Mapping morbidity 10 years prior to a diagnosis of young onset Alzheimer's disease

INTRODUCTION

Early symptoms in young onset Alzheimer's disease (YOAD) may be misinterpreted, causing delayed diagnosis. This population-based study aimed to map morbidity prior to YOAD diagnosis.

METHODS

In a register-based incidence density matched nested case-control study, we examined hospital-diagnosed morbidity for people diagnosed with YOAD in Danish memory clinics during 2016-2020 compared to controls in a 10-year period. Conditional logistic regression produced incidence rate ratios (IRRs).

RESULTS

The study included 1745 cases and 5235 controls. YOAD patients had a higher morbidity burden in the year immediately before dementia diagnosis, for certain disorders up to 10 years before. This was especially evident for psychiatric morbidity with the highest increased IRRs throughout the entire period and IRR 1.43 (95% confidence interval 1.14-1.79) in the 5-10-years before dementia diagnosis.

DISCUSSION

YOAD patients display a different pattern of morbidity up to 10 years prior to diagnosis. Awareness of specific alterations in morbidity may improve efforts toward a timely diagnosis.

HIGHLIGHTS

Retrospective, nested case-control study of young onset Alzheimer's disease (YOAD). YOAD cases had a higher morbidity burden than controls. YOAD cases had a higher psychiatric morbidity burden up to 10 years before diagnosis. Altered morbidity patterns could serve as an early warning sign of YOAD.

Serum metabolic signatures for Alzheimer's Disease reveal alterations in amino acid composition: a validation study

INTRODUCTION

Alzheimer's Disease (AD) is complex and novel approaches are urgently needed to aid in diagnosis. Blood is frequently used as a source for biomarkers; however, its complexity prevents proper detection. The analytical power of metabolomics, coupled with statistical tools, can assist in reducing this complexity.

OBJECTIVES

Thus, we sought to validate a previously proposed panel of metabolic blood-based biomarkers for AD and expand our understanding of the pathological mechanisms involved in AD that are reflected in the blood.

METHODS

In the validation cohort serum and plasma were collected from 25 AD patients and 25 healthy controls. Serum was analysed for metabolites using nuclear magnetic resonance (NMR) spectroscopy, while plasma was tested for markers of neuronal damage and AD hallmark proteins using single molecule array (SIMOA).

RESULTS

The diagnostic performance of the metabolite biomarker panel was confirmed using sparse-partial least squares discriminant analysis (sPLS-DA) with an area under the curve (AUC) of 0.73 (95% confidence interval: 0.59-0.87). Pyruvic acid and valine were consistently reduced in the discovery and validation cohorts. Pathway analysis of significantly altered metabolites in the validation set revealed that they are involved in branched-chain amino acids (BCAAs) and energy metabolism (glycolysis and gluconeogenesis). Additionally, strong positive correlations were observed for valine and isoleucine between cerebrospinal fluid p-tau and t-tau.

CONCLUSIONS

Our proposed panel of metabolites was successfully validated using a combined approach of NMR and sPLS-DA. It was discovered that cognitive-impairment-related metabolites belong to BCAAs and are involved in energy metabolism.

Impaired cholinergic integrity of the colon and pancreas in dementia with Lewy bodies

Dementia with Lewy bodies is characterized by a high burden of autonomic dysfunction and Lewy pathology in peripheral organs and components of the sympathetic and parasympathetic nervous system. Parasympathetic terminals may be quantified with 18F-fluoroetoxybenzovesamicol, a PET tracer that binds to the vesicular acetylcholine transporter in cholinergic presynaptic terminals. Parasympathetic imaging may be useful for diagnostics, improving our understanding of autonomic dysfunction and for clarifying the spatiotemporal relationship of neuronal degeneration in prodromal disease. Therefore, we aimed to investigate the cholinergic parasympathetic integrity in peripheral organs and central autonomic regions of subjects with dementia with Lewy bodies and its association with subjective and objective measures of autonomic dysfunction. We hypothesized that organs with known parasympathetic innervation, especially the pancreas and colon, would have impaired cholinergic integrity. To achieve these aims, we conducted a cross-sectional comparison study including 23 newly diagnosed non-diabetic subjects with dementia with Lewy bodies (74 ± 6 years, 83% male) and 21 elderly control subjects (74 ± 6 years, 67% male). We obtained whole-body images to quantify PET uptake in peripheral organs and brain images to quantify PET uptake in regions of the brainstem and hypothalamus. Autonomic dysfunction was assessed with questionnaires and measurements of orthostatic blood pressure. Subjects with dementia with Lewy bodies displayed reduced cholinergic tracer uptake in the pancreas (32% reduction, P = 0.0003) and colon (19% reduction, P = 0.0048), but not in organs with little or no parasympathetic innervation. Tracer uptake in a region of the medulla oblongata overlapping the dorsal motor nucleus of the vagus correlated with autonomic symptoms (rs = -0.54, P = 0.0077) and changes in orthostatic blood pressure (rs = 0.76, P < 0.0001). Tracer uptake in the pedunculopontine region correlated with autonomic symptoms (rs = -0.52, P = 0.0104) and a measure of non-motor symptoms (rs = -0.47, P = 0.0230). In conclusion, our findings provide the first imaging-based evidence of impaired cholinergic integrity of the pancreas and colon in dementia with Lewy bodies. The observed changes may reflect parasympathetic denervation, implying that this process is initiated well before the point of diagnosis. The findings also support that cholinergic denervation in the brainstem contributes to dysautonomia.

