Two-year neurodevelopmental outcome in extremely preterm-born children: The Austrian Preterm Outcome Study Group

AIM

The current study determined the neurodevelopmental outcome of extremely preterm infants at 2 years of age.

METHODS

All live-born infants 23-27 weeks of gestation born between 2011 and 2020 in Austria were included in a prospective registry. Neurodevelopmental outcome at 2 years of corrected age was assessed using Bayley Scales of Infant Development for both motor and cognitive scores, along with a neurological examination and an assessment of neurosensory function.

RESULTS

2378 out of 2905 (81.9%) live-born infants survived to 2 years of corrected age. Follow-up data were available for 1488 children (62.6%). Overall, 43.0% had no, 35.0% mild and 22.0% moderate-to-severe impairment. The percentage of children with moderate-to-severe neurodevelopmental impairment decreased with increasing gestational age and was 31.4%, 30.5%, 23.3%, 19.0% and 16.5% at 23, 24, 25, 26 and 27 weeks gestational age (p < 0.001). Results did not change over the 10-year period. In multivariate analysis, neonatal complications as well as male sex were significantly associated with an increased risk of neurodevelopmental impairment.

CONCLUSION

In this cohort study, a 22.0% rate of moderate-to-severe neurodevelopmental impairment was observed among children born extremely preterm. This national data is important for both counselling parents and guiding the allocation of health resources.

Emotion Recognition in Multiple System Atrophy: An Exploratory Eye-Tracking Study

OBJECTIVE

Emotional processing is a core feature of social interactions and has been well studied in patients with idiopathic Parkinson's disease (PD), albeit with contradictory.

RESULTS

. However, these studies excluded patients with atypical parkinsonism, such as multiple system atrophy (MSA). The objective of this exploratory study was to provide better insights into emotion processing in patients with MSA using eye tracking data.

METHODS

We included 21 MSA patients, 15 PD patients and 19 matched controls in this study. Participants performed a dynamic and a static emotion recognition task, and gaze fixations were analyzed in different areas of interest. Participants underwent neuropsychological testing and assessment of depression and alexithymia.

RESULTS

MSA patients were less accurate in recognizing anger than controls (p = 0.02) and had overall fewer fixations than controls (p = 0.001). In the static task, MSA patients had fewer fixations (p < 0.001) and a longer time to first fixation (p = 0.026) on the eye region. Furthermore, MSA patients had a longer fixation duration overall than PD patients (p = 0.004) and longer fixations on the nose than controls (p = 0.005). Alexithymia scores were higher in MSA patients compared to controls (p = 0.038).

CONCLUSION

This study demonstrated impaired recognition of anger in MSA patients compared to HCs. Fewer and later fixations on the eyes along with a center bias suggest avoidance of eye contact, which may be a characteristic gaze behavior in MSA patients.

Cardiovascular health profiles in adolescents being born term or preterm-results from the EVA-Tyrol study

BACKGROUND AND AIMS

Preterm birth has been linked with an increased risk of cardiovascular (CV) disease from childhood into adolescence and early adulthood. In this study, we aimed to investigate differences in CV health profiles between former term- and preterm-born infants in a cohort of Tyrolean adolescents.

METHODS

The Early Vascular Aging (EVA)-Tyrol study is a population-based non-randomized controlled trial, which prospectively enrolled 14- to 19-year-old adolescents in North Tyrol, Austria and South Tyrol, Italy between 2015 and 2018. Metrics of CV health (body mass index (BMI), systolic (SBP) and diastolic blood pressure (DBP), smoking, physical activity, dietary patterns, total cholesterol and fasting blood glucose) were assessed and compared between former term- and preterm-born girls and boys.

RESULTS

In total, 1,491 study participants (59.5% female, mean age 16.5 years) were included in the present analysis. SBP and DBP were significantly higher in former preterm-born adolescents (mean gestational age 34.6 ± 2.4 weeks) compared to term-born controls (p < 0.01). In the multivariate regression analysis these findings remained significant after adjustment for potential confounders in all models. No differences were found in all other CV health metrics. The number of participants meeting criteria for all seven health metrics to be in an ideal range was generally very low with 1.5% in former term born vs. 0.9% in former preterm born adolescents (p = 0.583).

