Incidence of Seizure and Associated Risk Factors in Patients in the Medical Intensive Care Unit (ICU) at Memorial Sloan Kettering Cancer Center (MSK) from 2016-2017

Background: Seizures and status epilepticus are common neurologic complications in the intensive care unit (ICU) but the incidence in a cancer ICU is unknown. It is important to understand seizure risk factors in cancer patients to properly diagnose the seizure type to ensure appropriate therapy. Methods: We identified patients admitted to the medical ICU at Memorial Sloan Kettering Cancer Center (MSK) from January 2016 to December 2017 who had continuous or routine electroencephalography (EEG) and identified clinical and electrographic seizures by chart review. Results: Of the 1059 patients admitted to the ICU between 2016 and 2017, 50 patients had clinical and/or electrographic seizures (incidence of 4.7%, 95% CI: 3.4-6.0). The incidences of clinical and electrographic seizure were 4.1% and 1.1%, respectively. In a multivariable stepwise regression model, history of seizure (OR: 2.9, 95% CI: 1.1-7.8, P: .03), brain metastasis (OR: 2.5, 95% CI: 1.1-5.8, P: .03), vasopressor requirement (OR: 2.2, 95% CI: 1.0-4.9, P: .05), and age < 65 (2.4, 95% CI: 1.2-5.0, P: .02) were associated with increased risk of seizure (either clinical or electrographic). Obtaining continuous EEG instead of routine EEG increased the yield of seizure detection significantly (OR: 3.9, 95% CI: 1.3-11.1, P: .01). No chemotherapy in the past 30 days, no antibiotic use, vasopressor requirement, and having a brain tumor increased risk of electrographic seizure. Length of continuous EEG > 24 h significantly increased the chances of both clinical and electrographic seizure detection, (OR: 2.6 [95% CI: 1.2-5.7] and 15.0 [95% CI: 2.7-82.5], respectively). Conclusions: We identified known and cancer-related risk factors which can aid clinicians in diagnosing seizures in cancer ICUs. Long-term video EEG monitoring should be considered, particularly given the treatable and reversible nature of seizures.

P-430 Sperm genomic integrity, telomere dynamics and gene expression in recurrent implantation failure

Study question

Does sperm affect the implantation and early embryogenesis?

Summary answer

Deranged sperm genomic integrity, limited repair mechanisms, aberrant gene expression have the potential to be transmitted to developing embryo and affect implantation and embryonic development.

What is known already

The terminally differentiated, transcriptionally quiscent sperm cells are vulnerable to a host of factors which might affect its function. The spermatozoa with truncated repair mechanisms have the potential to fertilize the oocyte, but eventually result in high rates of pre and post implantation losses. Oxidative stress, deranged genomic integrity, aberrant gene expression in the sperm cell has the potential to affect fertilisation potential, implantation and embryonic viability. This has been seen to be correlated with decreased fertilisation, clevage rates and blastocyst development and thus impaired implantation rates.

Study design, size, duration

A case control study of 75 men from infertile couples who had recurrent implantation failure (RIF) in IVF cycles and 75 fertile controls at AIIMS, New Delhi, India. Study duration was 2 years.

Participants/materials, setting, methods

Semen samples from men from couples who had RIF were analyzed as per WHO 2010. Sperm reactive oxygen species (ROS) and DNA fragmentation index (DFI) was assessed by chemiluminiscence and sperm chromatin structure assay (SCSA) respectively. Relative sperm telomere length was evaluated from sperm DNA by q-PCR analysis. The expression of genes pertinent for early embryonic development was done by qPCR. The relative quantification was done after normalizing with GAPDH and β-actin by 2-ΔΔCt method.