Neuron-derived extracellular vesicles in blood reveal effects of exercise in Alzheimer's disease

BACKGROUND

Neuron-derived extracellular vesicles (NDEVs) in blood may be used to derive biomarkers for the effects of exercise in Alzheimer's disease (AD). For this purpose, we studied changes in neuroprotective proteins proBDNF, BDNF, and humanin in plasma NDEVs from patients with mild to moderate AD participating in the randomized controlled trial (RCT) of exercise ADEX.

METHODS

proBDNF, BDNF, and humanin were quantified in NDEVs immunocaptured from the plasma of 95 ADEX participants, randomized into exercise and control groups, and collected at baseline and 16 weeks. Exploratorily, we also quantified NDEV levels of putative exerkines known to respond to exercise in peripheral tissues.

RESULTS

NDEV levels of proBDNF, BDNF, and humanin increased in the exercise group, especially in APOE ε4 carriers, but remained unchanged in the control group. Inter-correlations between NDEV biomarkers observed at baseline were maintained after exercise. NDEV levels of putative exerkines remained unchanged.

CONCLUSIONS

Findings suggest that the cognitive benefits of exercise could be mediated by the upregulation of neuroprotective factors in NDEVs. Additionally, our results indicate that AD subjects carrying APOE ε4 are more responsive to the neuroprotective effects of physical activity. Unchanged NDEV levels of putative exerkines after physical activity imply that exercise engages different pathways in neurons and peripheral tissues. Future studies should aim to expand upon the effects of exercise duration, intensity, and type in NDEVs from patients with early AD and additional neurodegenerative disorders.

TRIAL REGISTRATION

The Effect of Physical Exercise in Alzheimer Patients (ADEX) was registered in ClinicalTrials.gov on April 30, 2012 with the identifier NCT01681602.

Validity of the Brief Assessment of Impaired Cognition case-finding instrument for identification of dementia subgroups and staging of dementia

BACKGROUND AND PURPOSE

The aims of this study were to examine the psychometric properties of the Brief Assessment of Impaired Cognition (BASIC) case-finding instrument in clinical settings focusing on (i) test-retest reliability, (ii) the discriminative validity of BASIC and its components for identification of Alzheimer disease (AD) dementia and non-AD dementia, and (iii) the association of expert clinical rating of cognitive status with BASIC performance.

METHODS

The test-retest reliability analysis was based on a sample of general practice patients (n = 59) retested with a mean interval of 19 days. Discriminative validity analyses and analysis of the association of cognitive status with BASIC performance were based on data from the primary validation study of BASIC in memory clinics.

RESULTS

The test-retest reliability of BASIC was high (r = 0.861). No significant difference in discriminative validity was found for identification of AD dementia (sensitivity = 0.99, specificity = 0.98) and non-AD dementia (sensitivity = 0.90, specificity = 0.98). All components of BASIC contributed to the high discriminative validity of both AD and non-AD dementia. BASIC performance was significantly correlated with expert clinical rating of the cognitive status of patients. A crude staging model for cognitive status using BASIC score intervals had superior classification accuracy (70%) compared to a Mini-Mental State Examination (MMSE) score range-based model (58% accuracy).

CONCLUSIONS

BASIC is a reliable and valid case-finding instrument for AD dementia and non-AD dementia in clinical settings. BASIC performance is significantly associated with the degree of cognitive impairment, and BASIC seems to be superior to MMSE for staging of impairment.

Aerobic exercise does not affect serum neurofilament light in patients with mild Alzheimer's disease

Introduction

Aerobic exercise has been shown to modify Alzheimer pathology in animal models, and in patients with multiple sclerosis to reduce neurofilament light (NfL), a biomarker of neurodegeneration.

Objective

To investigate whether a 16-week aerobic exercise program was able to reduce serum NfL in patients with mild Alzheimer's disease (AD).

Methods

This is a secondary analysis of data from the multi-center Preserving Cognition, Quality of Life, Physical Health, and Functional Ability in Alzheimer's disease: The Effect of Physical Exercise (ADEX) study. Participants were randomized to 16 weeks of moderate intensity aerobic exercise or usual care. Clinical assessment and measurement of serum NfL was done at baseline and after the intervention.

Results

A total of 136 participants were included in the analysis. Groups were comparable at baseline except for APOEε4 carriership which was higher in the usual care group (75.3 versus 60.2%; p = 0.04). There was no effect of the intervention on serum NfL [intervention: baseline NfL (pg/mL) 25.76, change from baseline 0.87; usual care: baseline 27.09, change from baseline -1.16, p = 0.09].

Conclusion

The findings do not support an effect of the exercise intervention on a single measure of neurodegeneration in AD. Further studies are needed using other types and durations of exercise and other measures of neurodegeneration.

Clinical trial registration

clinicaltrials.gov, identifier NCT01681602.

Updated S2 K guidelines for the management of bullous pemphigoid initiated by the European Academy of Dermatology and Venereology (EADV)

BACKGROUND

Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or, most frequently, generalized bullous lesions. A subset of patients only develops excoriations, prurigo-like lesions, and eczematous and/or urticarial erythematous lesions. The disease, which is significantly associated with neurological disorders, has high morbidity and severely impacts the quality of life.

OBJECTIVES AND METHODOLOGY

The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology sought to update the guidelines for the management of BP based on new clinical information, and new evidence on diagnostic tools and interventions. The recommendations are either evidence-based or rely on expert opinion. The degree of consent among all task force members was included.