CONCLUSIONS

Preterm birth is associated with elevated SBP and DBP in adolescence, which was even confirmed for former late preterm-born adolescents in our cohort. Our findings underscore the importance of promoting healthy lifestyles in former term- as well as preterm-born adolescents. In addition, we advise early screening for hypertension and long-term follow-up in the group of preterm-born individuals.

Prophylactic low-dose paracetamol for ductal closure and neurodevelopmental outcome in very preterm infants

AIM

To investigate the direct effect of prophylactic low-dose paracetamol administration for ductal closure on neurodevelopmental outcome in very preterm infants who did not receive ibuprofen or surgical ligation for treatment of a patent ductus arteriosus.

METHODS

Infants <32 gestational weeks born 10/2014 - 12/2018 received prophylactic paracetamol (paracetamol group, n=216); infants born 02/2011 - 09/2014 did not receive prophylactic paracetamol (control group, n=129). Psychomotor (PDI) and mental (MDI) outcome were assessed using Bayley Scales of Infant Development at 12 and 24 months corrected age.

RESULTS

Our analyses showed significant differences in PDI and MDI at age 12 months (B=7.8 (95%CI 3.90-11.63), p<0.001 and B=4.2 (95%CI 0.81-7.63), p=0.016). At age 12 months the rate of psychomotor delay was lower in the paracetamol group (OR 2.22, 95%CI 1.28-3.94, p=0.004). There was no significant difference between the rates of mental delay at any time-point. All group differences remained significant after adjustment for potential confounders (PDI 12 months B=7.8 (95%CI 3.77-11.34), p<0.001, MDI 12 months B=4.3 (95%CI 0.79-7.45), p=0.013, PDI <85 12 months OR 2.65 (95%CI 1.44-4.87), p=0.002).

CONCLUSION

We found no impairment of psychomotor and mental outcome at age 12 and 24 months in very preterm infants after prophylactic low-dose paracetamol administration.

Prevalence and differences of ideal cardiovascular health in urban and rural adolescents in the Region of Tyrol: results from the EVA Tyrol study

Purpose

Early adoption of a healthy lifestyle has positive effects on cardiovascular health (CVH) in adulthood. In this study, we aimed to assess CVH metrics in a cohort of healthy teenagers with focus on differences between rural and urban areas.

Methods

The Early Vascular Aging (EVA) Tyrol study is a population-based non-randomized controlled trial, which prospectively enrolled 14- to 19-year-old adolescents in North Tyrol, Austria and South Tyrol, Italy between 2015 and 2018. Data from the baseline and control group (prior to health intervention) are included in the current analysis. CVH determinants (smoking, body mass index, physical activity, dietary patterns, systolic and diastolic blood pressure, total cholesterol and fasting blood glucose) were assessed and analyzed for urban and rural subgroups separately by univariate testing. Significant variables were added in a generalized linear model adjusted for living in urban or rural area with age and sex as covariates. Ideal CVH is defined according to the guidelines of the American Heart Association.

Results

2031 healthy adolescents were enrolled in the present study (56.2% female, mean age 16.5 years). 792 adolescents (39.0%) were from urban and 1239 (61.0%) from rural areas. In 1.3% of adolescents living in urban vs. 1.7% living in rural areas all CVH determinants were in an ideal range. Compared to the rural group, urban adolescents reported significantly longer periods of moderate to vigorous-intensive activity (median 50.0 min/day (interquartile range 30–80) vs. median 40.0 min/day (interquartile range 25–60), p < 0.01). This observation remained significant in a generalized linear model (p < 0.01). There were no significant differences between the study groups regarding all other CVH metrics.

Conclusion

The low prevalence of ideal CVH for adolescents living in urban as well as rural areas highlights the need for early health intervention. Geographic differences must be taken into account when defining targeted subgroups for health intervention programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02156-6.