Main results and the role of chance

Seminal ROS levels (RLU/sec/million sperm) were seen to be significantly higher [57.75 (10.1-1186.9)] in cases with respect to controls [16.7(1.15-53.9)] (p &lt; 0.001***). The mean DFI of men undergoing ART was significantly higher (37.7 ± 5.7) vs 23.2 ± 4.6%; p &lt; 0.001***) in cases as compared to controls. ROS and DFI levels correlated negatively with sperm concentration and progressive motility (p &lt; 0.001***). We analyzed the expression of FOXG1, SOX3, STAT4, RPS6, RBM9, RPL10A, RPS17, RPL29, WNT5A, HSP90, TOMM7, EIF5A genes. The expression of SOX3, RBM9, WNT5A, HSP90, TOMM7, and EIF5A showed a significant difference from control levels. The relative sperm telomere length was found to be significantly lower in RIF patients as compared to controls (p &lt; 0.001***).

Limitations, reasons for caution

The current study was a case control study and lacked randomization and also is limited by low sample size. There is a lack of stratification in the enrollment of participants due to difference in specific risk of occurrence and varied clinical history.

Wider implications of the findings

The analysis of spermatozoal gene expression is important for understanding the sperm differentiation, fertilization and early embryonic events. Correlation with oxidative stress, genomic integrity and telomere length may help in regulationof gene expression. It may help in establishing sperm gene expression as a potential biomarker.

Trial registration number

Not applicable

POS0566 PREDICTORS OF RESPONSE TO METHOTREXATE MONOTHERAPY IN ACTIVE RHEUMATOID ARTHRITIS: RESULTS FROM A MULTICENTRE, RANDOMIZED CONTROLLED TRIAL (MEIRA)

Background

Methotrexate (MTX) is the gold standard, first-line therapy for rheumatoid arthritis (RA). However, not all patients respond to MTX, and the predictors of its response or non-response have not yet been reliably identified. Identification of these predictors will facilitate personalized therapeutic choices, and improve patient outcomes.

Objectives

To identify the clinico-laboratory predictors of response to MTX monotherapy in active RA.

Methods

This study included patients with active RA (SJC≥2 and TJC≥4) aged 18-55 years, with disease duration <5 years, who were not receiving DMARDs (except HCQ and low-dose prednisolone) and had been enrolled in the multicentre, parallel group RCT comparing two different MTX escalation strategies in RA (MEIRA)1. All these patients received MTX monotherapy which was started at 15 mg/week, escalated to 25 mg/week by 4-8 weeks, and continued till 16 weeks. MTX response was defined as EULAR good or moderate response (based on DAS28-CRP-3v) at 16 weeks. Stepwise, multivariable logistic regression was done using key demographic (age, gender, BMI, comorbidities), clinical (disease duration, DAS28, HAQ), and laboratory parameters (RF, anti-CCP, ESR, CRP, RBC MTX-polyglutamates 1-4, IL-6, MMP-3) as independent variables to identify predictors of MTX response. A two-tailed p-value <0.05 was used for defining statistical significance. (Trial Reg: CTRI/2018/12/016549)

Results

Out of a total of 178 included patients [84% females, mean age 40 (9) years, mean DAS28-CRP=5.4 (1.1)], 113 (63.5%) were classified as MTX responders at 16 weeks. Age (OR=0.95, p=0.01), BMI (OR=1.12, p=0.006), and RF (OR=0.34, p=0.045) were found to be independent predictors of MTX response on multivariable analysis (Table 1). On sensitivity analysis with DAS28-ESR-based EULAR response, age (OR=0.94, p=0.003) and RF (OR=0.42, p=0.059) were replicated as independent predictors of MTX response, in addition to pre-treatment swollen joint count (OR=0.94, p=0.05).

Table 1.

Results of multivariable logistic regression analysis for prediction of response (as defined by DAS28-CRP-based EULAR good or moderate response) to methotrexate monotherapy in RA