RESULTS

Treatment depends on the severity of BP and patients' comorbidities. High-potency topical corticosteroids are recommended as the mainstay of treatment whenever possible. Oral prednisone at a dose of 0.5 mg/kg/day is a recommended alternative. In case of contraindications or resistance to corticosteroids, immunosuppressive therapies, such as methotrexate, azathioprine, mycophenolate mofetil or mycophenolate acid, may be recommended. The use of doxycycline and dapsone is controversial. They may be recommended, in particular, in patients with contraindications to oral corticosteroids. B-cell-depleting therapy and intravenous immunoglobulins may be considered in treatment-resistant cases. Omalizumab and dupilumab have recently shown promising results. The final version of the guideline was consented to by several patient organizations.

CONCLUSIONS

The guidelines for the management of BP were updated. They summarize evidence- and expert-based recommendations useful in clinical practice.

Physical Exercise May Increase Plasma Concentration of High-Density Lipoprotein-Cholesterol in Patients With Alzheimer's Disease

Lifestyle factors have been shown to increase the risk of developing Alzheimer’s disease (AD) later in life. Specifically, an unfavorable cholesterol profile, and insulin resistance are associated with increased risk of developing AD. One way to non-pharmacologically affect the levels of plasma lipids is by exercise, which has been shown to be beneficial in cognitively healthy individuals. In this randomized controlled trial y, we therefore aimed to clarify the effect of physical exercise on the lipid profile, insulin and glucose in patients with AD. In addition, we investigated the effect of apolipoproteinE genotype on total cholesterol, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein–cholesterol (LDL-C), and triglycerides (TG) in plasma from patients with AD. Plasma samples from 172 patients who underwent 16 weeks of moderate-to-high intensity exercise (n = 90) or treatment as usual (n = 82) were analyzed change from baseline for the levels of total cholesterol, LDL-C, HDL-C, TG, glucose, and insulin. In addition, we analyzed those from the exercise group who adhered to the protocol with an attendance of 2/3 or more of the exercise session and who followed the protocol of an intensity of 70% of the maximum heart rate. We found a significant increase in plasma HDL-C levels between the “high exercise sub-group” compared to control group. After intervention HDL-C was increased by 4.3% in the high-exercise group, and decreased by 0.7% in the control group, after adjustment for statin use. In conclusion, short term physical activity may be beneficial on the cholesterol profile in patients with AD.

Quantitative Signal Intensity in Fluid-Attenuated Inversion Recovery and Treatment Effect in the WAKE-UP Trial

Background and Purpose—

Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (fluid-attenuated inversion recovery relative signal intensity [FLAIR-rSI]) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke Trial), intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of diffusion weighted imaging fluid-attenuated inversion recovery mismatch, that is, in those with no marked fluid-attenuated inversion recovery hyperintensity in the region of the acute diffusion weighted imaging lesion. In this post hoc analysis, we investigated whether quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase.

Methods—

FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analyzed by binary logistic regression using different end points, that is, favorable outcome defined as mRS score of 0 to 1, independent outcome defined as mRS score of 0 to 2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for National Institutes of Health Stroke Scale at symptom onset and stroke lesion volume.

Results—

FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD, 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS score of 0 to 1 ( P =0.169) and shift analysis ( P =0.086) but reached significance for mRS score of 0 to 2 ( P =0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical end points with increasing FLAIR-rSI.

Conclusions—

In patients in whom no marked parenchymal fluid-attenuated inversion recovery hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of diffusion weighted imaging lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset.

Brief Assessment of Impaired Cognition (BASIC)-Validation of a new dementia case-finding instrument integrating cognitive assessment with patient and informant report

OBJECTIVES

The aim of this study was to develop and validate a new brief and accurate case-finding instrument for dementia and cognitive impairment. Previous research indicates that combining cognitive tests with informant and/or patient report may improve accuracy in dementia case-finding. The Brief Assessment of Impaired Cognition (BASIC) integrates these three sources of information.

METHODS

BASIC was prospectively validated in five memory clinics. Patients consecutively referred from general practice were tested at their initial visit prior to diagnosis. Control participants were primarily recruited among participating patients' relatives. Expert clinical diagnosis was subsequently used as gold standard for estimation of the classification accuracy of BASIC.

RESULTS

A very high discriminative validity (specificity 0.98, sensitivity 0.95) for dementia (n = 122) versus socio-demographically matched control participants (n = 109) was found. In comparison, the MMSE had 0.90 specificity and 0.82 sensitivity. Extending the discriminative validity analysis to cognitive impairment (both dementia and MCI, n = 162) only slightly reduced the discriminative validity of BASIC whereas the discriminative validity of the MMSE was substantially attenuated. Administration time for BASIC was approximately 5 minutes compared with 10 to 15 minutes for the MMSE.

CONCLUSIONS

BASIC was found to be an efficient and valid case-finding instrument for dementia and cognitive impairment in a memory clinic setting.

The process of disclosing a diagnosis of dementia and mild cognitive impairment: A national survey of specialist physicians in Denmark

Background

Although general recommendations for diagnostic disclosure of dementia are available, little is known about how these recommendations are implemented. The aim of the current study was to investigate the process and content of dementia diagnostic disclosure meetings, and to compare key aspects of disclosing a diagnosis of dementia and mild cognitive impairment.

Method

A total of 54 specialist physicians in Danish dementia diagnostic departments completed an online survey on their practices regarding diagnostic disclosure of dementia and mild cognitive impairment. The influence of respondent characteristics was assessed, and differences on key aspects of disclosing a diagnosis of dementia and mild cognitive impairment were analyzed.