Cardiovascular autonomic function testing in multiple system atrophy and Parkinson's disease: an expert-based blinded evaluation

PURPOSE

Multiple system atrophy (MSA) and Parkinson's disease (PD) are sporadic neurodegenerative diseases characterized by an accumulation of misfolded α-synuclein. Cardiovascular autonomic failure develops in both MSA and PD, although studies indicate different sites of autonomic nervous system lesion. However, it is unclear whether this could potentially aid the differential diagnosis of these diseases. Here we determined whether cardiovascular autonomic function testing (CAFT) can discriminate between the parkinsonian variant of MSA (MSA-P) and PD based on either an expert-based blinded evaluation or a systematic comparison of cardiovascular autonomic function indices.

METHODS

We included 22 patients aged 55-80 with neurogenic orthostatic hypotension (nOH) who had been diagnosed with either clinically probable MSA-P (n = 11) according to current consensus criteria or clinically definite PD (n = 11) according to the Queen Square criteria. Three physicians with expertise in CAFT were blinded to the neurological diagnosis and were asked to identify the correct neurological diagnosis by applying a self-created evaluation scheme to the CAFT recordings. Afterwards, a systematic comparison of clinical-demographic characteristics and CAFT parameters was carried out.

RESULTS

Neither the raters (overall diagnostic accuracy: 58.46%) nor the evaluation scheme created post hoc (72.73%) showed reliable discriminatory capacity. The inter-rater reliability was slight (κ = 0.01). We observed no statistically significant differences in cardiovascular autonomic indices between PD and MSA-P patients.

CONCLUSION

CAFT is the gold standard for assessing the presence and severity of cardiovascular autonomic failure, but the results of our pilot study suggest that CAFT might be of limited value in the differential diagnosis between MSA-P and PD once nOH is present.

Physiotherapy improves motor function in patients with the Parkinson variant of multiple system atrophy: A prospective trial

BACKGROUND AND OBJECTIVES

Gait impairment and reduced mobility are disabling symptoms of multiple system atrophy. While physiotherapy is increasingly recognized as a valuable supplement to pharmacotherapy for patients with Parkinson's disease, data on the efficacy of physiotherapy for multiple system atrophy are lacking. This study aimed to explore the feasibility of two consecutive exercise-based interventions in patients with multiple system atrophy.

SUBJECTS AND METHODS

We included 10 patients with the parkinsonian variant of multiple system atrophy and 10 patients with Parkinson's disease, matched for gender and Hoehn & Yahr stage (≤3). Interventions consisted of a five-day inpatient physiotherapy program followed by a five-week unsupervised home-based exercise program. Outcomes included instrumented gait analysis, patient questionnaires, clinical rating scales and physical tests. Patients were examined at baseline, after the first inpatient treatment and again after the home-based intervention. Additionally, a structured telephone interview was performed immediately after the second intervention period.

RESULTS

Both patient groups exhibited a similar improvement of gait after the interventions, as measured by instrumented gait analysis. These effects reached their maximum level after inpatient physiotherapy and remained stable following the home-based exercise program. Patient questionnaires also showed improvements after the interventions, but motor clinical rating scales did not.

CONCLUSION

Our pilot results suggest that a short-term bout of physiotherapy is feasible, safe and improves gait performance in patients with multiple system atrophy. This highlights the potential of physiotherapy for this disabling condition where pharmacotherapy typically achieves poor effects. The present findings warrant a larger controlled study.

Clinical Heterogeneity in Cerebral Hemiatrophy Syndromes

Background

Cerebral hemiatrophy syndromes can present with variable neurological symptoms. In childhood epilepsy, mental retardation and neuropsychiatric disorders are common while in adults movement disorders, such as highly asymmetric parkinsonism or hemidystonia as well as neuropsychiatric problems have been reported.

Methods

Here, we present three adult patients with features that expand the clinical spectrum and give an overview of the most common clinical signs associated with this rare condition.

