Efficacy and safety of monoclonal antibody therapy in patients with neuromyelitis optica spectrum disorder: A systematic review and network meta-analysis

Introduction

Neuromyelitis optica spectrum disorder (NMOSD) is a devastating inflammatory CNS demyelinating disease. Two groups of monoclonal antibodies (mAbs) are used to prevent disease relapse, i.e., Food and Drug Administration (FDA)-approved mAbs (e.g., eculizumab satralizumab, inebilizumab), and off-label mAb drugs (e.g., rituximab and tocilizumab). The FDA-approved mAbs have high efficacy but more expensive compared to the off-labels, and thus are less accessible. This systematic review and network meta-analysis (NMA) was to assess the efficacy and safety of both classes of mAbs compared to the current standard treatments.

Methods

Systematically searches were conducted in MEDLINE and SCOPUS from inception until July 2021. Randomized-controlled trials (RCTs) were eligible if they compared any pair of treatments (mAbs, immunosuppressive drugs, or placebo) in adult patients with NMOSD. Studies with AQP4-IgG positive or negative were used in the analysis. Probability of relapse and time to event were extracted from the Kaplan-Meier curves using Digitizer. These data were then converted into individual patient time-to-event data. A one-stage mixed-effect survival model was applied to estimate the median time to relapse and relative treatment effects using hazard ratios (HR). Two-stage NMA was used to determine post-treatment annualized relapse rate (ARR), expanded disability status score (EDSS) change, and serious adverse events (SAE). Risk of bias was assessed using the revised cochrane risk of bias tool.

Results

A total of 7 RCTs with 776 patients were eligible in the NMA. Five of the seven studies were rated low risk of bias. Both FDA-approved and off-label mAbs showed significantly lower risk of relapse than standard treatments, with HR (95% CI) of 0.13 (0.07, 0.24) and 0.16 (0.07, 0.37) respectively. In addition, the FDA-approved mAbs had 20% lower risk of relapse than the off-label mAbs, but this did not reach statistical significance. The ARRs were also lower in FDA-approved and off-label mAbs than the standard treatments with the mean-difference of−0.27 (-0.37,−0.16) and−0.31(-0.46,−0.16), respectively.

Conclusion

The off-label mAbs may be used as the first-line treatment for improving clinical outcomes including disease relapse, ARR, and SAEs for NMOSD in countries where resources and accessibility of the FDA-approved mAbs are limited.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=283424, identifier: CRD42021283424.

Hyperglycemia-induced isolated aphasic status epilepticus a case-report and literature review

Neurological manifestations of nonketotic hyperglycemia are frequently seen, with mainly symptoms of confusion or coma. While hyperglycemia-induced seizures are less common, isolated aphasic status epilepticus is very rare, difficult to diagnose, and may be unrecognized by clinicians. In this case report, a 51-year-old man who presented with confusion and incoherent speech for two weeks is discussed. He was diagnosed with nonketotic hyperglycemia, whose electroencephalography (EEG) findings were suggestive of isolated aphasic status epilepticus. His magnetic resonance imaging (MRI) of the brain showed subcortical T2/FLAIR hypointense lesions with cortical T2/FLAIR hyperintensities and restricted diffusion. Although this condition usually responds well to intensive insulin therapy and fluid replacement, many researchers found some persistent aphasic seizures that did not improve until the addition of anti-seizure medications (ASMs).

Clinical Manifestations of Sporadic Creutzfeldt-Jakob Disease in a Public Neurological Hospital in Thailand

INTRODUCTION

Sporadic Creutzfeldt-Jakob disease (sCJD) is one of the common causes of rapidly progressive dementia. However, because of the variety of its clinical presentations, a definite diagnosis in public hospitals is not always possible. Therefore, this study will provide more information about the clinical data of probable sCJD cases in Thailand.

METHODS

This case series of probable sCJD patients who visited the Neurological Institute of Thailand during 2018 to 2023 was conducted. Demographic data, clinical presentations, brain MRI, EEG, CSF analyses, and clinical course were reviewed.

RESULTS

A total of 17 probable sCJD cases were studied. Eleven patients were female (64.71%) with a median age of 62 (IQR: 14.5) years. The median onset of symptoms was 2 months (IQR: 2) before hospital visit, in which cognitive impairment was the most common first presentation (29.41%) followed by ataxia (23.53%), and visual disturbances (17.65%). Most patients had typical high signal intensities at both caudate/putamen and cortical regions (76.47%). Generalized periodic discharges with triphasic morphology were found in 11/14 patients with EEG results (78.57%).

CONCLUSION

sCJD has a diverse clinical presentation that resembles other cognitive disorders. Detailed assessment of signs and symptoms, together with proper investigations, could help to differentiate this condition in a resource-limited setting.

Cognitive Impairment and Risk Factors in Post-COVID-19 Hospitalized Patients

Introduction

Numerous reports regarding cognitive deficits after the coronavirus disease 2019 (COVID-19), described as "brain fog," have been published. However, the clinical presentations and risk factors of post-COVID-19 cognitive impairment are controversial. This study aimed to assess (a) the prevalence of cognitive impairment after COVID-19 hospitalization, (b) characteristics of the cognitive deficits, (c) risk factors of post-COVID-19 cognitive impairment, and (d) comparison of cognitive function between post-COVID-19 patients and healthy people.

