observed in patients compared with controls (6.9 vs. 1.7%, P = 0.011, adjusted OR: 4.39, 95% CI: 1.40-13.78). Stratifying according to the clinical syndrome, significant differences were observed between the behavioral variant of frontotemporal dementia and controls (GG frequency: 6.3 vs. 1.7%, P = 0.02, OR:4.0, 95%, CI = 1.24-12.92), as well as between patients with progressive aphasia compared with controls (15.4 vs. 1.7%, P = 0.014, OR = 11.30, 95%, CI = 1.63-78.45), but not in patients with SD versus controls (8.3 vs. 1.7%, P = 0.18, OR = 5.24, 95% C.I. = 0.45-60.63). No significant differences in allelic and genotypic frequencies of the DCUN1D1 rs4859147 SNP were found.

CONCLUSIONS

The GG genotype of the DCUN1D1 rs4859147 SNP represents a risk factor for the development of FTLD, increasing the risk of about fourfold.

Novel exon 1 progranulin gene variant in Alzheimer's disease

BACKGROUND AND PURPOSE

Progranulin (PGRN) expression is increased in activated microglia in Alzheimer's disease (AD) brain, suggesting a potential role in this pathology.

METHODS

A mutation scanning of exons and flanking regions of PGRN was carried out in 120 patients with sporadic frontotemporal lobar degeneration and 145 with sporadic AD.

RESULTS

Amongst variants not yet deposited, a novel allelic variant was identified in Exon 1 (g100169G > A). It leads to an amino acidic change (p.Gly35Arg) and was observed in a patient with late onset AD. In silico analysis predicted that this mutation is possibly damaging. A second variant (g.100165C > T), resulting in a silent mutation (pAsp33Asp), was found in a patient with semantic dementia and in another with early onset AD. Both variants were absent in 226 controls. In addition, two rare non-pathogenic variants lying very close to PGRN splice-site regions (IVS2 + 7-->G > A and IVS7 + 7-->G > A) were observed. Transcriptional analysis in peripheral blood mononuclear cells from patients demonstrated they do not affect exon splicing.

CONCLUSIONS

A novel putative PGRN mutation leading to an amino acidic substitution was identified in a patient with clinical AD.

Neuronal nitric oxide synthase C276T polymorphism increases the risk for frontotemporal lobar degeneration

The neuronal nitric oxide synthase (nNOS) is abundantly expressed in the brain and its transcripts have been found in the frontal cerebral cortex. Eighty-nine patients with different neurodegenerative tau-related disorders, including 71 patients with frontotemporal lobar degeneration (FTLD), 12 with progressive supranuclear palsy (PSP) and 6 with corticobasal degeneration (CBD), were genotyped for the C276T single nucleotide polymorphism (SNP) in exon 29 of the nNOS gene and compared with 190 age-matched controls (CON). A significantly increased allelic frequency of the T allele was observed in patients compared with CON (40.4% vs. 29.7%, P = 0.014, OR: 1.94, CI: 1.15-3.27). Considering each disorder separately, significance was reached for FTLD only (39.4%, P = 0.0248 versus controls, OR: 1.96, CI: 1.11-3.47). However, the frequency of the T allele was elevated also in patients with PSP (45.8%) and CBD (41.7%). No differences were observed stratifying according to gender or apolipoprotein E status. The C276T SNP acts as risk factor for sporadic FTLD, possibly influencing NOS1 transcription. Studies in larger populations are needed to confirm its role in PSP and CBD.

Cholinergic balance in dementia with Lewy bodies: reversible worsening of Parkinsonism at rivastigmine dosage modulation

We describe a patient with probable dementia with Lewy bodies (DLB) whose Parkinsonism worsened after administration of rivastigmine within the therapeutic dose range. Some extrapyramidal signs (EPS) then reversed to pre-treatment level after rivastigmine dose reduction. We draw attention to the need of EPS monitoring during titration of cholinesterase inhibitors in patients with DLB. This is the first report to our knowledge of iatrogenic worsening of Parkinsonism which was successfully managed by dose reduction.