Results

All three patients had prominent neuropsychiatric symptoms such as mood swings and increased irritability. Furthermore, one patient developed hemichorea which can be a rare presentation of cerebral hemiatrophy.

Conclusions

Cerebral hemiatrophy syndromes are a heterogeneous group of disorders that may also present with neuropsychiatric symptoms or hemichorea.

Hypoxia triggers high-altitude headache with migraine features: A prospective trial

Background

Given the high prevalence and clinical impact of high-altitude headache (HAH), a better understanding of risk factors and headache characteristics may give new insights into the understanding of hypoxia being a trigger for HAH or even migraine attacks.

Methods

In this prospective trial, we simulated high altitude (4500 m) by controlled normobaric hypoxia (FiO2 = 12.6%) to investigate acute mountain sickness (AMS) and headache characteristics. Clinical symptoms of AMS according to the Lake Louise Scoring system (LLS) were recorded before and after six and 12 hours in hypoxia. O2 saturation was measured using pulse oximetry at the respective time points. History of primary headache, especially episodic or chronic migraine, was a strict exclusion criterion.

Findings

In total 77 volunteers (43 (55.8%) males, 34 (44.2%) females) were enrolled in this study. Sixty-three (81.18%) and 40 (71.4%) participants developed headache at six or 12 hours, respectively, with height and SpO2 being significantly different between headache groups at six hours ( p < 0.05). Binary logistic regression model revealed a significant association of SpO2 and headache development ( p < 0.05, OR 1.123, 95% CI 1.001–1.259). In a subgroup of participants, with history of migraine being a strict exclusion criterion, hypoxia triggered migraine-like headache according to the International Classification of Headache Disorders (ICHD-3 beta) in n = 5 (8%) or n = 6 (15%), at six and 12 hours, respectively.

Interpretation

Normobaric hypoxia is a trigger for HAH and migraine-like headache attacks even in healthy volunteers without any history of migraine. Our study confirms the pivotal role of hypoxia in the development of AMS and beyond that suggests hypoxia may be involved in migraine pathophysiology.

Cause-specific mortality in adult epilepsy patients from Tyrol, Austria: hospital-based study

Epilepsy is a devastating condition with a considerable increase in mortality compared to the general population. Few studies have focused on cause-specific mortality which we analyse in detail in over 4,000 well-characterized epilepsy patients. The cohort comprised of epilepsy patients ≥18, treated between 1970 and 2009 at the epilepsy clinic of Innsbruck Medical University, Austria, and living in the province of Tyrol, Austria. Epilepsy diagnosis was based on ILAE guidelines (1989); patients with brain tumor were excluded. Deceased patients and causes of death (ICD-codes) were obtained via record linkage to the national death registry. We computed age-, sex-, and period-adjusted standardized mortality rates (SMR) for 36 diagnoses subgroups in four major groups. Additional analyses were performed for an incidence cohort. Overall cohort: 4,295 patients, 60,649.1 person-years, 822 deaths, overall SMR 1.7 (95 % CI 1.6–1.9), highest elevated cause-specific SMR: congenital anomalies [7.1 (95 % CI 2.3–16.6)], suicide [4.2 (95 % CI 2.0–8.1)], alcohol dependence syndrome [3.9 (95 % CI 1.8–7.4)], malignant neoplasm of esophagus [3.1 (95 % CI 1.2–6.4)], pneumonia [2.7 (95 % CI 1.6–4.2)]. Incidence cohort: 1,299 patients, 14,215.4 person-years, 267 deaths, overall SMR 1.8 (95 % CI 1.6–2.1), highest elevated cause-specific SMR congenital anomalies [10.8 (95 % CI 1.3–39.3)], suicide [6.8 (95 % CI 1.4–19.8)], alcohol dependence syndrome (6.4 [95 % CI 1.8–16.5)], pneumonia [3.9 (95 % CI 1.8–7.4)], cerebrovascular disease at 3.5 (95 % CI 2.6–4.6). Mortality due to mental health problems, such as suicide or alcohol dependence syndrome, malignant neoplasms, and cerebrovascular diseases was highly increased in our study. In addition to aim for seizure freedom, we suggest improving general health promotion, including cessation of smoking, lowering of alcohol intake, and reduction of weight as well as early identification of psychiatric comorbidity in patients with epilepsy.

