The Multiple Sclerosis Inventory of Cognition for Adolescents (MUSICADO): A brief screening instrument to assess cognitive dysfunction, fatigue and loss of health-related quality of life in pediatric-onset multiple sclerosis

OBJECTIVE

Screening for cognitive impairment (CI), fatigue and also Health-related quality of life (HRQoL) in patients with pediatric-onset multiple sclerosis (POMS) is of utmost importance in clinical practice. The aim of this study was to establish a new and validated pediatric screening tool "MUSICADO" that is easy to use and time economical.

METHODS

106 patients with POMS aged 12-18 years and 210 healthy controls (HCs) stratified for age and education underwent neuropsychological testing including a screening test "Multiple Sclerosis Inventory of Cognition" for adults and 8 standardized cognitive tests and established scales to assess fatigue and HRQoL.

RESULTS

The phonemic verbal fluency task (RWT "s-words"), the Trail Making Test A (TMT-A), and the Digit Span Forward discriminated significantly between patients and HCs (p = 0.000, respectively) and showed the highest proportion of test failure in patients (24.5%, 17.9%; 15.1%, respectively). Therefore, they were put together to form the cognitive part of the "MUSICADO". After applying a scoring algorithm with balanced weighting of the subtests and age and education correction and a cut-off score for impairment, 35.8% of patients were categorized to be cognitively impaired (specificity: 88.6%). Fatigue was detected in 37.1% of the patients (specificity: 94.0%) and loss of HRQoL in 41.8% (specificity 95.7%) with the screening version, respectively.

CONCLUSION

The MUSICADO is a newly designed brief and easy to use screening test to help to early identify CI, fatigue, and loss of HRQoL in patients with POMS as cut scores are provided for all three items. Further studies will have to show its usability in independent samples of patients with POMS.

Factors influencing patient satisfaction with the first diagnostic consultation in multiple sclerosis: a Swiss Multiple Sclerosis Registry (SMSR) study

BACKGROUND

Patient satisfaction is predictive of adherence, malpractice litigation and doctor-switching.

OBJECTIVE

To investigate which factors of the first diagnostic consultation (FDC) influence patient satisfaction and which topics persons with multiple sclerosis (PwMS) thought were missing.

METHODS

Using retrospective patient-reported data of the Swiss Multiple Sclerosis Registry from PwMS with relapsing disease onset, we fitted ordered logistic regression models on satisfaction with FDC, with socio-demographic and FDC features as explanatory factors.

RESULTS

386 PwMS diagnosed after 1995 were included. Good satisfaction with the FDC was associated with a conversation more than 20 min [multivariable odds ratio, 95% confidence interval 3.9 (2.42; 6.27)], covering many topics [1.35 (1.19; 1.54) per additional topic], the presence of a significant others [1.74 (1.03; 2.94) ], and shared decision making [3.39 (1.74; 6.59)]. Not receiving a specific diagnosis was main driver for low satisfaction [0.29 (0.15; 0.55)]. Main missing topics concerned long-term consequences (reported by 6.7%), psychological aspects (6.2%) and how to obtain support and further information (5.2%).

CONCLUSIONS

A conversation of more than 20 min covering many MS relevant topics, a clear communication of the diagnosis, the presence of a close relative or significant other, as well as shared decision making enhanced patient satisfaction with the FDC. ClinicalTrials.gov Identifier: NCT02980640.

4-Demethoxydaunorubicin Administered Orally in Advanced Breast Cancer

Twenty-five patients with advanced breast cancer were treated with 4-demethoxydaunorubicin (4-DMDR), a new antitumor analogue of daunorubicin, at the dose of 15-20 mg/m2/day X 3 days by oral route every 3-4 weeks. All patients were previously treated with chemotherapy and/or hormone therapy but none with anfhracyclines. Of 23 evaluable patients, 1 complete and 5 partial remissions (26%) were observed for a median duration of 4+ months. Leukopenia and nausea occurred in 61% of the patients, vomiting in 30%, diarrhea in 17% and alopecia in 43%. There were 2 cases with minimal and transient EKG variations. 4-DMDR, administered orally in advanced breast cancer, was found to be generally well tolerated. Nevertheless, randomized trials with adriamycin or epirubicin are necessary to compare and to define the therapeutic activity and the toxicity of 4-DMDR.