Results

The results suggest that among Danish specialist physicians, there is a general consensus regarding the organization of diagnostic disclosure meetings. However, differences in employed terminology and information provided when disclosing a dementia diagnosis were evident. Significant differences were present on key aspects of the diagnostic disclosure of dementia and mild cognitive impairment. For instance, 91% would use the term dementia during diagnostic disclosures compared to just 72% for mild cognitive impairment.

Conclusion

The range of practices reflected in the present study confirms the complexity of diagnostic disclosure and highlights the importance of preparation and follow-up strategies to tailor the disclosure process to the needs of individual patients with dementia and their caregivers. Due to earlier diagnosis of neurodegenerative disorders, more research is urgently needed on this aspect of the diagnostic process, especially to develop evidence-based models for the disclosure of mild cognitive impairment.

Thrombolysis in acute ischemic stroke is associated with lower long-term hospital bed day use: A nationwide propensity score-matched follow-up study

Background Thrombolysis with intravenous recombinant tissue-type plasminogen activator improves functional outcome in acute ischemic stroke. Few studies have investigated the effects of thrombolysis in a real-world setting. We evaluated the impact of thrombolysis on long-term hospital bed day use and the risk of readmission due to stroke-related complications. Methods We conducted a register-based nationwide propensity score-matched follow-up study among ischemic stroke patients in Denmark (2004-2011). Thrombolysed patients were propensity-score matched with non-thrombolysed acute ischemic stroke patients admitted to stroke centers not yet offering thrombolysis in 2004-2006. The outcomes were length of the stroke admission, total all-cause hospital bed day use during the first year after the stroke, and the long-term risk of readmissions. Thrombolysed and non-thrombolysed patients were compared using multivariable log-linear regression and Cox regression. Results We identified 1095 thrombolysed and 1095 propensity score matched eligible but non-thrombolysed acute ischemic stroke patients. The median length of the stroke admission was 9 days in the thrombolysed group and 13 days in the non-thrombolysed group (adjusted geometric mean ratio, 0.88; 95% CI: 0.78-1.00). The median all-cause hospital bed day use within the first year was 12 days in the thrombolysed group and 19 days in the non-thrombolysed group (adjusted geometric mean ratio, 0.82; 95% CI: 0.73-0.92). There was no significant difference in the overall risk of readmission (adjusted hazard ratio, 0.91; 95% CI: 0.79-1.04); however, thrombolysis was associated with reduced risk of pneumonia (adjusted hazard ratio, 0.59; 95% CI: 0.35-0.97). Conclusions Thrombolysis in ischemic stroke was associated with lower long-term hospital bed day use and decreased risk of readmission due to pneumonia.

Abstract W MP27: Treatment with Intravenous Thrombolysis in Acute Ischemic Stroke is Associated with Reduced Bed Day Use: A Nationwide Propensity Score Matched Follow-Up Study

Introduction: Several studies have demonstrated the beneficial effects of intravenous tissue-type plasminogen activator (IV-tPA) on neurological outcome in acute ischemic stroke. It is uncertain whether the improved neurological outcome also translates into less morbidity and lower need for hospital admissions during follow-up.

Methods: We conducted a register-based nationwide propensity score-matched follow-up study among ischemic stroke patients in Denmark (2004-2011). IV-tPA-treated patients were propensity-score matched with IV-tPA eligible but non-treated ischemic stroke patients from stroke centers not offering tPA. The adjusted Hazard ratio (HR) for first readmission was estimated by multivariable Cox regression among patients who survived the initial stroke admission. Total all-cause bed day use in the first year after stroke admission was determined for patients with a potential follow-up time of at least one year and was compared between groups by a paired t-test after logarithmic transformation.

Results: We identified 1896 IV-tPA-treated and 1896 corresponding propensity-score matched non-treated patients surviving the initial stroke admission. A total of 43.2% of the patients were readmitted to hospital during a median of 0.8 years. The adjusted HR for first readmission was 0.93 (95% CI: 0.79-1.09) when comparing IV-tPA-treated with non-treated patients. In 1462 matched pairs followed the first year after stroke the median all-cause bed day use was 10 (IQR: 4-37) in the group of tPA-treated and 16 (IQR: 6-43) in the group of non-treated patients. The relative bed day use was 0.81 (95% CI: 0.74-0.88) when comparing IV-tPA-treated with non-treated patients.

Conclusion: Use of IV-tPA in ischemic stroke patients was associated with lower long-term all-cause hospital bed day use.

Acute ischemic stroke and long-term outcome after thrombolysis: nationwide propensity score-matched follow-up study

BACKGROUND AND PURPOSE

Data on long-term outcome after intravenous tissue-type plasminogen activator (tPA) in ischemic stroke are limited. We examined the risk of long-term mortality, recurrent ischemic stroke, and major bleeding, including intracranial and gastrointestinal bleeding, in intravenous tPA-treated patients when compared with intravenous tPA eligible but nontreated patients with ischemic stroke.

METHODS

We conducted a register-based nationwide propensity score-matched follow-up study among patients with ischemic stroke in Denmark (2004-2011). Cox regression analysis was used to compute adjusted hazard ratios for all outcomes.

