Recurrent Ipsilateral C5 Nerve Palsy Associated With Hereditary Neuropathy With Liability to Pressure Palsy

Hereditary neuropathy with liability to pressure palsy (HNPP) is an autosomal dominant disorder caused by heteroplasmic deletion of the peripheral myelin protein 22 (PMP22) gene. HNPP typically presents with clinical features such as peroneal nerve palsy or cubital tunnel syndrome, which are caused by mechanical compression. Diagnosing cases where neuropathy is absent at the pressure site can be challenging. This is a case study of an 18-year-old man who underwent surgery on the left side of his neck over 10 years ago to remove lymphadenopathy. Following the surgery, he experienced recurrent weakness but only sought medical attention when muscle weakness persisted for longer than a week postoperatively. Upon admission, the patient exhibited neurological symptoms consistent with C5 neuropathy, mainly affecting the deltoid muscles. No serological abnormalities were found to be associated with neuropathy. Neither magnetic resonance imaging nor computed tomography scans detected any lesions around the C5 nerve root. The posture during sleep was believed to cause excessive extension of the C5 nerve root, leading to the assumption that there was some vulnerability in the nerve. A transient sensory loss in the area innervated by the ulnar nerve prompted us to examine the fluorescence in situ hybridization study on the blood sample, which revealed a deletion of the PMP22 gene. The patient was diagnosed with HNPP and was advised to avoid risky postures. Following the implementation of these lifestyle changes, he did not experience any further weakness in his shoulders.

Enteral tube nutrition for geriatric post-stroke dysphagia evaluation (ENGE) score to evaluate the risk of dysphagia after acute ischemic stroke

BACKGROUND

Post-stroke dysphagia (PSD) is a common complication after stroke. Early PSD prediction is essential for patient stratification for intensive oral intake rehabilitation. We aimed to develop a PSD prediction score using clinical data obtained at admission.

METHODS

We examined consecutive patients with acute ischemic stroke between 2018 and 2019. The dysphagia status 14 days after admission was assessed using the Functional Oral Intake Scale (FOIS). PSD was defined as FOIS 1-3, which represents tube-dependent nutrition. Using multivariable logistic regression analysis, we constructed the Enteral tube Nutrition for Geriatric post-stroke dysphagia Evaluation (ENGE) score. The discriminative performance of the ENGE score was analyzed by receiver operating curve analysis. The reproducibility of the ENGE score was validated using patient data in 2020.

RESULTS

PSD developed in 84 of 488 patients (median age 78 years; 57% males). The ENGE score ranged from 0 to 6, with 1 point assigned for older age (≥78 years), 1 for high premorbid modified Rankin Scale (mRS) (≥1), 3 for high NIHSS score (≥12), and 1 for low serum albumin (<3.0 mg/dl). The area under the curve (AUC) of the ENGE score for discriminating PSD was 0.88 (95% confidence interval [CI] 0.83-0.92), and a score of 3 or more had a higher positive likelihood ratio. In the validation cohort, the AUC of the ENGE score for PSD was 0.85 (95% CI 0.78-0.91), which was similar to the derivation cohort (p = 0.491).

CONCLUSIONS

The ENGE score predicts severe PSD after acute ischemic stroke with good reproducibility.

Eustachian Valve-Enhanced Paradoxical Cerebral Embolism: A Case Report

Cryptogenic stroke includes many suspicious embolic causes that do not fulfill the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification criteria. Atrial fibrillation (AF) is one of the major hidden causes of cryptogenic stroke, and an implantable loop recorder (ILR) is widely used for detecting AF. Herein, we report a case of paradoxical cerebral embolism due to a large Eustachian valve with large PFO under no molecular complete remission (CR) of acute monocytic leukemia (AMoL). A 75-year-old man arrived at our emergency room because of aphasia and right hemiparesis. He had a history of two cryptogenic strokes and implanted ILR. Magnetic resonance imaging showed left middle cerebral artery occlusion with slight acute ischemic lesion. The red clot was retrieved by mechanical thrombectomy, and complete recanalization was achieved. We checked ILR, but there was no AF. Transesophageal echocardiography revealed a large patent foramen ovale (PFO) and the large Eustachian valve in the right atrium. Although obvious deep vein thrombosis (DVT) was not detected in venous ultrasonography of the lower extremities, Wilms' tumor 1 messenger ribonucleic acid (WT1mRNA) expression level was high, and AMoL was considered to be not in molecular CR, suggesting a high risk of thrombosis to the large Eustachian valve. From large PFO and no molecular CR of AMoL, we diagnosed him with paradoxical cerebral embolism. Ruling out of AF by ILR and other etiologies, such as aortic or carotid atherosclerosis and pulmonary shunt, also supported the diagnosis of paradoxical cerebral embolism. Even in the absence of obvious DVT, paradoxical cerebral embolism should be considered in cases of a large Eustachian valve and PFO with a hypercoagulable state.

