Creatine Kinase MB Isoenzyme Is a Complementary Biomarker in Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is an invariably fatal neurodegenerative disease with limited therapeutic options. There is an urgent need for novel biomarkers to be used as surrogates for new therapeutic trials and disease monitoring. In this study, we sought to systematically study creatine kinase isoenzyme MB (CK-MB) in a real-world cohort of ALS patients, assess the diagnostic performance, and evaluate its association with other laboratory and clinical parameters. We reviewed data from 194 consecutive patients that included 130 ALS patients and 64 disease control patients (primary lateral sclerosis [PLS], benign fasciculations syndrome [BFS], Huntington's disease [HD] and Alzheimer's disease [AD]). CK-MB was elevated in the sera of more than half of all patients with ALS. In patients with spinal-onset ALS, CK-MB levels were significantly higher than in patients with other neurodegenerative diseases. Patients with slower rates of functional decline had a significantly higher baseline CK-MB. Furthermore, CK-MB elevations correlated with cardiac troponin T (cTnT) and with revised ALS Functional Rating Scale (ALSFRS-R) bulbar subcategory. We posit that measuring CK-MB in ALS patients in a complimentary fashion could potentially aid in the diagnostic workup of ALS and help discriminate the disease from some ALS mimics and other neurodegenerative diseases. CK-MB levels also may provide valuable prognostic information regarding disease aggressiveness as well as correlations with specific phenotypic presentations.

Supervised, Self-Administered Tablet-Based Cognitive Assessment in Neurodegenerative Disorders and Stroke

INTRODUCTION

As the population ages, the prevalence of cognitive impairment is expanding. Given the recent pandemic, there is a need for remote testing modalities to assess cognitive deficits in individuals with neurological disorders. Self-administered, remote, tablet-based cognitive assessments would be clinically valuable if they can detect and classify cognitive deficits as effectively as traditional in-person neuropsychological testing.

METHODS

We tested whether the Miro application, a tablet-based neurocognitive platform, measured the same cognitive domains as traditional pencil-and-paper neuropsychological tests. Seventy-nine patients were recruited and then randomized to either undergo pencil-and-paper or tablet testing first. Twenty-nine age-matched healthy controls completed the tablet-based assessments. We identified Pearson correlations between Miro tablet-based modules and corresponding neuropsychological tests in patients and compared scores of patients with neurological disorders with those of healthy controls using t tests.

RESULTS

Statistically significant Pearson correlations between the neuropsychological tests and their tablet equivalents were found for all domains with moderate (r > 0.3) or strong (r > 0.7) correlations in 16 of 17 tests (p < 0.05). All tablet-based subtests differentiated healthy controls from neurologically impaired patients by t tests except for the spatial span forward and finger tapping modules. Participants reported enjoyment of the tablet-based testing, denied that it provoked anxiety, and noted no preference between modalities.

CONCLUSIONS

This tablet-based application was found to be widely acceptable to participants. This study supports the validity of these tablet-based assessments in the differentiation of healthy controls from patients with neurocognitive deficits in a variety of cognitive domains and across multiple neurological disease etiologies.

Validation of a Mobile, Sensor-based Neurobehavioral Assessment With Digital Signal Processing and Machine-learning Analytics

BACKGROUND

The Miro Health Mobile Assessment Platform consists of self-administered neurobehavioral and cognitive assessments that measure behaviors typically measured by specialized clinicians.

OBJECTIVE

To evaluate the Miro Health Mobile Assessment Platform's concurrent validity, test-retest reliability, and mild cognitive impairment (MCI) classification performance.

METHOD

Sixty study participants were evaluated with Miro Health version V.2. Healthy controls (HC), amnestic MCI (aMCI), and nonamnestic MCI (naMCI) ages 64-85 were evaluated with version V.3. Additional participants were recruited at Johns Hopkins Hospital to represent clinic patients, with wider ranges of age and diagnosis. In all, 90 HC, 21 aMCI, 17 naMCI, and 15 other cases were evaluated with V.3. Concurrent validity of the Miro Health variables and legacy neuropsychological test scores was assessed with Spearman correlations. Reliability was quantified with the scores' intraclass correlations. A machine-learning algorithm combined Miro Health variable scores into a Risk score to differentiate HC from MCI or MCI subtypes.