RESULTS

Among 4292 ischemic strokes (2146 intravenous tPA-treated and 2146 propensity score-matched nonintravenous tPA-treated patients), with a follow-up for a median of 1.4 years, treatment with intravenous tPA was associated with a lower risk of long-term mortality (adjusted hazard ratio, 0.66; 95% confidence interval, 0.49-0.88). The long-term risk of recurrent ischemic stroke (adjusted hazard ratio, 1.05; 95% confidence interval, 0.68-1.64) and major bleeding (adjusted hazard ratio, 0.59; 95% confidence interval, 0.24-1.47) did not differ significantly between the intravenous tPA-treated and nontreated patients.

CONCLUSIONS

Treatment with intravenous tPA in patients with ischemic stroke was associated with improved long-term survival.

Registration of acute stroke: validity in the Danish Stroke Registry and the Danish National Registry of Patients

BACKGROUND

The validity of the registration of patients in stroke-specific registries has seldom been investigated, nor compared with administrative hospital discharge registries. The objective of this study was to examine the validity of the registration of patients in a stroke-specific registry (The Danish Stroke Registry [DSR]) and a hospital discharge registry (The Danish National Patient Registry [DNRP]).

METHODS

Assuming that all patients with stroke were registered in either the DSR, DNRP or both, we first identified a sample of 75 patients registered with stroke in 2009; 25 patients in the DSR, 25 patients in the DNRP, and 25 patients registered in both data sources. Using the medical record as a gold standard, we then estimated the sensitivity and positive predictive value of a stroke diagnosis in the DSR and the DNRP. Secondly, we reviewed 160 medical records for all potential stroke patients discharged from four major neurologic wards within a 7-day period in 2010, and estimated the sensitivity, specificity, positive predictive value, and negative predictive value of the DSR and the DNRP.

RESULTS

Using the first approach, we found a sensitivity of 97% (worst/best case scenario 92%-99%) in the DSR and 79% (worst/best case scenario 73%-84%) in the DNRP. The positive predictive value was 90% (worst/best case scenario 72%-98%) in the DSR and 79% (worst/best case scenario 62%-88%) in the DNRP. Using the second approach, we found a sensitivity of 91% (95% confidence interval [CI] 81%-96%) and 58% (95% CI 46%-69%) in the DSR and DNRP, respectively. The negative predictive value was 91% (95% CI 83%-96%) in the DSR and 72% (95% CI 62%-80%) in the DNRP. The specificity and positive predictive value did not differ among the registries.

CONCLUSION

Our data suggest a higher sensitivity in the DSR than the DNRP for acute stroke diagnoses, whereas the positive predictive value was comparable in the two data sources.

Post-stroke pathological crying: frequency and correlation to depression

While pathological crying has classically been described as a disturbance of the motor concomitants of emotional affect that is unrelated to mood, recent studies indicate that there may in fact be a correlation. We therefore undertook a study of post-stroke pathological crying in relation to mood score/depression and lesion site in an unselected stroke population the first year following stroke. The study population comprised 211 patients with first ever stroke (median age 69 years, range 25-80). The patients were included in the study within 7 days of the onset of stroke, and follow-up examinations were made at 1 month, 6 months and 1 year. Computerized tomography brain scans were obtained on Days 5-10. The frequency of pathological crying was 14% at 1 month, 10% at 6 months and 11% at 1 year. The overall 1 year incidence was 19%. Pathological crying correlated significantly to mood score and post-stroke depression (p < 0.005), as well as to lesion size (p < 0.05), Barthel Index (p < 0.05), Motricity Index (p < 0.005) and intellectual impairment (p < 0.05), but not to lesion location, sex, age, history of stroke or depression, predisposing disease or social distress before the stroke incident Post-stroke pathological crying was common and persistent in 11% of patients at 1 year and correlated strongly to mood score and post-stroke depression. The indication for treatment of pathological crying is therefore further strengthened.

[Thrombolysis for acute ischaemic stroke]

Thrombolysis is the only effective medical therapy for acute ischaemic stroke. The treatment has been approved in Europe since 2002. This article briefly summarises the pharmacological background of thrombolysis in cerebral ischaemic stroke. International experience with thrombolysis within the last decade as well as the successful implementation of thrombolysis in Denmark within the last 3 years is reviewed. Attention is drawn to new neuroradiological diagnostic techniques and future therapeutic possibilities.

Infection dynamics of Lawsonia intracellularis in pig herds

Little information is known about the natural course and within-herd prevalence of porcine proliferative enteropathy caused by Lawsonia intracellularis. The objective of the study was to investigate the within-herd dynamics of naturally acquired L. intracellularis infection in pigs from weaning to slaughter. The study was designed as a longitudinal survey where 100 pigs from five herds were randomly selected at weaning (approximately 4 weeks of age). Every second week until slaughter (10-12 times, i.e. 20-24 weeks) the pigs were weighed and faecal as well as blood samples were collected. Faecal shedding of L. intracellularis was assessed by real time-PCR and sero-conversion by an indirect immunofluorescence antibody test (IFAT). Clinical disease was not reported but infection was present in all herds and the PCR assay indicated infection in 75% of pigs examined. Most L. intracellularis infected pigs were shedding at 10-12 weeks of age (22-29 kg) and shed for 2-6 successive weeks. After 18 weeks of age all shedding had ceased and re-infection at PCR detectable level was not seen. Variable L. intracellularis associated impact on growth rate was observed. Immediately before bacterial shedding and during early infection the average growth rate declined whereas a compensatory impact was observed during later infection and after bacterial shedding had ceased. The performance of the IFAT resembled the bacteriological test almost perfectly. Sero-conversion was first detected at 12-14 weeks of age. Relative to the bacterial shedding, the onset of sero-conversion was a little delayed, in general, most pigs had sero-converted 2 weeks after the first shedding. Once sero-converted, 92% of the pigs remained sero-positive over the entire survey period.