Sleep disturbances, mental toughness, and physical activity in patients with multiple sclerosis (MS) compared to healthy adolescents and young adults

Background

Multiple sclerosis (MS) is the commonest chronic autoimmune demyelinating and inflammatory disease of the CNS, afflicting both body and mind. Typical symptoms are fatigue, paraesthesia and depression, along with cognitive impairments. Whereas there is extant research on fatigue, depression, and cognitive impairment of patients with MS during the clinical course, no research focused on sleep, psychological functioning, and physical activity (PA) at the moment of the diagnose. The aims of the present study were therefore to assess possible state markers of mental toughness (MT) as a dimension of psychological functioning, sleep disturbances (SD), PA among patients at the moment of the diagnose, and to compare these data with those of healthy adolescents and healthy young adults.

Methods

A total of 23 patients with recently diagnosed MS (M = 32.31 years), 23 healthy adolescents (M = 17.43 years), and 25 healthy young adults (M = 20.72 years) took part in the study. They completed questionnaires covering socio-demographic data, MT, SD, and PA.

Results

Patients with MS reported similar MT traits as adolescents, and an equal amount of moderate PA and SD as young adults. Further, patients reported a lower level of vigorous PA, compared to healthy adolescents and young adults.

Conclusions

Compared to healthy adolescents and young adults, patients at the moment of the diagnose of MS reported similar MT traits, SD and moderate PA. The pattern of results suggests that at the moment of the diagnose MS is not predictable by poor MT, poor sleep, and decreased level of moderate PA.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

[Value and acceptance of risk assessment for Alzheimer's disease]

BACKGROUND

It is quite common that people suffering from cognitive impairment only visit a doctor when the symptoms have already reached an advanced stage. This is often due to a fear of Alzheimer’s disease or a dread of exhausting diagnostic procedures and exposure of personal details; however, an early diagnosis and therapy increases the chance of preserving the quality of life for a longer period of time.

OBJECTIVES

Evaluation of a risk assessment for Alzheimer’s disease by magnetic resonance imaging (MRI) with respect to the acceptance and value by participants.

METHODS

In this prospective preventive study 106 subjects between the age of 39 and 89 years (median age 68 years) with general risk factors were included and underwent a risk assessment for Alzheimer’s disease by standard MRI of the brain using a 1 T open MRI with subsequent hippocampal volumetry. Participants were stratified into two distinct subgroups according to the individual hippocampal atrophy status, one with elevated and the other with reduced risk. All participants were thoroughly interviewed regarding anxieties and mental well-being before and after the risk assessment.

RESULTS

As expected, participants with a reduced risk had a significant improvement in well-being and a reduction of fears and worries after the examination. Neither a significant deterioration of the mental situation nor an increase of fears and worries was found for participants with an elevated risk. Of the participants 90% stated that MRI-based risk stratification generated positive perspectives for the future. The assessment revealed a high acceptance by most of the participants (94%).

CONCLUSION

An MRI-based risk assessment is beneficial to the patient’s quality of life and as a low threshold approach may induce more individuals with concerns to take advantage of an early diagnosis of Alzheimer’s disease.

[DemTect 40- and DemTect 80+: New scoring routines for these age groups]

The DemTect, a frequently used cognitive screening tool for the German-speaking population, has been proven to be age-, but not education-dependent. To date, scoring routines for persons under and over 60 years of age have been available. In order to describe the age-effect more specifically, the DemTect was administered to persons under 40 (n = 105; median 33 years [18 - 39]) and over 80 years of age [n = 68; median 83 years [80 - 93}). After transformation of the raw scores, which are based on the mean and standard deviation of the respective reference group, an adequate attribution of scores could be achieved and no differences between the groups can be observed in the total score or the subtest scores. The median of the transformed total score was 16 [5 – 18] for the younger and 15 [5 – 18] for the older age group. The new scoring routines supplement the scoring procedures of the DemTect for these age groups.