RESULTS

In HC, correlations of Miro Health variables with legacy test scores ranged 0.27-0.68. Test-retest reliabilities ranged 0.25-0.79, with minimal learning effects. The Risk score differentiated individuals with aMCI from HC with an area under the receiver operator curve (AUROC) of 0.97; naMCI from HC with an AUROC of 0.80; combined MCI from HC with an AUROC of 0.89; and aMCI from naMCI with an AUROC of 0.83.

CONCLUSION

The Miro Health Mobile Assessment Platform provides valid and reliable assessment of neurobehavioral and cognitive status, effectively distinguishes between HC and MCI, and differentiates aMCI from naMCI.

Is Aphasia Treatment Beneficial for the Elderly? A Review of Recent Evidence

Purpose

We review recent literature regarding aphasia therapy in the elderly. Relevant articles from the last 5 years were identified to determine whether or not there is evidence to support that various therapeutic approaches can have a positive effect on post-stroke aphasia in the elderly.

Recent findings

There were no studies examining the effects of aphasia therapy specifically in the elderly within the timeframe searched. Therefore, we briefly summarize findings from 50 relevant studies that included large proportions of participants with post-stroke aphasia above the age of 65. A variety of behavioral and neuromodulation therapies are reported.

Summary

We found ample evidence suggesting that a variety of behavioral and neuromodulatory therapeutic approaches can benefit elderly individuals with post-stroke aphasia.

A Radon Background-subtraction Algorithm for Electronic Personal Dosimeters

Many first responders are outfitted with electronic personal dosimeters to recognize and be alerted to radiological hazards during their response operations. These dosimeters provide invaluable measurement data for force protection, allowing the first responder to assess a response situation and take protective measures for themselves and other individuals involved based on instrument readings of dose rate or cumulative dose. However, capabilities of common electronic personal dosimeters to identify and distinguish various contributions to the instrument reading, in particular from natural radiological sources, are rather limited. An algorithm has been developed for two-channel electronic personal dosimeters that quantifies the signal contribution from radon progeny and allows for background subtraction from radon and radon progeny in the instrument reading. This algorithm will be particularly useful in operational scenarios where first responders may be subject to rapidly changing levels of natural background radiation, which could mimic the presence of anthropogenic sources of ionizing radiation.

Fasciitis necrotisans - duplicitas casuum

Necrotizing fasciitis is a dangerous bacterial infectious disease that is not commonplace in Czech society. On the other hand, neither is it so rare that the majority of surgeons should not come across it occasionally. In the early stages, pathological changes in fascia, subcutaneous tissue and even skin may run an inconspicuous course. However, this can rapidly deteriorate into shock and sepsis which may lead to multi-organ failure and an imminent life-threatening condition. The fatality rate of necrotizing fasciitis among high-risk groups (e.g. diabetics, patients who are immuno-compromised, obese and/or elderly, malnourished, or with a history of drug use), is particularly steep, reaching as high as 73%. Treatment for this condition consists of early, radical surgical intervention in conjunction with targeted antibiotherapy. Complex resuscitative and intensive care, including rehabilitation, are standard components of post-surgical management. Use of hyperbaric oxygen therapy, if such an opportunity exists, is also recommended. Interdisciplinary collaboration is a vital prerequisite for successful treatment. This article describes two case-studies of necrotizing fasciitis that occurred in men of similar age during a three-year period. Both patients presented with very similar and complicated disease courses, and both were successfully treated by the same interdisciplinary team comprised of clinicians from various specialized departments. Key words: necrotizing fasciitis - radical necrectomy - antibiotherapy - hyperbaric oxygen therapy - complex resuscitative and intensive care.