VariableOR (unadjusted)Unadjusted p-valueOR (adjusted)Adjusted p-valueAge0.97 (0.93-1.002)0.060.95 (0.91-0.99)0.01Male sex0.78 (0.35-1.76)0.55-BMI1.1 (1.02-1.19)0.011.12 (1.03-1.22)0.006Presence of comorbidities0.67 (0.31-1.44)0.31-Disease duration0.98 (0.79-1.22)0.87-Baseline DAS281.1 (0.81-1.49)0.54-Baseline HAQ1.04 (0.66-1.64)0.86-Baseline TJC1.01 (0.96-1.05)0.72-Baseline SJC0.97 (0.91-1.02)0.24-Baseline ESR1.01 (1.00-1.02)0.27-Baseline CRP1.00 (0.99-1.01)0.85-RF positive0.31 (0.11-0.85)0.020.34 (0.12-0.98)0.045Anti-CCP positive0.73 (0.27-1.99)0.54-MTX PG1 (16 weeks)0.99 (0.94-1.04)0.69-MTX PG2 (16 weeks)0.98 (0.95-1.02)0.37-MTX PG3 (16 weeks)0.99 (0.96-1.02)0.43-MTX PG4 (16 weeks)0.99 (0.95-1.03)0.62-Serum IL-6 (baseline)0.98 (0.95-1.02)0.33-Serum MMP-3 (baseline)1.00 (1.00-1.00)0.48-

BMI= Body Mass Index, CCP= Cyclic Citrullinated Peptides, CRP= C-reactive protein, DAS= Disease Activity Score, ESR= Erythrocyte Sedimentation Rate, HAQ= Health Assessment Questionnaire, MTX= Methotrexate, PG= polyglutamate, OR=Odds Ratio, RF=Rheumatoid Factor, SJC= Swollen Joint Count, TJC= Tender Joint Count

Note: Only variables with p-value <0.2 on univariable analysis were included in the multivariable analysis.

Conclusion

Younger age, RF negativity, higher BMI, and lower pre-treatment swollen joint count are potential predictors of response to MTX monotherapy in RA.

References

[1]Jain S, Dhir V, Aggarwal A, et al. Comparison of two dose escalation strategies of methotrexate in active rheumatoid arthritis: a multicentre, parallel group, randomised controlled trial. Ann Rheum Dis. 2021;80(11):1376-1384.

Disclosure of Interests

None declared.

Polysaccharide conjugates surpass monosaccharide ligands in hepatospecific targeting - Synthesis and comparative in silico and in vitro assessment

Ligands with the polysaccharide headgroups have been recently reported by our group to possess enhanced interaction with asialoglycoprotein receptor (ASGPR) in silico as compared to ligands having galactose moieties. This enhanced interaction is a result of the polymer's backbone support in anchoring the ligand in a specific orientation within the bilayer. In this paper, we have attempted to provide an in vitro proof of concept by performing a comparative evaluation of polysaccharide and monosaccharide-based ligands. Docking was performed to understand interaction with ASGPR in silico. Agarose and galactose conjugates with behenic acid were synthesized, purified, and characterized to yield biocompatible hepatospecific ligands which were incorporated into nanoliposomes. Cellular internalization of these targeted liposomes was studied using confocal microscopy and flow cytometry. The toxicity potential was assessed in vivo. Results indicated that the polysaccharide-based ligand increased cellular uptake due to better interaction with the receptor as compared to ligand bearing a single galactose group. In addition to developing novel liver targeting ligands, the study also established proof of concept that has been suggested by earlier in silico investigations. The approach can be used to design targeting ligands and develop formulations with improved targeting efficacy.

Abstract 703: An inflammatory leptomeningeal signature in cancer patients with neurologic manifestations of COVID-19

Background: COVID-19 is associated with a wide spectrum of neurologic manifestations, which can emerge weeks to months after the initial infection. Cancer patients are at a heightened risk of severe infections due to their immunocompromised status. Leading hypotheses predict that SARS-CoV-2 neuroinvasion or neurologic toxicity from the systemic cytokine storm may account for neurologic dysfunction.

Methods: We prospectively evaluated cancer patients with confirmed SARS-CoV-2 infection and subsequent neurologic manifestations at an NCI-designated cancer center. Evaluations included neurologic examinations, brain imaging, electroencephalogram, and cerebrospinal fluid (CSF) analysis for SARS-CoV-2 detection by RT-PCR for viral RNA and ELISA for nucleocapsid (N) and spike (S2) proteins. Additional proteomic analysis compared the CSF of patients with COVID-19 (CoV+) to cancer- and brain metastasis-matched COVID-19-negative controls (CoV-), and to patients with other cancer-associated neuroinflammatory conditions, including immune effector cell-associated neurotoxicity syndrome (ICANS) and autoimmune encephalitis.