The possible contribution of the amygdala to memory

The processing of episodic memories is believed to depend on the proper functioning of so-called bottleneck structures through which information apparently must pass in order to be stored long term. These regions are seen in the basal forebrain, the medial diencephalon, and the medial temporal lobe. We here report a case with circumscribed bilateral temporal lobe damage, principally involving the amygdaloid area. Neuropsychological investigation demonstrated preserved intelligence, intact general memory and several other undisturbed cognitive functions, but a specific, affect-related, memory disorder. We conclude from these findings that the role of the amygdala is to process mnemonic events in a way that a specific emotional significance can be found and reactivated. Therefore it is suggested that the amygdala is likely to be a bottleneck structure for affect-related long-term memory functions.

Detecting variations of blood volume shift due to heart beat from respiratory inductive plethysmography measurements in man

The simultaneous study of the cardiac and respiratory activities and their interactions is of great physiological and clinical interest. For this purpose, we want to investigate if respiratory inductive plethysmography (RIP) can be used for cardiac functional exploration. We propose a system, based on RIP technology and time-scale approaches of signal processing, for the extraction of cardiac information. This study focuses on the monitoring of blood volume shift due to heart beat, noted ▵Vtr_c and investigates RIP for the detection of ▵Vtr_c variations by comparison to stroke volume (SV) variations estimated by impedance cardiography (IMP). We proposed a specific respiratory protocol assumed to induce significant variations of the SV. Fifteen healthy volunteers in the seated and supine positions were asked to alternate rest respiration and maneuvers, consisting in blowing into a manometer. A multi-step treatment including a variant of empirical mode decomposition was applied on RIP signals to extract cardiac volume signals and estimate beat-to-beat ▵Vtr_c. These were averaged in quasi-stationary states at rest and during the respiratory maneuvers, and analysed in view of SV estimations from IMP signals simultaneously acquired. Correlation and statistical tests over the data show that RIP can be used to detect variations of the cardiac blood shift in healthy young subjects.

The "Altitudinal Anton's syndrome": coexistence of anosognosia, blindsight and left inattention

We describe a 69-year-old patient with superior altitudinal hemianopia who contentiously denied having any visual impairment after stroke in the lower banks of both calcarine fissures. Although the patient did not produce intentional responses to visual stimuli in the blind fields, he showed reduced reaction times to stimuli presented in the inferior visual fields when they were primed by identical stimuli in the superior blind fields. Furthermore he showed left extinction to the double stimulation and delayed reaction times for left unprimed stimuli in the inferior fields. Based on these findings we discuss the possibility that blindsight and right hemisphere damage might be both necessary conditions for denying bilateral blindness.

Inhibition of cardiac leptin expression after infarction reduces subsequent dysfunction

Leptin is known to exert cardiodepressive effects and to induce left ventricular (LV) remodelling. Nevertheless, the autocrine and/or paracrine activities of this adipokine in the context of post-infarct dysfunction and remodelling have not yet been elucidated. Therefore, we have investigated the evolution of myocardial leptin expression following myocardial infarction (MI) and evaluated the consequences of specific cardiac leptin inhibition on subsequent LV dysfunction. Anaesthetized rats were subjected to temporary coronary occlusion. An antisense oligodesoxynucleotide (AS ODN) directed against leptin mRNA was injected intramyocardially along the border of the infarct 5 days after surgery. Cardiac morphometry and function were monitored by echocardiography over 11 weeks following MI. Production of myocardial leptin and pro-inflammatory cytokines interleukin (IL)-1β and IL-6 were assessed by ELISA. Our results show that (1) cardiac leptin level peaks 7 days after reperfused MI; (2) intramyocardial injection of leptin-AS ODN reduces early IL-1β and IL-6 overexpression and markedly protects contractile function. In conclusion, our findings demonstrate that cardiac leptin expression after MI could contribute to the evolution towards heart failure through autocrine and/or paracrine actions. The detrimental effect of leptin could be mediated by pro-inflammatory cytokines such as IL-1β and IL-6. Our data could constitute the basis of new therapeutic approaches aimed to improve post-MI outcome.