Results of accelerated radiotherapy for supraglottic carcinoma: a Massachusetts General Hospital and Massachusetts Eye and Ear Infirmary experience

BACKGROUND

Carcinoma of the supraglottic larynx is a relatively common malignancy treated with either surgery, radiotherapy, or a combined approach.

METHODS

The radiotherapy records of 190 patients with carcinoma of the supraglottic larynx treated at the Massachusetts General Hospital (MGH) and Massachusetts Eye and Ear Infirmary (MEEI) from 1981 to 1992 were reviewed. Of these patients, 164 were available for evaluation for local control and 169 for disease-specific survival. The patients were treated with accelerated hyperfractionated radiotherapy to 67.2-72 Gy/1.6 Gy per fraction twice a day in 6 weeks. The median follow-up was 56 months. Five-year actuarial local and regional control, relapse-free and overall survival, and voice-preservation rates were analyzed.

RESULTS

For T1, T2, T3, and T4 tumors, local control rates were 96%, 86%, 76%, and 43%, respectively (p < .01), and the corresponding relapse-free survival rates were 78%, 82%, 64%, and 40% (p < .01). For the patients with N0, N1, and N2-3 disease, local control rates at the primary site were 86%, 74%, and 46%, respectively (p < .01), and the corresponding relapse-free survival rates were 79%, 53%, and 39% (p < .01). Including surgical salvage, the ultimate local control rates were 96%, 93%, 88%, and 51%, respectively (p < .01). Voice preservation rate for the entire group was 79% and for T1, T2, T3, and T4 tumors, rates were 96%, 80%, 72%, and 43%, respectively.

CONCLUSIONS

Our experience with accelerated hyperfractionated radiotherapy for supraglottic carcinoma showed excellent locoregional control, relapse-free survival, and laryngeal preservation. The radiation toxicity was acceptable. The T and N stages were significant predictors of outcome, and the T4 tumors and node-positive neck disease portended a poor prognosis and therefore should be considered for protocols that include adjuvant therapies.

Acetylcholine and histamine are transmitter candidates in identifiable mechanosensitive neurons of the spider Cupiennius salei: an immunocytochemical study

Histochemical and indirect immunocytochemical techniques were used to search for neuroactive substances and transmitter candidates in identified sensory neurons of two types of cuticular mechanoreceptors in the spider Cupiennius salei Keys.: (1) in lyriform slit-sense organ VS-3 (comprising 7-8 cuticular slits each innervated by 2 bipolar neurons), and (2) in tactile hairs (each supplied by 3 bipolar sensory cells). All neurons are mechanosensitive. A polyclonal antibody against choline acetyltransferase (ChAT) strongly labeled all cell bodies and afferent fibers of both mechanoreceptor types. Western blot analysis using the same antibody against samples of spider sensory hypodermis and against samples from the central nervous system demonstrated a clear band at 65 kDa, corresponding to the molecular mass of ChAT in insects. Moreover, staining for acetylcholine esterase (AChE) revealed AChE activity in one neuron of each mechanoreceptor type. Incubation with a polyclonal antibody against histamine clearly labeled one neuron in each set of sensilla, whereas activity in the remaining one or two cells was near background. All mechanoreceptor preparations treated with a polyclonal antiserum against serotonin tested negative, whereas sections through the central nervous system of the same spiders were clearly labeled for serotonin. The presence of ChAT-like immunoreactivity and AChE implicates acetylcholine as a transmitter candidate in the two mechanoreceptive organs. We assume that histamine serves as a mechanosensory co-transmitter in the central nervous system and may also act at peripheral synapses that exist in these sensilla.