The number of pregnancies is a risk factor for Alzheimer's disease

Epidemiological data show a higher prevalence of late-onset Alzheimer's disease (AD) in women. The estrogenic deficiency in the post-menopausal period is suspected to be the cause of the gender-related risk of the disease, but studies on the estrogenic therapy and occurrence of AD were not consistent and sometimes contradicting. The aim of this study is to investigate whether a higher exposure to endogenous estrogens is associated with lower risk of dementia or not. Two hundred and four AD patients and 201 control women were considered. By interviews, we evaluated different variables, indirectly correlated to estrogenic natural exposure, as well as educational level and head trauma. These data were correlated in the AD group with the disease progression, as well as with the age at onset. Unexpectedly, we found a significant higher number of pregnancies in the AD than in the control group. Within the AD cases, the number of lifetime pregnancies is related to an earlier onset of the disease. As previously reported, we confirmed that the educational level is a protective factor and that major head trauma represents a risk factor in developing AD. The higher number of pregnancies and a less frequency of nulliparous women, indirectly relate the AD group to a higher estro-progestinic exposure. These findings suggest that it is the increase of progesterone or estrogens level--and not the estrogens decrease, as previously indicated by other authors--that could play a role in the Alzheimer's pathology.

Isothiazoles. Part XV. A mild and efficient synthesis of new antiproliferative 5-sulfanylsubstituted 3-alkylaminoisothiazole 1,1-dioxides

5-Sulfanyl-3-alkylaminoisothiazole dioxide derivatives have been identified as a new class of potent inhibitors of rat aortic myocite proliferation. They were prepared by applying a simple methodology able to introduce a heteroatom on C-5 of the 3-alkylaminoisothiazole dioxide system. 3-Aminosubstituted-5-chloroisothiazole dioxides react smoothly not only with S-nucleophiles but also with N- and O-nucleophiles affording the corresponding 5-heterosubstituted isothiazole dioxides through an addition-elimination reaction. The behavior of 3-alkylamino-4-bromo-isothiazole 1,1-dioxide with S-, N- and O-nucleophiles affording the same products has also been described. On the contrary, the 3-amino-4,5-unsubstituted isothiazole dioxide system reacts easily only with sulfur nucleophiles affording the corresponding 4,5-dihydro-5-sulfanylderivatives through a simple Michael addition reaction.

Dementia with Lewy bodies with supranuclear gaze palsy: a matter of diagnosis

Description of a case of probable dementia with Lewy bodies featuring parkinsonism, dementia and supranuclear gaze palsy. This is the first patient to our knowledge affected with vertical gaze palsy receiving clinical diagnosis of DLB when alive and to be treated with cholinesterase inhibitors.

Clinical aspects of the AIDS dementia complex in relation to histopathological and immunohistochemical variables

To correlate cerebral histopathological and immunohistochemical changes in the neuroclinical features of the AIDS dementia complex (ADC), autopsy results of 28 ADC patients were related, in a retrospective analysis, to scores on a standardised neurological examination performed at neurologic onset. From a histopathological point of view, the cases were classified as follows: 9 cases of HIV leucoencephalopathy (HIVL; diffuse myelin damage and rare microglial nodules), 7 cases of HIV encephalitis (HIVE; several microglial nodules and no myelin damage) and 12 cases of mixed HIVL and HIVE (HIVL-E). The groups differed significantly with respect to symptoms and CD4 count at neurologic onset, survival and neurological impairment. Immunohistochemically, the interstitial component (p24-positive cells scattered singly within the white matter) was significantly more prevalent in HIVL, and the micronodular component (p24-positive cells confined within microglial nodules) in HIVE. Neurological damage was worse in cases with a high prevalence of interstitial component or a low prevalence of micronodular component. HIVE, HIVL and HIVL-E are distinct clinical forms of ADC. Neurological impairment is related to white matter damage.