Cognitive impairment in patients with a schizoaffective disorder: a comparison with bipolar patients in euthymia

Objectives

Several studies have shown persistent neurocognitive impairment in patients with a bipolar affective disorder (BD) even in euthymia as well as in patients with a schizoaffective disorder (SAD). The aim of our study was to compare the neuropsychological performance between these two groups. Confounding variables were controlled to enhance our understanding of cognitive dysfunction in both BD and SAD.

Methods

Several domains of neurocognitive function, executive function, memory, attention, concentration and perceptuomotor function were examined in 28 euthymic SAD patients and 32 BD patients by using a neuropsychological test battery. The Hamilton Depression Rating Scale (HAMD), Montgomery-Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) were used to evaluate the patients' clinical status. Data analysis was performed by using a multivariate analysis of covariance (ANCOVA/MANCOVA).

Results

Euthymic SAD patients showed greater cognitive impairment than euthymic BD patients in the tested domains including declarative memory and attention. Putative significant group differences concerning cognitive flexibility vanished when controlled for demographic and clinical variables. Age and medication were robust predictors to cognitive performance of both SAD and BD patients.

Conclusions

Our results point out the worse cognitive outcome of SAD compared to BD patients in remission. Remarkably, the variance is higher for some of the test results between the groups than within each group, this being discussed in light of the contradictive concept of SAD.

Managing fatigue: clinical correlates, assessment procedures and therapeutic strategies

The majority of patients with Multiple Sclerosis (MS) experience fatigue and for many susabjects concerned it is the most disabling symptom. Fatigue is most prominent in the afternoon and may be aggravated by heat. It has a tremendous negative impact on quality of life and is often one of the major reasons for early retirement and unemployment. Against further assumptions, fatigue can occur at all stages and is often present at the onset of the disease. Reliable assessment however, is difficult as it is a subjectively perceived lack of physical and/or mental energy interfering with intended activities and has to be differentiated from depression, consequences of sleep disorders, cognitive decline, and side-effects of medication. Moreover, fatigue is not directly related to overall disease evolution, to disability levels or localized lesions, although an association with dysfunction of fronto-thalamo-basal-ganglia circuits seems likely. Several therapeutic approaches including pharmacological as well as non-pharmacological strategies are available but an evidence-based specific gold-standard for the treatment of fatigue is still missing.

Cognitive decline in multiple sclerosis: impact of topographic lesion distribution on differential cognitive deficit patterns

Background: Multiple sclerosis (MS) is often accompanied by cognitive dysfunction. A negative correlation between cerebral lesion load and atrophy and cognitive performance has been pointed out almost consistently. Further, the distribution of lesions might be critical for the emergence of specific patterns of cognitive deficits.

Objective: The current study evaluated the significance of total lesion area (TLA) and central atrophy for the prediction of general cognitive dysfunction and tested for a correspondence between lesion topography and specific cognitive deficit patterns.

Methods: Thirty-seven patients with MS underwent neuropsychological assessment and magnetic resonance imaging. Lesion burden and central atrophy were quantified. Patients were classified into three groups by means of individual lesion topography (punctiform lesions/periventricular lesions/confluencing lesions in both periventricular and extra-periventricular regions).

Results: TLA was significantly related to 7 cognitive variables, whereas third ventricle width was significantly associated with 20 cognitive parameters. The three groups differed significantly in their performances on tasks concerning alertness, mental speed, and memory function.

Conclusion: Third ventricle width as a straight-forward measure of central atrophy proved to be of substantial predictive value for cognitive dysfunction, whereas total lesion load played only a minor role. Periventricular located lesions were significantly related to decreased psychomotor speed, whereas equally distributed cerebral lesion load did not. These findings support the idea that periventricular lesions have a determinant impact on cognition in patients with MS.

Routine ultrasound-guided liver biopsy versus echo-assisted procedure in viral chronic hepatitis

PURPOSE

Ultrasound (US)-assisted liver biopsy is the most widespread practice for the staging of chronic hepatitis, but there are no data about a comparison with the US-guided procedure in terms of safety and diagnostic yield. The aim of this study was a retrospective analysis about 357 biopsies performed by using both these techniques.

