Phase I clinical trial of intracerebroventricular transplantation of allogeneic neural stem cells in people with progressive multiple sclerosis

We report the analysis of 1 year of data from the first cohort of 15 patients enrolled in an open-label, first-in-human, dose-escalation phase I study (ClinicalTrials.gov: NCT03282760, EudraCT2015-004855-37) to determine the feasibility, safety, and tolerability of the transplantation of allogeneic human neural stem/progenitor cells (hNSCs) for the treatment of secondary progressive multiple sclerosis. Participants were treated with hNSCs delivered via intracerebroventricular injection in combination with an immunosuppressive regimen. No treatment-related deaths nor serious adverse events (AEs) were observed. All participants displayed stability of clinical and laboratory outcomes, as well as lesion load and brain activity (MRI), compared with the study entry. Longitudinal metabolomics and lipidomics of biological fluids identified time- and dose-dependent responses with increased levels of acyl-carnitines and fatty acids in the cerebrospinal fluid (CSF). The absence of AEs and the stability of functional and structural outcomes are reassuring and represent a milestone for the safe translation of stem cells into regenerative medicines.

Factors Associated with Delirium in COVID-19 Patients and Their Outcome: A Single-Center Cohort Study

Background: A significant proportion of patients with coronavirus disease 2019 (COVID-19) suffer from delirium during hospitalization. This single-center observational study investigates the occurrence of delirium, the associated risk factors and its impact on in-hospital mortality in an Italian cohort of COVID 19 inpatients. Methods: Data were collected in the COVID units of a general medical hospital in the South of Italy. Socio-demographic, clinical and pharmacological features were collected. Diagnosis of delirium was based on a two-step approach according to 4AT criteria and DSM5 criteria. Outcomes were: dates of hospital discharge, Intensive Care Unit (ICU) admission, or death, whichever came first. Univariable and multivariable proportional hazards Cox regression models were estimated, and risks were reported as hazard ratios (HR) along with their 95% confidence intervals (95% CI). Results: A total of 47/214 patients (22%) were diagnosed with delirium (21 hypoactive, 15 hyperactive, and 11 mixed). In the multivariable model, four independent variables were independently associated with the presence of delirium: dementia, followed by age at admission, C-reactive protein (CRP), and Glasgow Coma Scale. In turn, delirium was the strongest independent predictor of death/admission to ICU (composite outcome), followed by Charlson Index (not including dementia), CRP, and neutrophil-to-lymphocyte ratio. The probability of reaching the composite outcome was higher for patients with the hypoactive subtype than for those with the hyperactive subtype. Conclusions: Delirium was the strongest predictor of poor outcome in COVID-19 patients, especially in the hypoactive subtype. Several clinical features and inflammatory markers were associated with the increased risk of its occurrence. The early recognition of these factors may help clinicians to select patients who would benefit from both non-pharmacological and pharmacological interventions in order to prevent delirium, and in turn, reduce the risk of admission to ICU or death.

The Impact of Lifetime Alcohol and Cigarette Smoking Loads on Amyotrophic Lateral Sclerosis Progression: A Cross-Sectional Study

Background—Amyotrophic lateral sclerosis (ALS) is a devastating and untreatable motor neuron disease; smoking and alcohol drinking may impact its progression rate. Objective—To ascertain the influence of smoking and alcohol consumption on ALS progression rates. Methods—Cross-sectional multicenter study, including 241 consecutive patients (145 males); mean age at onset was 59.9 ± 11.8 years. Cigarette smoking and alcohol consumption data were collected at recruitment through a validated questionnaire. Patients were categorized into three groups according to ΔFS (derived from the ALS Functional Rating Scale-Revised and disease duration from onset): slow (n = 81), intermediate (80), and fast progressors (80). Results—Current smokers accounted for 44 (18.3%) of the participants, former smokers accounted for 10 (4.1%), and non-smokers accounted for 187 (77.6%). The age of ALS onset was lower in current smokers than non-smokers, and the ΔFS was slightly, although not significantly, higher for smokers of >14 cigarettes/day. Current alcohol drinkers accounted for 147 (61.0%) of the participants, former drinkers accounted for 5 (2.1%), and non-drinkers accounted for 89 (36.9%). The log(ΔFS) was weakly correlated only with the duration of alcohol consumption (p = 0.028), but not with the mean number of drinks/day or the drink-years. Conclusions: This cross-sectional multicenter study suggested a possible minor role for smoking in worsening disease progression. A possible interaction with alcohol drinking was suggested.