Asymmetric synthesis of 2-amino-3-hydroxynorbornene-2-carboxylic acid derivatives

The enantioselective synthesis of 2-amino-3-hydroxynorbornene-2-carboxylic acid derivatives (5) was studied using the Diels-Alder reaction between cyclopentadiene and different dienophiles, i.e., alkyl 5-oxo-2-phenyloxazol-4-methylenecarbonates (1) or 2-benzoylamino-3-alkoxycarbonyloxy-acrylates (12), operating with different Lewis acids and both with thermal and with ultrasound conditions. The enantioselective synthesis of the exo/endo compounds 5c,d and 5'c,d was achieved starting from the chiral menthyl acrylates 12b,c using Mg(ClO(4))(2) as the catalyst and ultrasound. The cycloadducts were obtained in very good yield, in mild conditions, in short time, and in good diastereomeric excess (exo, 80%; endo, 87%). Finally, the use of alkylidene-oxazolones or acrylates and EtAlCl(2) or Mg(ClO(4))(2) as the catalyst allowed control of the cycloaddition reaction in favor of the exo or endo products.

Synthesis of 2-amino-5-sulfanyl-1,3,4-thiadiazole derivatives and evaluation of their antidepressant and anxiolytic activity

Recently a series of 2-amino-5-sulfanyl-1,3,4-thiadiazole derivatives bearing different substituents were synthesized and screened pharmacologically in order to evaluate their central nervous system activity. The purpose of this study was to evaluate the effects of the title compounds on CNS activity by varying the substituents in the thiadiazole moiety. It was found that some of these compounds possess marked antidepressant and anxiolytic properties comparable in efficiency to the reference drugs Imipramine and Diazepam. The most potent compound 3k was further investigated to complete its pharmacological profile with respect to undesired side effects. Behavioral results showed that 3k is a very promising compound, characterized by a mixed antidepressant-anxiolytic activity accompanied by a therapeutic dose range that is essentially 2 orders of magnitude less than that at which side effects such as sedation and amnesia are evident.

Conformationally constrained serine analogues: synthesis of new 2-amino-3-hydroxynorbornanecarboxylic acid derivatives

A synthesis of the new oxazolone 2, functionalized with the ethoxycarbonyloxy group on methylenic carbon, is presented, starting from 4-hydroxymethylenoxazolone 1 and ethyl chlorocarbonate. Oxazolone 2 was reacted with cyclopentadiene in the presence of EtAlCl(2), giving the two diastereoisomeric cycloadducts exo-3 and endo-3 in a 70:30 ratio. Selective hydrolysis of the lactone ring (THF, HCl) gave the corresponding acids 5 and 6 which were transformed into hydroxyacid derivatives 7 and 8, respectively, operating in an ethanolic solution of Me(2)NH. The new 3-hydroxy-2-aminonorbornane-2-carboxylic acids 11 and 12, in which the serine skeleton is included, were obtained by reduction of acids 5 and 6 to derivatives 9 and 10 and a subsequent hydrolysis with HCl.

A Novel Class of Conformationally Constrained, Masked Cysteines: Synthesis of 2-Alkyl- and 2-Arylsulfanyl-1-aminocyclopropanecarboxylic Acids

A convenient synthesis of 4-sulfanylmethylene-5(4H)-oxazolones 3 was realized starting from 4-(chloromethylene)oxazolone 1 and mercaptans 2. Oxazolones 3 were used as starting materials for the preparation of unknown 2-sulfanyl-1-aminocyclopropanecarboxylic acid derivatives 5 and7. Oxazolones 3 were cyclopropanated at the exocyclic double bond with diazomethane, giving a mixture of the two (Z)- and (E)-spirocyclopropane oxazolones 4 with good diastereoselectivity. These were then treated with ethanol and DMAP to produce the corresponding carboxylates 5. The trityl derivative 5d was converted into a mixture of diastereoisomeric disulfides 6 using iodine in ethanol solution. Disulfides 6 are convenient synthons for the preparation of 3-sulfanyl-substituted 2,3-methanoamino acids 7.

Microglial nodular encephalitis and ventriculoencephalitis due to cytomegalovirus infection in patients with AIDS: two distinct clinical patterns

In patients with AIDS, cerebral infection due to cytomegalovirus (CMV) results in two distinct neuropathological patterns: microglial nodular encephalitis (MGNE) and ventriculoencephalitis (VE). In order to identify clinical features to facilitate the differential diagnosis of these two forms of CMV encephalopathy in living patients, we retrospectively reviewed the clinical records of 18 patients with MGNE or VE diagnosed at autopsy. We identified the following clinical features as distinguishing the two encephalopathies: (1) MGNE manifests earlier than VE; (2) the onset of MGNE is acute, whereas the onset of VE is insidious; (3) the onset of MGNE is marked by confusion and delirium, which do not occur in VE; (4) VE is frequently associated with radiculopathy, which is absent in MGNE; and (5) VE is associated with more marked alterations in cerebrospinal fluid (high protein levels and pleocytosis). The early neurological manifestations of MGNE should prompt a search for systemic CMV infection, which may lead to earlier treatment.

