Fluorescein Angiography Findings in Susac Syndrome: A Multicenter Retrospective Case Series

BACKGROUND

Susac syndrome is a vasculopathy, resulting in the classic triad of branch retinal artery occlusion (BRAO), inner ear ischemia, and brain ischemia. In this retrospective chart review, we characterize fluorescein angiography (FA) findings and other ancillary studies in Susac syndrome, including the appearance of persistent disease activity and the occurrence of new subclinical disease on FA.

METHODS

This multicenter, retrospective case series was institutional review board-approved and included patients with the complete triad of Susac syndrome evaluated with FA, contrasted MRI of the brain, and audiometry from 2010 to 2020. The medical records were reviewed for these ancillary tests, along with demographics, symptoms, visual acuity, visual field defects, and findings on fundoscopy. Clinical relapse was defined as any objective evidence of disease activity during the follow-up period after initial induction of clinical quiescence. The main outcome measure was the sensitivity of ancillary testing, including FA, MRI, and audiometry, to detect relapse.

RESULTS

Twenty of the 31 (64%) patients had the complete triad of brain, retinal, and vestibulocochlear involvement from Susac syndrome and were included. Median age at diagnosis was 43.5 years (range 21-63), and 14 (70%) were women. Hearing loss occurred in 20 (100%), encephalopathy in 13 (65%), vertigo in 15 (75%), and headaches in 19 (95%) throughout the course of follow-up. Median visual acuity at both onset and final visit was 20/20 in both eyes. Seventeen (85%) had BRAO at baseline, and 10 (50%) experienced subsequent BRAO during follow-up. FA revealed nonspecific leakage from previous arteriolar damage in 20 (100%), including in patients who were otherwise in remission. Of the 11 episodes of disease activity in which all testing modalities were performed, visual field testing/fundoscopy was abnormal in 4 (36.4%), MRI brain in 2 (18.2%), audiogram in 8 (72.7%), and FA in 9 (81.8%).

CONCLUSIONS

New leakage on FA is the most sensitive marker of active disease. Persistent leakage represents previous damage, whereas new areas of leakage suggest ongoing disease activity that requires consideration of modifying immunosuppressive therapy.

The Neurology of Immune-Mediated Disorders in Women

Many neuroinflammatory disorders have a predilection for women; even if there is no female predominance, neuroinflammatory conditions in women pose a management challenge for several reasons. Disease activity of these conditions may change during pregnancy and commonly increases in the postpartum period. Uncontrolled disease activity may affect pregnancy outcomes. Moreover, immunomodulating agents that are used to suppress the disease activity may have a negative impact on fertility, pregnancy, and fetal outcomes, and on infants who are breastfed. Adverse effects of immunosuppressants extend beyond the reproductive issues and may include bone loss, increased risk of cancers, and infectious complications. The successful management of women with these disorders requires that not only practitioners understand and recognize the adverse effects of immunosuppressants, but also seek to prevent adverse outcomes through counseling about contraceptive choices, safety monitoring, risk surveillance, and other strategies.

Autoimmune Encephalitis in Critical Care: Optimizing Immunosuppression

Autoimmune diseases affecting the nervous systems are a common cause of admission to the intensive care unit (ICU). Although there exist several well-described clinical syndromes, patients more commonly present with progressive neurologic dysfunction and laboratory and radiographic evidence of central nervous system (CNS) inflammation. In the critical care setting, the urgency to intervene to prevent permanent damage to the nervous system and secondary injury from the systemic manifestations of these syndromes often conflicts with diagnostic uncertainty. Furthermore, treatment is limited by current therapeutic agents that remain non-specific for individual diseases, especially for those whose pathophysiology remains unclear. Primary autoimmune, paraneoplastic, parainfectious, and iatrogenic neurologic disorders all share the common underlying pathophysiology of an adaptive immune response directed against an antigen within the nervous system. Several different mechanisms of immune dysfunction are responsible for pathogenesis within each of these categories of disease, and it is at this level of pathophysiology that the most effective and appropriate therapeutic decisions are made. In this review, we outline the basic diagnostic and therapeutic principles in the management of autoimmune diseases of the nervous system in the ICU. We approach these disorders not as lists of distinct clinical syndromes or molecular targets of autoimmunity but rather as clusters of syndromes based on these common underlying mechanisms of immune dysfunction. This approach emphasizes early intervention over precise diagnosis. As our understanding of the immune system continues to grow, this framework will allow for a more sophisticated approach to the management of patients with these complex, often devastating but frequently reversible, neurologic illnesses.