MATERIALS AND METHODS

We analysed 176 US-guided biopsies and and 181 US-assisted liver biopsies performed in the same unit in patients with chronic viral hepatitis. We recorded the number of passes, sample fragmentation and sample size, number of portal spaces and degree of fibrosis. Mortality and morbidity were also assessed. Differences between the two groups of needle biopsies were analysed statistically by the Welch test, with significance at p<0.05.

RESULTS

Specimens obtained by US-guided liver biopsy were 27 mm long (range 25-28.9 mm) versus 13 mm mean value (range 12.2-13.9 mm, p<0.0001) of samples from US-assisted liver biopsies and contained 15.7 portal tracts (range 14.7-16.7) versus 11 mean value (range 10-11.9, p<0.0001) of specimens obtained by echo-assisted needle biopsy. Mortality and major complication rate was zero in our series. Both groups of liver biopsies were comparable with respects to number of passes and sample fragmentation.

CONCLUSIONS

Both methods showed overlapping security. The diagnostic yield seems to be greater if liver biopsy is performed by the echo-guided technique.

Cognitive functions in primary central nervous system lymphoma: literature review and assessment guidelines

BACKGROUND

Treatment-related neurotoxicity has been recognized as a significant problem in patients with primary central nervous system lymphoma (PCNSL) as effective treatment has increased survival rates. There is, however, a paucity of research on cognitive functions in this population.

DESIGN

In a review of the literature, a total of 17 articles that described cognitive outcome in adult PCNSL patients were identified.

RESULTS

The studies that assessed cognitive functions after whole-brain radiotherapy combined with chemotherapy reported cognitive impairment in most patients. Patients treated with chemotherapy alone had either stable or improved cognitive performance in most studies. Methodological problems, however, limited the ability to ascertain the specific contribution of disease and various treatment interventions to cognitive outcome. On the basis of the literature review, a battery of cognitive and quality-of-life (QoL) measures to be used in prospective clinical trials was proposed. The battery is composed of five standardized neuropsychological tests, covering four domains sensitive to disease and treatment effects (attention, executive functions, memory, psychomotor speed), and QoL questionnaires, and meets criteria for use in collaborative trials.

CONCLUSION

The incorporation of formal and systematic cognitive evaluations in PCNSL studies will improve our understanding of treatment-related neurotoxicity in this population.

Fatigue in multiple sclerosis: relation to depression, physical impairment, personality and action control

Athough fatigue is one of the most common symptoms of multiple sclerosis, it is yet poorly understood and therefore difficult to manage. To clarify the nature of fatigue we investigated its relationship to depression, physical impairment, personality and action control and compared these variables between a sample of 41 MS patients and 41 healthy controls. Physical impairment was assessed by the EDSS and all other dimensions, using questionnaires. Stepwise linear regression analyses revealed that physical impairment was related to physical fatigue in MS patients. Depression was the main factor influencing fatigue among both, MS patients and controls. What clearly differentiated the two groups was the correlation between fatigue and action control. Decreased levels of action control imply attentional and motivational deficits and were only found in fatigued MS patients. Our study indicates that motivational disturbances might be specific for MS related fatigue. Multiple Sclerosis 2007; 13: 1161—1167. http://msj.sagepub.com

Liposome-encapsulated doxorubicin plus cyclophosphamide as first-line therapy in metastatic breast cancer: A phase II study