Results: Between May and July 2020, we evaluated 18 COVID-19-positive cancer patients with a wide range of solid tumor and hematologic malignancies. Thirteen (72.2%) of our patients received tumor-directed treatment within 30 days of SARS-CoV-2 infection. Neurologic diagnoses include protracted critical care delirium (N=10), limbic encephalitis (N=4), refractory headaches (N=2), rhombencephalitis (N=1), and large-territory infarctions (N=1). A median delay of 19 days (range 0-77) existed between onset of respiratory symptoms and neurologic manifestations. Among 13 patients who underwent CSF analysis, there was no evidence of SARS-CoV-2 neuroinvasion by RT-PCR in the CSF (N=13) or by N and S2 protein detection (N=10). Targeted proteomic analysis detected a significant accumulation of IL-6 and -8, IFN-gamma, CXCL-1, -6, -9, -10, and -11, CCL-8 and -20, MMP-10 and 4E-BP1 in the CSF of CoV+ patients (N=10) relative to matched CoV- controls (pooled, p=0.029). Combined analysis of these 12 inflammatory mediators revealed CoV+ cytokine levels approaching that of ICANS. CSF MMP-10, a marker of neurodegeneration, correlated with neurologic dysfunction by Karnofsky performance status (p=0.011) and by disability rating scale (p=0.086) at the time of lumbar puncture.

Conclusion: A durable accumulation of IFN-gamma-mediated cytokines is detected in the CSF of cancer patients with neurologic manifestations of COVID-19, in the absence of detectable neuroinvasion. We hypothesize that cytokine-mediated neuroinflammation is responsible for the prolonged neurologic sequela of COVID-19. Our findings suggest a potential role for anti-inflammatory treatments in the management of such patients.

Citation Format: Jessica A. Wilcox, Jan Remsik, N. Esther Babady, Tracy A. McMillen, Behroze A. Vachha, Neil A. Halpern, Vikram Dhawan, Marc Rosenblum, Christine A. Iacobuzio-Donahue, Edward K. Avila, Bianca Santomasso, Adrienne Boire. An inflammatory leptomeningeal signature in cancer patients with neurologic manifestations of COVID-19 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 703.

Critically ill patients with severe immune checkpoint inhibitor related neurotoxicity: A multi-center case series

PURPOSE

Serious immune checkpoint inhibitor (ICI)-related neurotoxicity is rare. There is limited data on the specifics of care and outcomes of patients with severe neurological immune related adverse events (NirAEs) admitted to the Intensive Care Unit (ICU).

MATERIALS AND METHODS

Retrospective study of patients with severe NirAEs admitted to the ICU at 3 academic centers between January 2016 and December 2018. Clinical data collected included ICI exposure, type of NirAE (central [CNS] or peripheral nervous system [PNS) disorders), and patient outcomes including neurological recovery and mortality.

RESULTS

Seventeen patients developed severe NirAEs. Eight patients presented with PNS disorders; 6 with myasthenia gravis (MG), 1 had a combination of MG and polyneuropathy and 1 had Guillain-Barre syndrome. Nine patients had CNS disorders (6 seizures and 5 had concomitant encephalopathy. During ICU admission, 65% of patients required mechanical ventilation, 35% vasopressors, and 18% renal replacement therapy. The median ICU and hospital length of stay were 7 (2-36) and 18 (4-80) days, respectively. Hospital mortality was 29%. At hospital discharge, 18% of patients made a full neurologic recovery, 41% partial recovery, and 12% did not recover.

CONCLUSION

Severe NirAEs while uncommon, can be serious or even life-threatening if not diagnosed and treated early.

AB0276 HOW FAST CAN METHOTREXATE BE ESCALATED IN RHEUMATOID ARTHRITIS? A MULTICENTRE, PARALLEL-GROUP RANDOMIZED CONTROLLED TRIAL (MEIRA)

Background:

Literature regarding the optimal dose escalation strategy of methotrexate (MTX) in RA is scant and ambiguous (1). Concerns regarding the safety of rapid escalation may lead to delayed attainment of the optimal dose and treatment target.