Geriatric nutrition risk index predicts prolonged post-stroke dysphagia in acute ischemic stroke

BACKGROUND

Post-stroke dysphagia (PSD) is a common complication after stroke. Malnutrition inhibits stroke recovery and is associated with stroke mortality. However, no studies have investigated the effects of nutritional state at admission on prolonged PSD.

METHODS

We retrospectively analyzed ischemic stroke patients in our institute from January 2018 to December 2020. Swallowing function was assessed using the Food Oral Intake Scale; prolonged PSD was defined as levels 1-3 at 14 days after admission. The Geriatric Nutritional Risk Index (GNRI) was used to assess nutritional risks, which were classified as follows: >98, no nutritional risk; 92-98, mild nutritional risk; 82-92, moderate nutritional risk; and <82, severe nutritional risk. The association between GNRI and prolonged PSD was assessed.

RESULTS

Of 580 patients (median age, 81 years; male, 53%), prolonged PSD was detected in 117 patients. Patients with severe dysphagia had older age, higher pre-stroke modified Rankin Scale score, lower GNRI, and higher National Institutes of Health Stroke Scale score. Logistic regression analysis revealed that lower GNRI was independently associated with prolonged PSD (continuous value; adjusted odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00-1.05). In addition, when "severe" and "moderate" nutritional risk was analyzed as a single class, moderate or severe nutritional risk (GNRI < 92) was independently associated with prolonged PSD (adjusted OR 2.50, 95% CI 1.29-4.87), compared with no nutritional risk patients (GNRI > 98).

CONCLUSIONS

In acute ischemic stroke, lower GNRI at admission was independently associated with prolonged PSD, suggesting that GNRI at admission might identify patients at risk of prolonged PSD.

Abstract WP191: Post Stroke Dysphagia Prediction Score In Acute Ischemic Stroke In Japan

Background and Purpose: Post stroke dysphagia (PSD) is a common complication after stroke. The earlier prediction of PSD is essential for patient stratification for intensive rehabilitation, but there was no scoring system for predicting PSD. We aimed to develop the PSD prediction score.

Methods: We examined consecutive patients with acute ischemic stroke between 2018-2020. Patients with in-hospital-death were excluded. Dysphagia state was assessed using food oral intake scale (FOIS) score at hospital discharge. PSD was defined as FOIS 1-3, which represent tube-dependent nutrition. For the assessment of reproducibility of PSD score, patients were divided into derivation and validation cohort. Using the derivation cohort, PSD score was developed from associated factors to discriminate PSD by logistic regression analysis. Discriminative performance was analyzed by receiver operating curve (ROC) analysis. Reproducibility of PSD score was validated using the validation cohort.

Results: Among 795 patients (median 77 years; male, 57%), 556 (70%) patients were assigned as derivation cohort and 239 (30%) patients were assigned as validation cohort. In the derivation cohort, older age (≥85 years), low BMI (≦18.5 kg/m 2 for aged <70 years and ≦ 20 kg/m 2 for aged ≥70 years), high NIHSS score (≥16), and low serum albumin (≦3.0 mg/dl) were associated with PSD (Table). PSD score were ranged from 0 to 6 from these factors (Table). Area under the curve (AUC) of PSD score for PSD was 0.83 (95% confidence interval [CI] 0.78-0.88) with an appropriate cut-off value of 2 (sensitivity, 69%; specificity, 88%). In the validation cohort, the AUC of PSD score for PSD was 0.78 (95% CI 0.70-0.86), which was not significantly different in the AUC of the derivation cohort (AUC; 0.83 vs 0.78, p=0.30).

Conclusions: In acute ischemic stroke population, the discriminative performance of PSD score had acceptable for diagnosing PSD.