Higher brain extracellular potassium is associated with brain metabolic distress and poor outcome after aneurysmal subarachnoid hemorrhage

Introduction

Elevated brain potassium levels ([K⁺]) are associated with neuronal damage in experimental models. The role of brain extracellular [K⁺] in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) and its association with hemorrhage load, metabolic dysfunction and outcome has not been studied so far.

Methods

Cerebral microdialysis (CMD) samples from 28 poor grade aSAH patients were analyzed for CMD [K⁺] for 12 consecutive days after ictus, and time-matched to brain metabolic and hemodynamic parameters as well as corresponding plasma [K⁺]. Statistical analysis was performed using a generalized estimating equation with an autoregressive function to handle repeated observations of an individual patient.

Results

CMD [K⁺] did not correlate with plasma [K⁺] (Spearman’s ρ = 0.114, P = 0.109). Higher CMD [K⁺] was associated with the presence of intracerebral hematoma on admission head computed tomography, CMD lactate/pyruvate ratio >40 and CMD lactate >4 mmol/L (P < 0.05). In vitro retrodialysis data suggest that high CMD [K⁺] was of brain cellular origin. Higher CMD [K⁺] was significantly associated with poor 3-month outcome, even after adjusting for age and disease severity (P < 0.01).

Conclusions

The results of this pilot study suggest that brain extracellular [K⁺] may serve as a biomarker for brain tissue injury in poor-grade aSAH patients. Further studies are needed to elucidate the relevance of brain interstitial K⁺ levels in the pathophysiology of secondary brain injury after aSAH.

Presentation, diagnosis, and management of multiple system atrophy in Europe: final analysis of the European multiple system atrophy registry

Multiple system atrophy (MSA) is a Parkinson's Disease (PD)-like α-synucleinopathy clinically characterized by dysautonomia, parkinsonism, cerebellar ataxia, and pyramidal signs in any combination. We aimed to determine whether the clinical presentation of MSA as well as diagnostic and therapeutic strategies differ across Europe and Israel. In 19 European MSA Study Group centres all consecutive patients with a clinical diagnosis of MSA were recruited from 2001 to 2005. A standardized minimal data set was obtained from all patients. Four-hundred thirty-seven MSA patients from 19 centres in 10 countries were included. Mean age at onset was 57.8 years; mean disease duration at inclusion was 5.8 years. According to the consensus criteria 68% were classified as parkinsonian type (MSA-P) and 32% as cerebellar type (MSA-C) (probable MSA: 72%, possible MSA: 28%). Symptomatic dysautonomia was present in almost all patients, and urinary dysfunction (83%) more common than symptomatic orthostatic hypotension (75%). Cerebellar ataxia was present in 64%, and parkinsonism in 87%, of all cases. No significant differences in the clinical presentation were observed between the participating countries. In contrast, diagnostic work up and therapeutic strategies were heterogeneous. Less than a third of patients with documented orthostatic hypotension or neurogenic bladder disturbance were receiving treatment. This largest clinical series of MSA patients reported so far shows that the disease presents uniformly across Europe. The observed differences in diagnostic and therapeutic management including lack of therapy for dysautonomia emphasize the need for future guidelines in these areas.