Reliability of clinical diagnosis of dystonia

BACKGROUND

There is only one small single-center study on the reliability of the diagnosis of focal dystonia. The aim of this study was to assess the inter-rater reliability of dystonia diagnosis among neurologists with different professional experience.

METHODS

Twenty-nine adults (18 with dystonia, 9 with other movement disorders, and 2 healthy controls) were videotaped while undergoing neurological examination and during the process of collecting information on the history of their condition. Each case was diagnosed by 35 blind raters (12 general neurologists, 21 neurology residents, and 2 experts in movement disorders) from different hospitals. Sensitivity and specificity were calculated confronting raters with the gold standard (the caring physician). Inter-rater agreement was measured by the Kappa statistic.

RESULTS

Specificity and sensitivity were 95.2 and 66.7%, 76.3 and 75.2%, 84.6 and 71.6% for experts, general neurologists, and residents, respectively. Kappa values on dystonia diagnosis ranged from 0.30 to 0.46. The agreement was moderate for experts and residents (0.40-0.60) and fair for general neurologists (0.20-0.40). Kappas were the highest among experts for cranial and laryngeal dystonia (0.61-1), but not for cervical dystonia (0.37).

CONCLUSIONS

The diagnosis of dystonia is difficult and only partially mirrors a physician's background.

Long-term functional outcome and health status of patients with critical illness polyneuromyopathy

OBJECTIVE

The aim of this study was to investigate the long-term functional outcome and health status of patients with critical illness polyneuromyopathy (CIPNM).

METHOD AND SUBJECTS

One hundred and twenty-four consecutive survival intensive care unit patients admitted to a neuro-rehabilitation Unit from January 2003 to December 2007 were identified. Patients with proven CIPNM by the electromyography were prospectively followed. The Barthel and modified Rankin Scales (mRS) were administered to all patients at baseline, discharge and follow-up. The SF-36 questionnaire was administered to ascertain health status. Each patient underwent an individually tailored rehabilitation therapy.

RESULTS

Forty-two subjects (23M, 19F, mean age 58.4 ± 13.9) were enrolled. Of these, 30 patients were diagnosed electrophysiologically with CIP, six with critical illness myopathy (CIM) and six with a finding combination of CIP and CIM (CIP/CIM) subtype. The mean Barthel scores at baseline, discharge and follow-up were 16.7 ± 8.6, 81.7 ± 16.4 and 86.7 ± 15.9 (P < 0.001) and the median mRS scores were 5 (IQR: 5-5), 3 (IQR: 0-5) and 1 (IQR: 0-5). The mean length of neuro-rehabilitation stay was 76.2 ± 28.1 days. The SF-36 questionnaire administered at follow-up (mean 31.7 ± 15.8 months), showed significantly lower values compared to Italian normative.

CONCLUSION

ICU patients with CIPNM treated in a neuro-rehabilitation setting resulted in a good functional outcome. Despite complete recovery, patients with CIPNM experienced difficulties in health status.

Prevalence of primary focal or segmental dystonia in adults in the district of foggia, southern Italy: a service-based study

BACKGROUND

Primary focal or segmental dystonia is a rare clinical condition including early-onset dystonia, which has the tendency to generalize, and late-onset dystonia, which may be focal or segmental. The prevalence of late-onset dystonia ranges from 30 to 7,320 cases per million, but no data are available in Italy.

METHODS

A service-based study was conducted in the period 1 January 2001 through 31 December 2002 in the administrative district of Foggia, southern Italy (population 541,653). Cases were traced through hospital discharge diagnosis, botulinum toxin services, day hospital access, ear, nose and throat, ophthalmology and orthopedic surgery specialists, and territorial outpatient services. Inclusion criteria were age 17 years or older, residency in the study area and a diagnosis of primary focal/segmental dystonia.