Objectives:

To compare the efficacy, safety and tolerability of fast versus usual dose escalation of oral MTX in RA.

Methods:

This multicenter, open-label (assessor blinded) RCT included patients with active RA (SJC≥2 and TJC≥4) aged 18-55 years, not on DMARDs (except HCQ and/or low-dose prednisolone) and with disease duration <5 years. Patients were randomized 1:1 into two groups with the same starting dose of oral MTX (15 mg/week), but escalated either by 5 mg every 2 weeks (fast escalation group) or 5 mg every 4 weeks (usual escalation group), till a maximum of 25 mg/wk. Primary outcome was proportion of EULAR good responders at 16 weeks. Secondary outcomes were change in DAS28-3 and EULAR responders (good or moderate) at 8 and 16 weeks, change in Indian HAQ at 16 weeks, and symptomatic (questionnaire based) and laboratory adverse effects over 16 weeks. RBC MTX polyglutamate-3 levels were measured using HPLC in both groups. There was an open-label extension phase till 24 weeks (use of other DMARDs was permitted beyond 16 weeks if target was not met), and DAS28-3 at 24 weeks was compared.

Trial Reg: CTRI/2018/12/016549

Results:

178 patients (mean age 39.8 (8.6) years, 84% females) with mean disease duration of 1.9 (1.4) years were randomized (89 in each group). Mean DAS28ESR-3 and DAS28CRP-3 at enrollment were 6.3 (0.9) and 5.4 (1.1). At 16 weeks, there was no significant difference in good EULAR response by DAS28ESR-3 (5.6, 7.9%, p=0.9) or DAS28CRP-3 (28.1, 22.5%, p=0.8) between the two groups (Figure 1). The change in DAS28-ESR-3 at 8, 16 and 24 weeks (or by DASCRP-3, not shown) and improvement in HAQ at 16 weeks were also not significantly different (Table 1). Notably, there was no significant difference in symptomatic GI or CNS adverse effects, incidence of cytopenia, transaminitis or rates of drug discontinuation. RBC MTX polyglutamate-3 levels at 8 and 16 weeks were also similar (Table 1).

Table 1.

Key secondary efficacy and safety outcomes

ParameterUsualFastp-valueEfficacyDelta DAS28-ESR-3 (Mean±SD) -8 wk  -ITT (n=178)-0.9 ± 1.0-0.8 ± 0.90.5  -PP (n=139)-1.2 ± 1.0-1.1 ± 1.00.5 -16 wk  -ITT-1.3 ± 1.1-1.3 ± 1.00.9  -PP-1.6 ± 1.1-1.6 ± 0.91 -24 wk  -ITT-1.6 ± 1.3-1.5 ± 1.10.3  -PP-2.1 ± 1.2-1.8 ± 1.10.14Delta Indian HAQ (16 wk)-0.7 ± 0.6-0.8 ± 0.60.2Adverse effectsSerious AE00-Death00-Symptomatic AE ever* n (%)Vomiting7 (8)7 (8)1Nausea22 (26)26 (30)0.5Stomach ache16 (19)17 (20)0.9Loss of appetite/bad taste21 (25)27 (31)0.3Lethargy20 (24)21 (25)1Dizziness19 (23)16 (19)0.5Irritability/anxiety14 (16)14 (16)1Laboratory AE ever* [n/N times done (%)]Transaminitis episodes (>40IU/L)52/224 (23)52/219 (24)0.9  -Significant (>80 IU/L)5/224 (2)8/219 (4)0.4Thrombocytopenia episodes (<150000/uL)10/224 (5)13/218 (6)0.5 -Significant (<100000/uL)2/224 (1)2/218 (1)1Leucopenia episodes (<4000/uL)2/224 (1)3/220 (1.5)0.8 -Significant (<3500/uL)1/224 (0.5)2/220 (1)0.8Methotrexate levelsMTX-polyglutamate-3 (nmol/L)-8 wk25.8 ± 10.526.9 ± 13.60.6-16 wk40.7 ± 20.940.1 ± 23.40.9

*Ever=any time during the study

ITT= intention-to-treat, PP=per-protocol, AE=adverse effect

Figure 1.