Progression of multiple system atrophy (MSA): A prospective natural history study by the European MSA Study Group (EMSA SG)

The disease-specific Unified Multiple System Atrophy Rating Scale (UMSARS) has been developed recently and validated for assessing disease severity in multiple system atrophy (MSA). Here, we aimed at (1) assessing rates of disease progression in MSA and (2) validating UMSARS for sensitivity to change over time. Impairment was assessed at two time points 12 months apart using UMSARS Part I (historical review), UMSARS Part II (motor examination), as well as measures of global disease severity, including UMSARS Part IV, Hoehn and Yahr (HY) Parkinson's disease staging, Schwab England Activities of Daily Living (SE ADL), and a three-point global Severity Scale (SS3). Fifty patients (male:female ratio, 1:0.9; possible MSA, 16%; probable MSA, 84%; MSA-parkinsonian, 58%; MSA-cerebellar, 42%) were assessed twice with an interval of 12.3 months. UMSARS II scores progressed by 57.3% (P<0.0001) and UMSARS I scores by 35.6% (P<0.0001) in relation to the respective baseline scores with no differences between motor subtypes, diagnostic categories and gender. Significant inverse correlations between (1) UMSARS I or UMSARS II progression and (2) baseline disability measures (i.e., the respective UMSARS or SS3 scores) and disease duration were found. Furthermore, the increases in HY staging, SE ADL and SS3 correlated significantly with UMSARS I, UMSARS II, and UMSARS IV progression. This report is the first prospective study showing rapid annual UMSARS rates of decline in MSA. Our data contribute to the ongoing validation process of UMSARS, and they facilitate the planning and implementation of future neuroprotective intervention trials.

The European Multiple System Atrophy-Study Group (EMSA-SG)

Introduction. The European Multiple System Atrophy-Study Group (EMSA-SG) is an academic network comprising 23 centers across Europe and Israel that has constituted itself already in January 1999. This international forum of established experts under the guidance of the University Hospital of Innsbruck as coordinating center is supported by the 5th framework program of the European Union since March 2001 (QLK6-CT-2000-00661). Objectives. Primary goals of the network include (1) a central Registry for European multiple system atrophy (MSA) patients, (2) a decentralized DNA Bank, (3) the development and validation of the novel Unified MSA Rating Scale (UMSARS), (4) the conduction of a Natural History Study (NHS), and (5) the planning or implementation of interventional therapeutic trials. Methods. The EMSA-SG Registry is a computerized data bank localized at the coordinating centre in Innsbruck collecting diagnostic and therapeutic data of MSA patients. Blood samples of patients and controls are recruited into the DNA Bank. The UMSARS is a novel specific rating instrument that has been developed and validated by the EMSA-SG. The NHS comprises assessments of basic anthropometric data as well as a range of scales including the UMSARS, Unified Parkinson's Disease Rating Scale (UPDRS), measures of global disability, Red Flag list, MMSE (Mini Mental State Examination), quality of live measures, i.e. EuroQoL 5D (EQ-5D) and Medical Outcome Study Short Form (SF-36) as well as the Beck Depression Inventory (BDI). In a subgroup of patients dysautonomic features are recorded in detail using the Queen Square Cardiovascular Autonomic Function Test Battery, the Composite Autonomic Symptom Scale (COMPASS) and measurements of residual urinary volume. Most of these measures are repeated at 6-monthly follow up visits for a total study period of 24 months. Surrogate markers of the disease progression are identified by the EMSA-SG using magnetic resonance and diffusion weighted imaging (MRI and DWI, respectively). Results. 412 patients have been recruited into the Registry so far. Probable MSA-P was the most common diagnosis (49% of cases). 507 patients donated DNA for research. 131 patients have been recruited into the NHS. There was a rapid deterioration of the motor disorder (in particular akinesia) by 26.1% of the UMSARS II, and - to a lesser degree - of activities of daily living by 16.8% of the UMSARS I in relation to the respective baseline scores. Motor progression was associated with low motor or global disability as well as low akinesia or cerebellar subscores at baseline. Mental function did not deteriorate during this short follow up period. Conclusion. For the first time, prospective data concerning disease progression are available. Such data about the natural history and prognosis of MSA as well as surrogate markers of disease process allow planning and implementation of multi-centre phase II/III neuroprotective intervention trials within the next years more effectively. Indeed, a trial on growth hormone in MSA has just been completed, and another on minocycline will be completed by the end of this year.