Lamotrigine for central poststroke pain: a randomized controlled trial

OBJECTIVE

Central poststroke pain (CPSP) is usually difficult to treat. Amitriptyline, the only oral preparation shown to be effective in a randomized controlled trial, is often associated with a range of side effects related to the many mechanisms of actions of tricyclic antidepressants. We investigated the effect of lamotrigine, a drug that reduces neuronal hyperexcitability, on poststroke pain.

METHODS

Thirty consecutive patients with CPSP (median age 59 years, range 37 to 77; median pain duration 2.0 years, range 0.3 to 12) from two centers participated in a randomized, double-blind, placebo-controlled cross-over study. The study consisted of two 8-week treatment periods separated by 2 weeks of wash-out. The primary endpoint was the median value of the mean daily pain score during the last week of treatment while treated with 200 mg/d lamotrigine. Secondary endpoints were median pain scores while on lamotrigine 25 mg/d, 50 mg/d, and 100 mg/d; a global pain score; assessment of evoked pain; areas of spontaneous pain; and allodynia/dysesthesia.

RESULTS

Lamotrigine 200 mg/d reduced the median pain score to 5, compared to 7 during placebo (p = 0.01) in the intent-to-treat population of 27 patients. No significant effect was obtained at lower doses. Twelve patients (44%) responded to the treatment. There was a uniform tendency to reduction of all secondary outcome measures, but lamotrigine only had significant effects on some of the secondary outcome measures. Lamotrigine was well tolerated with few and transient side effects. Two mild rashes occurred during lamotrigine treatment, one causing withdrawal from study.

CONCLUSIONS

Oral lamotrigine 200 mg daily is a well tolerated and moderately effective treatment for central poststroke pain. Lamotrigine may be an alternative to tricyclic antidepressants in the treatment of CPSP.

[Risk factors for depression after apoplexy]

An unselected cohort of 285 stroke patients, median age 69 years, was studied for correlation between potential risk factors and the one-year incidence of post-stroke depression (PSD). The following factors correlated significantly to PSD a history of previous stroke, a history of previous depression, female gender, living alone and social distress pre-stroke. Further, social inactivity, decrease in social activity, pathological crying and intellectual impairment at one month but not functional outcome correlated to PSD. A multivariate regression analysis showed that intellectual impairment explained 42% of the variance of the mood score. Major depression was unrelated to lesion location. We conclude the etiology of PSD is a complex mixture of pre-stroke personal and social factors and stroke-induced social, emotional and intellectual handicap.

Dementia of depression or depression of dementia in stroke?

This study describes the correlation between changes in mood symptoms assessed by the Hamilton Depression Rating Scale (HDRS) and intellectual impairment assessed by the Brief Cognitive Rating Scale (BCRS) and Mattis Dementia Rating Scale (MDRS) in 166 unselected 1-year survivors after stroke, in whom post-stroke depression (PSD) has previously been described and validated. The course of intellectual impairment associated with PSD was compared with the course of intellectual impairment in non-PSD patients. In general, improvement in mood symptoms was correlated with an improvement in intellectual function. However, in 53 PSD patients improvement in intellectual performance was absent, despite the fact that the patients reported being significantly less distressed by dementia symptoms. Antidepressive medication did not lead to any improvement in MDRS score. No evidence was found to support the hypothesis of 'dementia of depression'. To the contrary, the findings indicate 'depression of dementia'.

Risk factors for post-stroke depression

An unselected cohort of 285 stroke patients, median age 69 years, were studied for correlation between potential risk factors and the 1-year incidence of post-stroke depression (PSD). The following factors correlated significantly with PSD: a history of previous stroke, a history of previous depression, female gender, living alone and social distress prestroke. Further, social inactivity, decrease in social activity, pathological crying and intellectual impairment at 1 month but not functional outcome correlated to PSD. A multivariate regression analysis showed that intellectual impairment explained 42% of variance of mood score. Major depression was unrelated to lesion location. We conclude that etiology to PSD is a complex mixture of prestroke personal and social factors, and stroke induced social, emotional and intellectual handicap.

Sensory abnormalities in consecutive, unselected patients with central post-stroke pain

This study examined the sensory abnormalities in an unselected, consecutive group of patients with central post-stroke pain (CPSP) surviving more than 1 year after stroke. The sensory examination included clinical examination and quantitative measures with detection and pain thresholds to heat and cold stimuli, argon laser, von Frey hair and determination of stimulus-response function in the 10-45 degrees C range. Sensory examination was in 11 identified CPSP patients (5 female, 6 male; aged 43-80 years) carried out in the painful area using the contralateral homologue area as reference. Pain rating was performed using the McGill Pain Questionnaire and a VAS scale. All patients had ischemic (MRI verified) infarction. Of the 11 patients with supratentorial lesions, 5 had thalamic lesions; in addition, 7 patients had lesions in the brain stem/cerebellum. Median present spontaneous pain intensity on the VAS scale was 3.3 (range: 0-7.7). All patients had pain in the body part with sensory abnormalities, which in 8 patients extended the area with pain. Warm detection threshold was higher in the pain area in all patients, and all except 1 patient had increased cold detection threshold. Cold and heat pain thresholds were raised as well, but to a lesser degree. Sensibility to touch (von Frey hairs) and pain (argon laser) were changed in only 4 and 3 patients, respectively. A stimulus-response curve in the 10-45 degrees C range showed different patterns compared to the non-affected side. A cold allodynia in the 10-45 degrees C range was present in the painful area in 6 (56%) of the patients. The results support the theory that damage to the spino-thalamo-cortical pathway is a necessary condition in CPSP. It is proposed that the spontaneous pain in CPSP is linked to hyperexitability or spontaneous discharges in thalamic or cortical neurons that have lost part of their normal input.