EULAR response and change in DAS28ESR-3 over time

Conclusion:

A faster escalation of MTX (5 mg every 2 weeks) reaching 25 mg/week by 4 weeks did not have a significantly higher rate of adverse effects (symptomatic or laboratory) compared to an escalation by 5 mg every 4 weeks. Although not more efficacious, it may shorten the time to recognize MTX failure, and optimize treat-to-target.

References:

[1]Visser K, Katchamart W, Loza E, et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on RA: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis. 2009;68(7):1086–93

Disclosure of Interests:

None declared

Inflammatory Leptomeningeal Cytokines Mediate COVID-19 Neurologic Symptoms in Cancer Patients

SARS-CoV-2 infection induces a wide spectrum of neurologic dysfunction that emerges weeks after the acute respiratory infection. To better understand this pathology, we prospectively analyzed of a cohort of cancer patients with neurologic manifestations of COVID-19, including a targeted proteomics analysis of the cerebrospinal fluid. We find that cancer patients with neurologic sequelae of COVID-19 harbor leptomeningeal inflammatory cytokines in the absence of viral neuroinvasion. The majority of these inflammatory mediators are driven by type II interferon and are known to induce neuronal injury in other disease states. In these patients, levels of matrix metalloproteinase-10 within the spinal fluid correlate with the degree of neurologic dysfunction. Furthermore, this neuroinflammatory process persists weeks after convalescence from acute respiratory infection. These prolonged neurologic sequelae following systemic cytokine release syndrome lead to long-term neurocognitive dysfunction. Our findings suggest a role for anti-inflammatory treatment(s) in the management of neurologic complications of COVID-19 infection.

Inflammatory leptomeningeal cytokines mediate delayed COVID-19 encephalopathy

SARS-CoV-2 infection induces a wide spectrum of neurologic dysfunction. Here we show that a particularly vulnerable population with neurologic manifestations of COVID-19 harbor an influx of inflammatory cytokines within the cerebrospinal fluid in the absence of viral neuro-invasion. The majority of these inflammatory mediators are driven by type 2 interferon and are known to induce neuronal injury in other disease models. Levels of matrix metalloproteinase-10 within the spinal fluid correlate with the degree of neurologic dysfunction. Furthermore, this neuroinflammatory process persists weeks following convalescence from the acute respiratory infection. These prolonged neurologic sequelae following a systemic cytokine release syndrome lead to long-term neurocognitive dysfunction with a wide range of phenotypes.

Using tongue depressors to aid cord localization during collagenase injection for Dupuytren disease

The aim of this paper was to introduce a simple and effective method to aid in isolation and stabilization of Dupuytren cords for collagenase injection. Tongue depressors were used to isolate and stabilize the cord during the injection procedure. The area to be injected was sterilely prepared. An assistant was then directed to place a tongue depressor on both sides of the cord. A total of 35 patients with Dupuytren disease were treated. Follow-up lasted two years. Post-operative Disabilities of the Arm, Shoulder and Hand (DASH) scores was 4±2. Health-related quality of life measured with the EQ-5D index was 0.89±0.4. Recurrence rates of metacarpophalangeal joint and proximal interphalangeal joint were 11% and 14% respectively, using a flexion contracture of 20° to define recurrence. Collagenase treatment using a modified injection method with the aid of tongue depressors are a safe, effective way to treat Dupuytren contractures of the fingers. The technique can isolate the cord, which improves visualization of the cord. It may allow improved accuracy with needle placement and helps to decrease the complications and recurrence.

Stearylated cycloarginine nanosystems for intracellular delivery – simulations, formulation and proof of concept

Novel cationic agent liposomes performed better in silico translating in higher cellular uptake with reduced toxicity.