Methods

The study comprised 34 SARS-CoV-2-infected patients, admitted to the Neurological Institute of Thailand during the peak of COVID-19 pandemic in 2021-2022. These patients came for neuropsychological and clinical evaluations at 2-week follow-up visit. The cognitive impairment and characteristics were measured by TMSE and MoCA. Clinical risk factors and post-COVID-19 cognitive impairment were assessed. The comparison of cognitive function in post-acute COVID-19 patients and 22 healthy controls was also performed.

Results

The prevalence of post-COVID-19 cognitive impairment defined by a total MoCA score below 25 points was 61.76%. Years of education were the only predictive factors related to cognitive impairment. Our multivariate analysis revealed no statistical difference in cognitive outcomes between post-acute COVID-19 patients and healthy controls.

Conclusion

This study showed a moderate prevalence of cognitive dysfunction after COVID-19 hospitalization similar to previous reports. However, there was no significant difference in cognitive measurements between these patients and healthy people. Whether SARS-CoV-2 infection causes cognitive dysfunction is a myth or fact that still has a long way to prove via further longitudinal study.

Clinical Manifestations

BACKGROUND

Sporadic Creutzfeldt-Jakob disease (sCJD) is one of common causes of rapidly progressive dementia worldwide. However, because of the variety of its clinical presentations that mimic other cognitive disorders, the certain diagnosis in public hospitals is still limited. Therefore, this study provides more information about disease manifestations and clinical courses of probable sCJD cases in Thailand.

METHOD

The retrospective cross-sectional study of probable sCJD patients visited Neurological Institute of Thailand during 2018-2023 was conducted. Probable sCJD cases were diagnosed according to 2017 International CJD Surveillance Network Diagnostic Criteria. Demographic data, clinical presentations, brain MRI, EEG, CSF analyses, and clinical course were reviewed.

RESULT

The total of 17 probable sCJD cases were studied. There was 11 female (64.71%) with the median age of 62 (IQR 14.5) years. The median onset of symptom was 2 months (IQR 2) before hospital visit, which cognitive impairment is the most common first presentation (29.41%) followed by ataxia (23.53%) and visual disturbances (17.65%). Myoclonus was found in most patients during the disease course at 2 weeks prior to diagnosis. Most patients had typical high signal intensities at both caudate/putamen and cortical regions (76.47%). Generalized periodic discharges with triphasic morphology of 1-1.5 Hz were found in 11/14 patients with EEG results (78.57%). Most patients progressed to akinetic mutism and bed-bound within 1 month after hospital visit.

CONCLUSION

sCJD has diverse clinical presentations that resemble other cognitive disorders. Detailed assessment of signs and symptoms together with proper investigations could help to differentiate this condition in resource-limit setting.

Short communication: Evaluating roles of plasma glial fibrillary acidic protein as Alzheimer's disease biomarker in real-world multi-center memory clinics in Thailand

The roles of reactive astrocytes in Alzheimer's disease (AD) and the correlation between plasma glial fibrillary acidic protein (GFAP) and amyloid-β are emerging. Among 133 patients with cognitive complaints from multi-center memory clinics in Thailand, 73 had AD as defined either by cerebrospinal fluid core biomarkers or amyloid PET. Plasma GFAP demonstrated an AUC of 0.74 (95%CI: 0.65-0.83) for detecting AD and showed large effects on identifying AD status with Cohen's d = 0.81 (95%CI 0.44-1.18). LOESS regression illustrated that plasma GFAP increased from the early stages of AD. Plasma GFAP has potential applications across diverse populations.

The Bayesian approach for real-world implementation of plasma p-tau217 in tertiary care memory clinics in Thailand

INTRODUCTION

Plasma phosphorylated tau (p-tau)217 is a promising biomarker for Alzheimer's disease (AD) diagnosis, but its clinical implementation remains challenging. We propose a strategy based on Bayes' theorem and test it in real-life memory clinics.

METHODS

Memory clinic patients were evaluated by neurocognitive specialists for prespecified diagnosis and subsequently underwent blood collection for p-tau217, cerebrospinal fluid, or amyloid positron emission tomography. Using cross-validation, the Bayesian approach (pretest probability × individualized likelihood ratio) was compared to other models for AD diagnosis.

RESULTS

The Bayesian strategy demonstrated an area under the receiver operating characteristic curve (AUC) of 0.98 (95% confidence interval [CI]: 0.96-1.0), significantly outperforming multivariable logistic regression (p-tau217, age, apolipoprotein E; AUC 0.95, p = 0.024) and p-tau217 alone (AUC = 0.94, p = 0.007). When applying the two-threshold approach, the Bayesian strategy yielded an accuracy of 0.94 (95% CI: 0.88-1.0) without requiring confirmatory tests in 62.9% of the iterations.

DISCUSSION

The Bayesian strategy offers an effective and flexible approach to address the limitations of plasma p-tau217 in clinical practice.

HIGHLIGHTS

Incorporating pretest probability into the interpretation of plasma phosphorylated tau (p-tau)217 improves the diagnostic performance significantly. The strategy could obviate the need for confirmatory testing in most of the patients. Plasma p-tau217 proves useful as a biomarker for Alzheimer's disease in low- and middle-income country such as Thailand.