Light chain deposition disease neuropathy resembling amyloid neuropathy in a multiple myeloma patient

A 65-year-old man with IgG lambda multiple myeloma developed severe polyneuropathy with prominent thermal-pain sensory impairment and autonomic failure. Although the clinical presentation suggested amyloid neuropathy, nerve biopsy showed the immunohistochemical and ultrastructural features typical of light chain deposition disease (LCDD). A precise morphologic and clinical description of LCDD neuropathy is given for the first time in the present report.

Effects of HIV seropositivity and drug abuse on cognitive function

Fifty-eight HIV-positive drug abusers and 22 HIV-positive nondrug abusers at stages II-III and IV of the Centers for Disease Control classification were evaluated neuropsychologically. The study confirmed previous findings that drug abuse has a negative influence on cognitive function. It also emerges that seropositivity affects cognitive function, although the poor performance of group II-III patients compared to group IV may be explained by factors related to seropositivity (anxiety and panic) rather than the disease itself. It is concluded that disease-related factors probably determine cognitive performance in the earlier stages of HIV infection.

HIV infection and drug use: influence on cognitive function

OBJECTIVE

To examine the involvement of cognitive function in HIV-seropositive drug users (DU) in a pre-AIDS state.

DESIGN

Fifty-six HIV-positive DU were prospectively evaluated. They belonged to groups II, III and IV (subgroups A, C2 and E) of the 1987 Centers for Disease Control and Prevention classification, with anamnesis negative for neurological pathology. HIV-negative DU (n = 19) and non-DU (n = 27) were used as controls. Infection with HIV and use of toxic drugs were considered variables of influence on cognitive function.

METHOD

Subjects underwent neuropsychological evaluation by tests designed to explore cortical and subcortical function.

RESULTS

HIV-positive DU showed worse performance scores at the psychometric tests than HIV-negative non-DU, but there was no difference when compared with HIV-negative DU. Ex-DU showed better performance than active DU. No difference with regard to degree of disease evolution was observed among HIV-positive individuals (i.e., groups II and III versus group IV).

CONCLUSIONS

There was no evidence of cognitive deficits in HIV-positive individuals in non-AIDS phases to indicate early involvement by HIV at the cerebral level. Progression of the disease, prior to the AIDS phase, did not determine a worsening of intellectual performance. Instead, cognitive function was affected by the chronic and current use of toxic substances. In HIV-positive DU, a decline in cognitive function was found to be attributable to the chronic use of toxic substances rather than HIV infection.

Reversible bilateral opercular syndrome secondary to AIDS-associated cerebral toxoplasmosis

A case of reversible anterior bilateral opercular syndrome (Foix-Chavany-Marie syndrome) secondary to cerebral toxoplasma abscesses is described in a patient with AIDS. The symptoms regressed following antitoxoplasma and antiedema drug therapy. Although this is the first reported AIDS-related case, the syndrome is likely to recur in AIDS sufferers in whom multifocal cerebral lesions are common.

Neuropsychological performance in HIV-1-infected drug abusers

Twenty-five HIV-seropositive drug abusers (DA+HIV+) (groups II-III and IV [A, C2 and E] of the CDC classification) were evaluated by use of the WAIS scale to determine any possible involvement of cognitive functions in the not yet overt phases of AIDS. The results were compared with those obtained in two control populations composed of 19 seronegative drug abusers (DA+HIV-) and 24 healthy subjects (DA-HIV-) to evaluate, in addition to the disease, the possible effect of the use of alcohol and toxic substances on cognitive performance. In spite of the small number of subjects, the study indicated that drug abuse is the main factor, among those analyzed, in determining a decline in cognitive functions.