Incidence of central post-stroke pain

Central post-stroke pain (CPSP) is a neuropathic pain syndrome characterized by constant or intermittent pain in a body part occurring after stroke and associated with sensory abnormalities in the painful body part. This study describes CPSP prospectively during the first year after stroke and characterizes the cerebrovascular lesions and neurological signs associated with the CPSP syndrome. Two hundred and sixty-seven consecutively admitted patients younger than 81 years were examined in the first week, at 1, 6 and 12 months after stroke. Sensibility to touch (cotton wool), temperature (20 degrees C and 40 degrees C), and pinprick was studied using the contralateral face and extremity as control. A CT scan was done 8 (median) days (range: 1-34 days) after stroke. Two hundred and seven (78%) patients surviving at least 6 months who were able to communicate reliably formed the basis of the study. Abnormal sensory signs were found at least once in 87 (42%) patients. CPSP was found in 16 (8%) patients of whom all but 1 patient also had evoked dysesthesia or allodynia. Further 1 patient had persistent evoked dysesthesia but denied pain. CPSP was not related to sex or age. In patients with single acute cerebral lesions there were no relation between size or location of the lesions and the presence of CPSP. The pain was light in 6 (3%) patients and moderate to severe in 10 (5%) patients. The pain quality was usually lacerating or aching. Fifteen (94%) patients had decreased temperature, touch and pain sensibility and 9 (56%) reported allodynia to cold stimulation and another 9 (56%) patients reported this to touch.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effective treatment of depression following apoplexy with citalopram]

The aim of the study was to investigate the efficacy and safety of the selective serotonin reuptake inhibitor citalopram in treating post-stroke depression. A six-week double-blind placebo-controlled trial was undertaken. Diagnosis and outcome were determined using the Hamilton Depression Scale, and unwanted effects were measured using the UKU side effect rating scale. Sixty-six consecutive depressed patients entered the trial 2-52 weeks post-stroke. They were assigned to equally sized treatment and placebo groups. The initial level of depression and demographic parameters were comparable in the two groups. Significantly greater improvement was seen in patients treated with citalopram (10-40 mg/day) for three and six weeks. Half of the 28 patients who entered the trial two to six weeks post-stroke recovered within a month, independent of the treatment given. This indicates a high degree of spontaneous recovery in the early phase after stroke. In contrast, placebo recovery was infrequent in patients who started treatment seven weeks or more post-stroke. No serious side effects related to the treatment were detected, those present being mild and usually transient. The trial demonstrates that the selective serotonin reuptake inhibitor citalopram offers an advantageous new treatment of post-stroke depression that is both safe and effective.

Incidence of post-stroke depression during the first year in a large unselected stroke population determined using a valid standardized rating scale

This study describes the development of post-stroke depression (PSD) prospectively during the first year post-stroke in 285 unselected stroke patients. An appropriate unselected population-based control group without cerebral pathology is included for comparison. Psychiatric assessment with the Hamilton Depression Rating Scale (HDRS) was undertaken unmodified. PSD was defined as HDRS > or = 13. The one-year incidence of PSD among the 209 survivors able to communicate reliably at 1 month was 41%. Most cases develop within the first months following stroke (79%), the frequency of new cases of PSD at one year being 5%, a level comparable to that in the control group. Depressed and nondepressed stroke patients consistently scored 4 points greater on total HDRS than in the corresponding controls.

Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram

BACKGROUND AND PURPOSE

The aim of the study was to investigate the efficacy and safety of the selective serotonin reuptake inhibitor citalopram in treating poststroke depression, since available treatments are usually poorly tolerated.

METHODS

A 6-week double-blind, placebo-controlled trial was undertaken. Diagnosis and outcome were determined using the Hamilton Depression Scale, and unwanted effects were measured using the UKU side effect rating scale. Sixty-six consecutive depressed patients from an unselected population of 285 stroke patients aged 25 to 80 years entered the trial 2 to 52 weeks after stroke. They were assigned to equally sized treatment and placebo groups. The initial level of depression was comparable in the two groups (mean baseline Hamilton Depression scores, 19.4 and 18.9, respectively). Demographic parameters were also comparable in the two groups.

RESULTS

Significantly greater improvement was seen in patients treated with citalopram (10 to 40 mg/d) for 3 and 6 weeks, both when including all patients (intention-to-treat analysis, P < .05) and excluding patients who dropped out during the first 3 weeks (efficacy analysis, P < .005). Half of the 28 patients who entered the trial 2 to 6 weeks after stroke recovered within 1 month, independent of the treatment given. This indicates a high degree of spontaneous recovery in the early phase after stroke. In contrast, recovery was infrequent in placebo group patients who became depressed 7 weeks or more after stroke. No serious side effects related to the treatment were detected; those present were mild and usually transient.

CONCLUSIONS

This trial demonstrates that the selective serotonin reuptake inhibitor citalopram offers an advantageous new treatment of poststroke depression that is both safe and effective.