Network correlates of disease severity in multiple system atrophy

OBJECTIVE

Multiple system atrophy (MSA), the most common of the atypical parkinsonian disorders, is characterized by the presence of an abnormal spatial covariance pattern in resting state metabolic brain images from patients with this disease. Nonetheless, the potential utility of this pattern as a MSA biomarker is contingent upon its specificity for this disorder and its relationship to clinical disability in individual patients.

METHODS

We used [(18)F]fluorodeoxyglucose PET to study 33 patients with MSA, 20 age- and severity-matched patients with idiopathic Parkinson disease (PD), and 15 healthy volunteers. For each subject, we computed the expression of the previously characterized metabolic covariance patterns for MSA and PD (termed MSARP and PDRP, respectively) on a prospective single-case basis. The resulting network values for the individual patients were correlated with clinical motor ratings and disease duration.

RESULTS

In the MSA group, disease-related pattern (MSARP) values were elevated relative to the control and PD groups (p < 0.001 for both comparisons). In this group, MSARP values correlated with clinical ratings of motor disability (r = 0.57, p = 0.0008) and with disease duration (r = -0.376, p = 0.03). By contrast, MSARP expression in the PD group did not differ from control values (p = 1.0). In this group, motor ratings correlated with PDRP (r = 0.60, p = 0.006) but not with MSARP values (p = 0.88).

CONCLUSIONS

MSA is associated with elevated expression of a specific disease-related metabolic pattern. Moreover, differences in the expression of this pattern in patients with MSA correlate with clinical disability. The findings suggest that the MSARP may be a useful biomarker in trials of new therapies for this disorder.

Neurointensive care biophysiological monitoring

Monitoring various physiological parameters and their derangements provides a valuable tool for management of severely brain injured patients. The various parameters and their monitoring tools include but are not all inclusive are cerebral blood flow and oxygen monitoring, jugular bulb oximetry, intracerebral microdialysis and continuous electroencephalography. It needs to be seen how these devices are applied to improve patient outcomes.

Network correlates of the cognitive response to levodopa in Parkinson disease

OBJECTIVE

Cognitive dysfunction is common in Parkinson disease (PD), even early in its clinical course. This disease manifestation has been associated with impaired verbal learning performance as well as abnormal expression of a specific PD-related cognitive spatial covariance pattern (PDCP). It is not known, however, how this metabolic network relates to the cognitive response to dopaminergic therapy on the individual patient level.

METHODS

We assessed treatment-mediated changes in verbal learning and PDCP expression in 17 patients with PD without dementia who underwent cognitive testing and metabolic imaging in the unmedicated and levodopa-treated conditions. We also determined whether analogous changes were present in 12 other patients with PD without dementia who were evaluated before and during the treatment of cognitive symptoms with placebo.

RESULTS

Levodopa-mediated changes in verbal learning correlated with concurrent changes in PDCP expression (r = -0.60, p < 0.01). The subset of patients with meaningful cognitive improvement on levodopa (n = 8) exhibited concurrent reductions in PDCP expression (p < 0.01) with treatment; network modulation was not evident in the remaining subjects. Notably, the levodopa cognitive response correlated with baseline PDCP levels (r = 0.70, p = 0.002). By contrast, placebo did not affect PDCP expression, even in the subjects (n = 7) with improved verbal learning during treatment.

CONCLUSIONS

These findings suggest that cognitive dysfunction in PD may respond to treatment depending upon the degree of baseline PDCP expression. Quantification of treatment-mediated network changes can provide objective information concerning the efficacy of new agents directed at the cognitive manifestations of this disease.

Abnormal metabolic brain networks in Tourette syndrome

OBJECTIVES

To identify metabolic brain networks that are associated with Tourette syndrome (TS) and comorbid obsessive-compulsive disorder (OCD).

METHODS

We utilized [(18)F]-fluorodeoxyglucose and PET imaging to examine brain metabolism in 12 unmedicated patients with TS and 12 age-matched controls. We utilized a spatial covariance analysis to identify 2 disease-related metabolic brain networks, one associated with TS in general (distinguishing TS subjects from controls), and another correlating with OCD severity (within the TS group alone).