A 44-year-old man with eye, kidney, and brain dysfunction

Retinal vasculopathy with cerebral leukodystrophy (RVCL) is a rare, autosomal dominant condition caused by mutations of TREX1 (3-prime repair exonuclease-1). The phenotypic expressions range from isolated retinal involvement to varying degrees of retinopathy, cerebral infarction with calcium depositions, nephropathy, and hepatopathy. We report a case of RVCL caused by a novel TREX1 mutation. This patient's multisystem presentation, retinal involvement interpreted as "retinal vasculitis," and improvement of neuroimaging abnormalities with dexamethasone led to the accepted diagnosis of a rheumatologic disorder resembling Behçet disease. Clinicians should consider RVCL in any patient with retinal capillary obliterations associated with tumefactive brain lesions or nephropathy.

A neurologist's guide to safe use of immunomodulatory therapies

Increased understanding of the pathogenesis of immune-mediated neurologic conditions with concomitant development of new therapeutic agents modulating various aspects of the immune system has resulted in the use of innovative therapies in the treatment of these diseases. These novel immunomodulatory therapeutic regimens also augment the potential for complications, including severe adverse effects.In this review, the authors address practical issues regarding management of patients with neuroimmunological conditions treated with immunomodulatory therapies, including glucocorticoids, methotrexate, azathioprine, mycophenolate, cyclophosphamide, rituximab, tumor necrosis factor-α inhibitors, and intravenous immunoglobulins. Particular focus is placed on their infectious and noninfectious adverse effects, contraindications, safety monitoring, risk surveillance, and preventive strategies in clinical practice.

Can teaching research methodology influence students' attitude toward science? Cohort study and nonrandomized trial in a single medical school

BACKGROUND

Medical teaching aims to develop attitudes and behaviors underlying professional competence of future physicians. We investigated whether a mandatory course on scientific methodology in the second study year could affect students' attitudes toward science in medicine.

METHOD

In a longitudinal study, students (n = 241) enrolling in 2001-2002 academic year at a single medical school were followed up until graduation in 2006-2007. Each year, they filled out a Likert-type questionnaire of 18 statements evaluating attitude toward science. Direct influence of the course on students' attitudes was tested in a nonrandomized controlled trial with the 2006-2007 second year student cohort.

RESULTS

Positive students' attitudes toward science increased during study years (mean [SD] score of the maximum score of 90): from 57.6 (6.0) in the first to 69.8 (10.4) in the sixth year. There was a significant trend of increase in attitudes with the years of study (cubic trend by polynomial contrasts analysis, P = 0.011). Attendance of a course on research methodology significantly increased positive attitudes (score, 67.0 [7.0] before and 70.8 [7.5] after course, P = 0.032 vs control group), regardless of grade point average. The intervention had an effect even when the influence of the initial attitude was accounted for (F1,140 = 9.25, P = 0.003; analysis of covariance). The attitude changes after the course was greatest in students with low initial attitude scores (Spearman rinitial score, score difference, -0.44).

CONCLUSIONS

Medical students have positive attitudes toward science and scientific method in medicine. Attendance of a course on research methodology had positive short-term effect on students' attitudes toward science. This positive effect should be maintained by vertical integration of the course in the medical curriculum.

The recombinant amyloid-beta peptide Abeta1-42 aggregates faster and is more neurotoxic than synthetic Abeta1-42

Aggregation of the amyloid-beta (Abeta) peptide is considered a central event in the pathogenesis of Alzheimer's disease (AD). In order to bypass methodological bias related to a variety of impurities commonly present in typical preparations of synthetic Abeta, we developed a simple, generally applicable method for recombinant production of human Abeta and Abeta variants in Escherichia coli that provides milligram quantities of Abeta in very high purity and yield. Amyloid fibril formation in vitro by human Abeta1-42, the key amyloidogenic Abeta species in AD, was completed threefold faster with recombinant Abeta1-42 compared to synthetic preparations. In addition, recombinant Abeta1-42 was significantly more toxic to cultured rat primary cortical neurons, and it was more toxic in vivo, as shown by strongly increased induction of abnormal phosphorylation of tau and tau aggregation into neurofibrillary tangles in brains of P301L tau transgenic mice. We conclude that even small amounts of impurities in synthetic Abeta-including a significant fraction of racemized peptides that cannot be avoided due to the technical limitations of peptide synthesis--prevent or slow Abeta incorporation into the regular quaternary structure of growing beta-amyloid fibrils. The results validate the use of recombinant Abeta1-42 for both in vitro and in vivo studies addressing the mechanisms underlying Abeta aggregation and its related biological consequences for the pathophysiology, therapy, and prevention of AD.