Neural tolerability of iodixanol in mice and dogs after single and repeated intracisternal administration

The neural tolerability of iodixanol has been assessed in studies in mice and dogs. The animals received up to 4 injections in the cisterna cerebellomedullaris while under light anesthesia. Iotrolan was included as a reference study in 1 study. The observations comprised assessment of clinical behavior, cerebrospinal fluid analysis, hematology, clinical chemistry and/or macroscopic and microscopic examination at necropsy. In addition, the repeated-dose dog study, urinalysis and opthalmoscopy were performed, electrocardiograms obtained, and respiratory rate, blood pressure and rectal temperature measured. Clinical signs and minor pathological changes caused by the injection procedures were seen in all studies in some animals treated with iodixanol as well as in control animals. Single (2.0 g I/kg) and repeated (0.960 g I/kg) intracisternal administration of iodixanol to mice caused no significant toxicological effects. Two dogs treated with a high dose of iodixanol (0.256 g I/kg; 0.8 ml/kg) had pathological changes (meningeal inflammation and/or necrosis) that were more severe than those observed in control dogs. Single and repeated intracisternal administration of 0.128 g I/kg (0.4 ml/kg) of iodixanol to dogs, however, caused no significant toxicological effects. Apart from the findings in the 2 dogs, the neurological and neuropathological changes elicited by iodixanol were similar to those induced by control or reference substances. The results from these intracisternal toxcity studies in mice and dogs indicate a significant margin of safety regarding the use of iodixanol in clinical intra-thecal indications.

Reduction of animal use with improved procedure for acute tolerance assessment

A retrospective evaluation of previously conducted acute tolerance tests in rats and mice, following oral and intravenous routes of administration, and a review of the literature indicated that a minimum of three animals per group was adequate to characterize acute tolerance. Limited exploratory testing, using six compounds for which classical LD50 tests had been performed previously, indicated that fewer numbers of rats gave comparable results. A method is proposed by which the acute tolerance of a compound may be adequately characterized in both sexes using approximately 30 animals instead of the 70 to 100 used in the classical LD50 test. The objective of the testing procedure is identification of the maximum nonlethal dose or the minimum lethal dose, rather than determination of the LD50.

Mandibular osteotomies for tumor extirpation: the advantages of rigid fixation

Adequate exposure of intraoral tumors occupying the posterior oral cavity, base of tongue, tonsil, and superior hypopharynx for wide-field primary surgical resection is critical to precise tumor ablation. The exposure resulting from a mandibular osteotomy has greatly assisted the tumor ablation of these areas. This procedure has also been beneficial in providing exposure to the anterior skull base, pterygomaxillary, and infratemporal space, clivus, and nasopharynx. In evaluating various osteotomy sites and methods of fixation, we reviewed 26 patients treated for benign or malignant neoplasia of the head and neck requiring mandibulotomy. The osteotomy complication rate was 2 (29%) of 7 for wire osteosynthesis and 1 (5.3%) of 19 for plate osteosynthesis. All patients with osteotomy complications had received preoperative radiation therapy. The one complication in the plated group was associated with a lateral stairstep osteotomy and two screws on either side of the osteotomy. This study suggests advantages of absolute rigid internal fixation of mandibular osteotomies used for tumor ablation. It is also concluded that a midline osteotomy reapproximated with rigid internal fixation has the benefits of 1. primary bone healing by means of plating counteracting the balanced forces acting on the symphysis; 2. improved reapproximation with minimal bony loss, improving occlusion; 3. decreased incidence of osteoradionecrosis as the symphysis lies outside the usual radiation ports; 4. preservation of the neurovascular bundle; and 5. maintenance of osteotomy-site immobility in an infected field. This review helped identify surgical techniques that decrease the complications that are commonly associated with mandibular osteotomies for precise tumor ablation.

Clinical and histopathologic studies of two families with lattice corneal dystrophy and familial systemic amyloidosis (Meretoja syndrome)

Lattice corneal dystrophy associated with familial systemic amyloidosis (Meretoja syndrome) has rarely been described other than in patients of Finnish origin. The authors report two North American patients with this disease who manifest blepharochalasis, lattice corneal dystrophy, open-angle glaucoma, and cranial neuropathy. In one patient, a corneal intraepithelial and subepithelial pseudodendrite was managed by superficial keratectomy, and this same patient benefited from surgical brow suspension for facial muscular weakness. In the second patient, penetrating keratoplasty was complicated by a neurotrophic persistent epithelial defect. Corneal tissue from both superficial keratectomy and penetrating keratoplasty exhibited ultrastructurally characteristic amyloid filaments and associated elastoid material. Transmission electron microscopy of conjunctiva and skin biopsies similarly revealed amyloid deposits associated with most basement membranes, the perineurium and endoneurium of most peripheral nerves, and the intima and media of arteries. By immunoperoxidase staining, the corneal amyloid deposits were positive for the amyloid P-component protein but negative for the nonimmunoglobulin amyloid A protein and prealbumin. Serum prealbumin and amyloid A related protein were normal.