Pathoanatomic correlation between poststroke pathological crying and damage to brain areas involved in serotonergic neurotransmission

BACKGROUND AND PURPOSE

The aim of the study was to correlate the severity of poststroke pathological crying with lesion size and location.

METHODS

Twelve selected stroke patients were ranked in terms of overall clinical severity of the syndrome of pathological crying, and the size and location of the stroke lesion(s) were determined by magnetic resonance imaging.

RESULTS

The patients with the clinically most severe pathological crying had relatively large bilateral pontine lesions without lesions in the hemispheres. The intermediate group had bilateral central hemispheric lesions, and the clinically least affected patients had mainly unilateral large subcortical lesions.

CONCLUSIONS

Poststroke pathological crying may be attributable to stroke-induced partial destruction of the serotonergic raphe nuclei in the brain stem or their ascending projections to the hemispheres.

Headache in stroke

BACKGROUND AND PURPOSE

The etiology of headache in stroke is not known, and its relation to migraine and tension-type headache is unclear. The aim of our study was to investigate and classify headache appearing in stroke patients prospectively, using the new headache classification as determined by the Headache Classification Committee of the International Headache Society (1988).

METHODS

Two hundred eighty consecutively admitted patients aged younger than 81 years with acute stroke were examined and questioned about headache and prior headache complaints; 238 (85%) were able to communicate.

RESULTS

Sixty-five (27%) of the 238 patients experienced headache from 3 days before to 3 days after stroke. Headache occurred in 50% of patients with intracerebral hemorrhage, in 26% with infarction, and in 15% of patients with lacunar infarction. Headache was more common when stroke occurred in posterior circulation than anterior circulation (P < .02). Fifty-six patients were able to give further information about headache characteristics. The headache in thromboembolic stroke was classified as tension-type headache (25 patients), migraine-like headache (14 patients), and other headache (12 patients). Migraine was more frequent in vertebrobasilar stroke. Headache was lateralized in 33% of cases. In patients with unilateral headache and unilateral stroke lesion, the headache was ipsilateral in 14 of 17 cases. In infarction, severity of headache showed no relation to lesion size or lesion localization. Patients with previous tension-type headache and migraine experienced reactivation of known headache equally often.

CONCLUSIONS

(1) Headache occurs in one fourth of patients with acute stroke. (2) Unilateral headache is usually ipsilateral to stroke lesion. (3) Headache severity is not related to size of ischemic stroke lesion.

Citalopram for post-stroke pathological crying

Post-stroke pathological crying is a distressing condition in which episodes occur in response to minor stimuli without associated mood changes. There is preliminary evidence of disturbed serotoninergic neurotransmission in such cases. We investigated the effect of the selective serotonin reuptake inhibitor citalopram on uncontrolled crying in stroke patients in a double-blind placebo-controlled crossover study. 16 consecutive patients (median age 58.5 years, range 40-83) entered the 9-week study a median of 168 days (range 6-913) post stroke and were treated with citalopram 10-20 mg daily for 3 weeks. Crying history was determined from semistructured interviews and from diaries kept by the patients. Psychiatric assessment was made with the Hamilton depression scale (HDS), and unwanted effects were measured with the UKU side-effect scale. In 13 patients in whom frequency of crying could be assessed, the number of daily crying episodes decreased by at least 50% in all cases during citalopram treatment vs 2 patients during placebo treatment (p < 0.005, McNemar's test), the effect being rapid (1-3 days) and pronounced in 11 (73%). There was a concomitant significant decrease in depression rating from HDS 8.9 to 5.3 (p < 0.005, Wilcoxon's test). Citalopram was well tolerated, the few side-effects being mild and transient. We conclude that serotoninergic neurotransmission plays an important part in post-stroke pathological crying and that citalopram is an effective and well-tolerated treatment.

Dustbathing behaviour of uropygial gland extirpated domestic hens. Effects of dust deprivation

Dustbathing behaviour of uropygial gland extirpated and intact White Leghorn hens was studied after 27 and 75 h of deprivation of dust. Thereafter the hens were given access to dust (litter) and latency and duration of their first dustbathing bout were recorded. A short latency and/or a long duration were taken to indicate a strong urge to perform dustbathing. Judged by either of these criteria the gland extirpated birds showed a higher dustbathing tendency than the intact birds and in both groups the dustbathing tendency increased from 27 to 75 h of deprivation. Because of these findings the present study failed to support the “lipid regulation theory”: that the amount of lipid in the plumage should regulate the dustbathing tendency. Rank in the social hierarchy significantly influenced latency and duration of dustbathing but there was no simple correlation. After two weeks with constant access to litter no differences in the amount of feather lipids could be found between gland-extirpated and intact birds.

Video scanning for determination of the proportion of cortical tissue in the avian adrenal gland

The use of a video scanning apparatus (Leitz, T.A.S.) for the determination of the corticomedullary proportion in histological sections of the avian adrenal gland is described and statistically evaluated. When the video scanning method was applied to material from groups of domestic hens, which had been exposed to different experimental conditions, the results were similar to those obtained through the integrating method as described by Siller et al. (1975). The mean values obtained by both methods did not differ significantly, and there was a highly significant correlation between the counts for both methods applied on the same sections. When applying the video scanning method to 16 sections from four adrenals, repeated measurements on each of the sections showed considerable variation. However, this variation was found to be significantly smaller than the variation among the sections. It is suggested that the video scanning method could be made more precise by improvement of the staining procedure. However, on relatively large samples it seems to give reliable results, and it has a great advantage in reducing the tedious work involved in other available methods.