The T genotype of the MGMT C>T (rs16906252) enhancer single-nucleotide polymorphism (SNP) is associated with promoter methylation and longer survival in glioblastoma patients

Clinical studies in patients with newly diagnosed glioblastoma treated with temozolomide have shown that the methylation status of the O(6)-methylguanine-DNA methyltransferase (MGMT) gene is both predictive and prognostic of outcome. Methylation of the promoter region of MGMT is the most clinically relevant measure of MGMT expression and its assessment has become integral in current and planned clinical trials in glioblastoma. Our study confirmed that MGMT methylation, assessed by pyrosequencing, is associated with a significant survival benefit in glioblastoma patients treated with temozolomide (either concurrently with radiotherapy or sequential treatment). More interestingly, our study demonstrated that a promoter variant, the c.-56C>T (rs16906252) single nucleotide polymorphism (SNP) located within a cis-acting enhancer element at the proximal end of MGMT, is associated with the presence of MGMT promoter methylation in de novo glioblastoma. Furthermore, we show that the overall survival of patients carrying both the SNP and MGMT methylation showed a strong survival benefit when compared to either molecular event on their own. Promoter reporter experiments in MGMT methylated glioblastoma cell lines showed the T allele conferred a ∼30% reduction in normalised MGMT promoter activity compared to the wild-type haplotype. This might account for the propensity of the T allele to undergo promoter methylation, and in turn, the improved survival observed in carriers of the T allele. An independent validation on larger cohorts is required to confirm the prognostic and predictive value of individuals carrying the T allele.

LOV (light, oxygen, or voltage) domains of the blue-light photoreceptor phototropin (nph1): binding sites for the chromophore flavin mononucleotide

Phototropism, the bending response of plant organs to or away from a directional light source, is one of the best studied blue light responses in plants. Although phototropism has been studied for more than a century, recent advances have improved our understanding of the underlying signaling mechanisms involved. The NPH1 gene of Arabidopsis thaliana encodes a blue light-dependent autophosphorylating protein kinase with the properties of a photoreceptor for phototropism. NPH1 apoprotein noncovalently binds FMN to form the holoprotein nph1. The N-terminal region of the protein contains two LOV (light, oxygen, or voltage) domains that share homology with sensor proteins from a diverse group of organisms. These include the bacterial proteins NIFL and AER, both of which bind FAD, and the phy3 photoreceptor from Adiantium capillus-veneris. The LOV domain has therefore been proposed to reflect a flavin-binding site, regulating nph1 kinase activity in response to blue light-induced redox changes. Herein we demonstrate that the LOV domains of two nph1 proteins and phy3 bind stoichiometric amounts of FMN when expressed in Escherichia coli. The spectral properties of the chromopeptides are similar to the action spectrum for phototropism, implying that the LOV domain binds FMN to function as a light sensor. Thus, our findings support the earlier model that nph1 is a dual-chromophoric flavoprotein photoreceptor regulating phototropic responses in higher plants. We therefore propose the name phototropin to designate the nph1 holoprotein.

A phytochrome from the fern Adiantum with features of the putative photoreceptor NPH1

In plant photomorphogenesis, it is well accepted that the perception of red/far-red and blue light is mediated by distinct photoreceptor families, i.e., the phytochromes and blue-light photoreceptors, respectively. Here we describe the discovery of a photoreceptor gene from the fern Adiantum that encodes a protein with features of both phytochrome and NPH1, the putative blue-light receptor for second-positive phototropism in seed plants. The fusion of a functional photosensory domain of phytochrome with a nearly full-length NPH1 homolog suggests that this polypeptide could mediate both red/far-red and blue-light responses in Adiantum normally ascribed to distinct photoreceptors.

Serum and antral gastrin levels in fed and fasted rats: relation to aging

The effect of short fasting for up to 24 h on serum and antral gastrin concentrations and G cell ultrastructure has been examined in the young rat compared with the middle-aged rat. The serum gastrin levels at 24-h fasting were markedly reduced in both young and middle-aged rats. There was also a significant decrease in antral gastrin concentrations after 24 h of fasting in the middle-aged rats. By contrast, the antral gastrin concentrations in the young rats increased progressively and significantly with fasting for up to 24 h. These responses were associated with a significant increase in the content of secretory granules of G cell, which was at its greatest by 24 h. The antral gastrin level in the 48-h fasting rats was markedly reduced to a level below that for the prestarvation group. By 48 h of starvation, the amount of secretory granules in G cell was significantly reduced (P < 0.05) compared with the 24-h fasting group. These results indicate that the effects of fasting on the antral gastrin levels in young rats differ from those of the middle-aged and that starvation for up to 24 h caused a significant increase in the antral gastrin content in the young rats' stomach.