10646

Background: The objective of this study is to evaluate the efficacy and toxicity of the liposome- encapsulated doxorubicin (TLC D-99) plus cyclophosphamide (CTX) as first-line treatment of metastatic breast cancer in light of the potential cardioprotective effect of TLC D-99 as compared to conventional doxorubicin. Furthermore the study is aimed also to understand the role of troponin I as a sensitive marker of left ventricular dysfunction. Methods: Sixty-three patients as defined in a phase II group sequential design will be enrolled. Since september 2004, fifty-four patients with untreated metastatic breast cancer were enrolled. They received TLC D-99 at the dosage of 60 mg/m2 plus CTX 600 mg/m2, with cycles repeated every three weeks. Cardiac function was assessed by ultrasonography at baseline and every three weeks, as well as troponin I dosage. Results: The principal characteristics of the 54 actually enrolled patients were as follows: median age 60 years (range 33–75), median WHO performance status 1 (range 0–2) and dominant disease site (viscera/bone/soft tissue) 36/10/8. To date 39 pts are evaluable: 8 complete responses and 18 partial responses were observed for an overall response rate of 67%; a further 9 pts had stable disease and the remaining 4 pts progressed. Median number of administered cycles was 6. Median duration of response was 10 months (range 3–15+) and median duration of survival was 12+ months (range 2+-15+). Hematological toxicity consisted in leucopenia (G1-G2) in 11 patients ed anemia (G1-G2) in 10 pts; G1 thrombocytopenia was observed only in 2 pts. Non-hematological toxicity was generally mild with G1-G2 nausea/vomiting in 14 pts e G2 mucositis in one patient. Hair-loss was registered in 12 pts and it was G2 in 6 pts. As to concer cardiac toxicity, one patient developed an asymptomatic 20% decline of left ventricular ejection fraction from the baseline value. Conclusions: The preliminary data show that the combination of TLC D-99 plus CTX is active and well tolerated, with no unexpected toxicity. The relationship between cardiac function and troponin I is underway.

No significant financial relationships to disclose.

[Cognitive disorder in Parkinson's disease]

Over the course of Parkinson's disease, a substantial percentage of patients not only develop motor und vegetative disorders, but also significant cognitive deficits that can, in isolated cases, take on the proportions of dementia. Additionally, affective and emotional dysregulations extending to depressive disorders may become manifest. These impairments can be explained by the underlying neuropathology and the Parkinson-associated transmitter imbalances as well as by the changes this disease causes in the patients' daily lives. According to Gifford and Cummings [21], up to 75 percent of patients with moderate to severe dementia are not diagnosed by their general practitioners; this number proving much higher in patients with mild cognitive impairments and affective and emotional problems. Due to the masking symptoms of a Parkinson's condition, it can be assumed that these numbers are probably even higher in this patient group. Accordingly, cognitive, affective and emotional disorders should be included as an integral part of Parkinson's disease diagnostics.

Prognostic signs in melanoma: state of the art

Prognoses for melanoma patients are currently based on statistically confirmed parameters, above all the Breslow thickness and number of lymph node and/or distant metastases. However, metastases can develop even with "thin" melanomas (< 0.7 mm), while survival has been recorded in patients with tumours classified as "thick" (> 4 mm). This review of the literature examines the most recent advances in prognostic markers for melanoma (serological, immunohistochemical, histological, genetic and surgical). These markers offer interesting possibilities in terms of diagnostic certainty, identification of early growth phases and estimation of the tumour's potential for progression and metastasis. It is reasonable to assume that their combined use can provide useful information for formulating prognoses that are not only statistically valid but also individualized.

DemTect: a new, sensitive cognitive screening test to support the diagnosis of mild cognitive impairment and early dementia

OBJECTIVES

To design a new, highly sensitive psychometric screening to identify patients with mild cognitive impairment (MCI) and patients with dementia in the early stages of the disease.

METHODS

Five tasks were included in the DemTect: a word list, a number transcoding task, a word fluency task, digit span reverse, and delayed recall of the word list. The normation was performed with 145 healthy control subjects (CG). Furthermore, 97 MCI patients and 121 patients with possible Alzheimer's disease (AD) were tested with the DemTect and the MMSE. Classification rates for both tests were analysed.

RESULTS

On the basis of the CG data, age-dependant transformation algorithms for the DemTect subtests were defined, and an education correction was provided for the total transformed score. The patient groups scored significantly below the CG in both the DemTect and the MMSE. Compared to the MMSE, classification rates of the DemTect were superior for both the MCI and the AD group, with high sensitivities of 80% and 100%, respectively.

CONCLUSIONS

The DemTect is short (8-10 minutes), easy to administer, and its transformed total score (maximum 18) is independent of age and education. The DemTect helps in deciding whether cognitive performance is adequate for age (13-18 points), or whether MCI (9-12 points) or dementia (8 points or below) should be suspected.