Comparative morphometric study of tumor vasculature in human squamous cell carcinomas and their xenotransplants in athymic nude mice

When human tumor xenotransplants into nude mice are used as experimental models, it is important to know whether their microvascular anatomy is rather host or tumor specific. Therefore a morphometric comparison of the vascular network in human squamous cell carcinomas and their xenotransplants was carried out. Biopsies were taken from surgical specimens of three squamous cell carcinomas of the oral cavity. Part of the material was processed for histology and the rest was cut into 1-mm3 cubes and transplanted s.c. into the lateral thorax of athymic nude mice [NCr/Sed(nu/nu)]. The microvascular architecture of original tumors and of three first, one second, and one late generation xenografts was compared. Capillaries were identified in original human tumors by anti-factor VIII staining and in xenografts with antilaminin staining. The median distances between interphase tumor cells and blood vessels were determined and were found to be much longer in original human tumors than in xenografts, ranging from 81 microns to 99 microns and 53 microns to 65 microns, respectively. However, the characteristic qualitative histology of tumors appeared to be preserved in xenotransplants. Analysis of the topographic distribution of mitotic figures revealed that in both original tumors and xenotransplants proliferation of tumor cells was concentrated around blood vessels. Again, vascular distances in original tumors were significantly longer than in xenotransplants. In addition, xenotransplants into nude mice from a long passaged cell line from a human pharyngeal squamous cell carcinoma, FaDu, was investigated. FaDu showed a rare-fication of the capillary network with increasing tumor volume, but a constant median distance of mitotic figures from blood vessels. In conclusion, the pattern of spatial distribution of proliferating tumor cells as well as differentiation characteristics appear to be retained in xenograft tumors, but the density of the vascular system is host specific. This has to be taken into account when physiological parameters of blood supply are studied in xenotransplanted tumors.

MR imaging of a lymphangioma involving the masseter muscle

Lymphangiomas and cystic hygromas are tumors of lymphatic origin that are relatively common in the head and neck area. However, based on our literature review of this subject, the masseter muscle has never been implicated as a primary tumor site. It is our purpose to report such a case and to emphasize the value of magnetic resonance imaging for diagnosing a mass located in the masseteric region.

Treatment of advanced squamous cell carcinoma of the head and neck with cisplatin, bleomycin, and methotrexate (PBM)

Twenty-nine of 32 patients with advanced squamous cell carcinoma of the head and neck were treated with two courses of an intensive chemotherapy regimen consisting of cisplatin, bleomycin, and methotrexate (PBM). The frequency of toxic effects (in 29 evaluable patients) associated with this regimen was low. Serious neutropenia occurred in 17% and thrombocytopenia in 10% of the courses. Nausea (50%) and severe vomiting (6%) were easily managed. All 26 (100%) evaluable patients with squamous cell carcinoma had significant reduction (less than 50%) of measurable tumor. Complete regression was noted in seven patients (27%). Fifteen patients were treated with PBM prior to receiving radiation therapy or surgery as definitive treatment for their disease. Antitumor response in these patients was rapid, occurring within 3 weeks from the initiation of chemotherapy. Maximal antitumor effect was achieved by Week 6 of induction chemotherapy. No patient showed tumor regrowth prior to the institution of radiation therapy or surgery. Twelve patients with recurrent disease following previous radiotherapy and/or surgery also received PBM chemotherapy. In our study, previous radiotherapy or surgery did not diminish the antitumor effect of PBM, but toxicity was more severe.