Academic misconduct among medical students in a post-communist country

AIM

To assess the prevalence of, attitudes towards and willingness to report different forms of academic dishonesty among medical students in a post-communist transitional country.

METHODS

An anonymous, self-administered questionnaire was distributed to medical students in Years 2-6 at the Zagreb University School of Medicine; 827 (70%) valid questionnaires were returned and analysed.

RESULTS

Most of the students (94%) admitted cheating at least once during their studies. The most frequent type of misconduct was 'signing in an absent student on a class attendance list' (89.1%), and the least frequent 'paying for passing an examination' (0.7%). The number of committed types of misconduct out of 11 listed types increased from Year 2 (median 2) to Year 6 (median 4). Cheating behaviours could be clustered into 4 groups based on self-reported cheating, perceived prevalence of cheating, attitude towards cheating, and willingness to report cheating. The clustered behaviours that most students admitted to were perceived as the most frequent, more approved of and less likely to be reported. The strongest predictors of dishonest behaviour were attitude, perception of peer group behaviour and study year. Almost half (44%) the students said they would never report any form of cheating.

CONCLUSION

Academic misconduct is widespread among medical students at the largest medical school in Croatia and its prevalence is greater than that reported for developed countries. This may be related to social and cultural factors specific to a country in the midst of a post-communist transition to a market economy, and calls for measures to be instigated at an institutional level to educate against and prevent such behaviour.

Teaching research methodology in medical schools: students' attitudes towards and knowledge about science

OBJECTIVE

To explore the relationship between teaching scientific methodology in Year 2 of the medical curriculum and student attitudes towards and knowledge about science and scientific methodology.

DESIGN

Anonymous questionnaire survey developed for this purpose.

SETTING

Zagreb University School of Medicine, Croatia.

PARTICIPANTS

A total of 932 students (response rate 58%) from all 6 years were invited to participate.

MAIN OUTCOME MEASURES

Score on attitude scale with 45 Likert-type statements and score on knowledge test consisting of 8 multiple choice questions.

RESULTS

The average attitude score for all students was 166 +/- 22 out of a maximum of 225, indicating a positive attitude towards science and scientific research. The students' average score on the knowledge test was 3.2 +/- 1.7 on 8 questions. Students who had finished Year 2 had the highest mean attitude (173 +/- 24) and knowledge (4.7 +/- 1.7) scores compared with other year groups (P < 0.001, anova and Tukey posthoc test). For students who had attended a mandatory Year 2 course on the principles of scientific research in medicine (Years 3 to 6), multiple linear regression analysis showed that knowledge test score (B = 3.4; SE = 0.4; 95% confidence interval 2.5-4.2; P < 0.001) and average grades (B = 7.6; SE = 1.5; 95% CI 4.6-10.6; P < 0.001) were significant predictors of attitude towards science, but not sex or failure to pass a year (B = - 0.6; SE = 1.7; 95% CI - 3.9-2.6; P = 0.707; and B = - 3.1; SE = 1.9; 95% CI - 6.8-5.7; P = 0.097, respectively).

CONCLUSION

Medical students have generally positive attitudes towards science and scientific research in medicine. Attendance of a course on research methodology is related to a positive attitude towards science.

Knowledge about and attitude towards science of first year medical students

AIM

To assess the knowledge about and attitude towards science of students entering medical school, and to find out whether these parameters are influenced by their high school education, sex, place of residence, and rank achieved on the admission test.

METHODS

A total of 193 (82%) students who enrolled at the Zagreb University School of Medicine in 2001 filled out an anonymous questionnaire at their first lecture. The questionnaire consisted of demographic data, 20 statements on science adapted to a 1-5 Likert scale, and 8 multiple-choice test questions on knowledge of scientific research.

RESULTS

The students knowledge of scientific research was poor (out of 8 answers, 2.2 +/- 1.2 were correct) in spite of their positive attitude towards science (75 +/- 11 on a 20-100 scale). Higher ranking students at the admission test showed more positive attitude (Spearmans rho=-0.157, p=0.003). There was no interdependence between other personal data (sex, high school, and place of residence) and opinion/knowledge about science.

CONCLUSION

In Croatia, first-year medical students are not familiar with basic facts about the scientific methods and communication in medicine, but they have positive attitude towards scientific research. The only factor associated with more positive attitude towards science is higher rank at the admission test.