RESULTS

A total of 69 patients were included, giving a crude prevalence of 127.4 per 1,000,000 (women: 146.4; men: 107.0; age 18-34 years: 39.2; 35-54 years: 98.7; 55-74 years: 273.6; 75+ years: 163.3). The standardized rate was 137.5 (95% confidence interval 107.0-174.6). Blepharospasm was the commonest clinical condition (prevalence 68.2), followed by cervical dystonia (prevalence 44.8).

CONCLUSION

The prevalence of primary focal or segmental dystonia in Italy is in keeping with several other reports, but is lower than in studies performed in northern Europe, Minnesota, USA, and Japan. The difference in our results may be mostly explained by misdiagnosis, underascertainment of cases and a fairly limited observation period.

CT of 338 active professional boxers

Computed tomography (CT) was performed in 338 active professional boxers. CT scans were abnormal in 25 boxers (7%). The most common CT abnormality was brain atrophy (22 cases). Focal lesions of low attenuation consistent with posttraumatic encephalomalacia were noted in only three boxers. Boxers with abnormal CT scans did not differ from those with borderline or normal CT scans in regard to age, win-loss record, number of bouts, or history of an abnormal electroencephalogram. Thirty-seven boxers with borderline CT scans (49%) and 17 with abnormal CT scans (68%) reported a previous technical knockout (TKO) or knockout (KO), compared with only 89 (37%) of the 238 boxers with normal CT scans (P < .01). Brain atrophy was noted more frequently in boxers with a large cavum septum pellucidum (CSP) than in those with a small or no CSP (P < .05). Boxers with abnormal or borderline CT scans who experienced a TKO or KO were slightly older than those with normal CT scans and a history of a TKO or KO (P < .05).

Antiepileptic drugs as 'tracers' of disease. A calculation of the prevalence of epilepsy through an analysis of drug consumption. The Group for the Study of Epilepsy in General Practice

Antiepileptic drug (AED) consumption, expressed according to a standardized measurement of the average daily doses of each active principle (the defined daily dose, DDD), was assessed as a source of morbidity data to calculate the prevalence of AED takers. In a population of 51,220 from three areas in Italy (Arcisate, Treviglio, S. Giovanni Rotondo) all the patients treated with AEDs, traced by the local general practitioners, were examined by a neurologist. The diagnosis of epilepsy was confirmed in 199 of 223 AED takers, giving an overall prevalence rate of 3.94 per 1,000 (Arcisate 3.96; Treviglio 4.04; S. Giovanni Rotondo 3.89). There was a significant overlap between the observed and expected number of AED takers (the latter obtained from regional sales and expressed in DDD). Prevalence rates calculated from drug sales were 5.58 in Arcisate and 6.11 in Treviglio. The ratio of patients with epilepsy to AED takers in the two areas was 0.7 and corresponded to the mean proportion of AEDs prescribed for epilepsy in the years 1983-1988 by a sample of Italian physicians. Although the prevalence rate calculated from AED sales tends to approximate that of treated epilepsy, AEDs can be reasonably used as 'tracers' of disease for the easy access to drug sales in Italy, the appropriateness of the DDD as a standard measure of the daily doses of AED, the steady pattern of consumption, the comparability of data covering different areas and periods, and the stable proportion of drugs delivered for epilepsy.

Hypothyroidism and polyneuropathy

The prevalence and characteristics of polyneuropathy were assessed using standard clinical and electrophysiological criteria in 39 consecutive outpatients with primary hypothyroidism, 15 of whom were previously untreated. Subjective complaints, mainly paraesthesiae, were recorded from 25 cases (64%) and objective findings supporting a clinical diagnosis of polyneuropathy were present in 13 (33%). Using standard electrophysiological criteria, a definite diagnosis of polyneuropathy was made in 28 cases (72%). The commonest sites of abnormal nerve conduction were the sensory nerves, especially the sural nerve. Polyneuropathy was generally mild. None of the clinical and biochemical indicators of hypothyroidism were significantly correlated with the electrophysiological signs of peripheral nerve impairment or the diagnosis of polyneuropathy.