RESULTS

Analysis of the combined group of patients with TS and healthy subjects revealed an abnormal spatial covariance pattern that completely separated patients from controls (p < 0.0001). This TS-related pattern (TSRP) was characterized by reduced resting metabolic activity of the striatum and orbitofrontal cortex associated with relative increases in premotor cortex and cerebellum. Analysis of the TS cohort alone revealed the presence of a second metabolic pattern that correlated with OCD in these patients. This OCD-related pattern (OCDRP) was characterized by reduced activity of the anterior cingulate and dorsolateral prefrontal cortical regions associated with relative increases in primary motor cortex and precuneus. Subject expression of OCDRP correlated with the severity of this symptom (r = 0.79, p < 0.005).

CONCLUSION

These findings suggest that the different clinical manifestations of TS are associated with the expression of 2 distinct abnormal metabolic brain networks. These, and potentially other disease-related spatial covariance patterns, may prove useful as biomarkers for assessing responses to new therapies for TS and related comorbidities.

Transcriptional expression and gelatinolytic activity of matrix metalloproteinases in Henoch-Schonlein purpura

AIM

Accelerated extracellular matrix breakdown caused by the increased activity of matrix metalloproteinases (MMPs) has been implicated in several rheumatological disorders and systemic vasculitides, especially Takayasu's arteritis and Kawasaki disease. Therefore, the aim of the present study was to investigate the potential role of MMPs in Henoch-Schonlein purpura (HSP), an acute type of systemic vasculitis in children.

METHODS

We studied the activity of MMP-2 and MMP-9 in the sera using gelatin zymography and the transcriptional expression in peripheral blood mononuclear cells using semi-quantitative RT-PCR in 20 patients with HSP in acute and convalescent phase and in 20 healthy children, who were siblings of the subjects with same age group.

RESULTS

All 20 children with HSP showed increased levels of serum activity of MMP-2 and MMP-9 in acute phase as compared with their convalescent phase [MMP-2 (p > 0.05); MMP-9 (p > 0.05)] and their control counterparts [MMP-2 (p < 0.001); MMP-9 (p < 0.001)]. Similarly, transcriptional expression of MMPs was found to be higher in the acute phase of HSP than in convalescent phase [MMP-2 (p < 0.05); MMP-9 (p < 0.001)] and in their healthy controls [MMP-2 (p < 0.001); MMP-9 (p < 0.01)].

CONCLUSION

The presence of excessive transcriptional expression and gelatinolytic activity of MMPs may be downstream to the actual aetiopathogenetic factors.

Abnormal striatal and thalamic dopamine neurotransmission: Genotype-related features of dystonia

OBJECTIVE

To determine whether changes in D(2) receptor availability are present in carriers of genetic mutations for primary dystonia.

METHODS

Manifesting and nonmanifesting carriers of the DYT1 and DYT6 dystonia mutations were scanned with [(11)C] raclopride (RAC) and PET. Measures of D(2) receptor availability in the caudate nucleus and putamen were determined using an automated region-of-interest approach. Values from mutation carriers and healthy controls were compared using analysis of variance to assess the effects of genotype and phenotype. Additionally, voxel-based whole brain searches were conducted to detect group differences in extrastriatal regions.

RESULTS

Significant reductions in caudate and putamen D(2) receptor availability were evident in both groups of mutation carriers relative to healthy controls (p < 0.001). The changes were greater in DYT6 relative to DYT1 carriers (-38.0 +/- 3.0% vs -15.0 +/- 3.0%, p < 0.001). By contrast, there was no significant difference between manifesting and nonmanifesting carriers of either genotype. Voxel-based analysis confirmed these findings and additionally revealed reduced RAC binding in the ventrolateral thalamus of both groups of mutation carriers. As in the striatum, the thalamic binding reductions were more pronounced in DYT6 carriers and were not influenced by the presence of clinical manifestations.

CONCLUSIONS

Reduced D(2) receptor availability in carriers of dystonia genes is compatible with dysfunction or loss of D(2)-bearing neurons, increased synaptic dopamine levels, or both. These changes, which may be present to different degrees in the DYT1 and DYT6 genotypes, are likely to represent susceptibility factors for the development of clinical manifestations in mutation carriers.

A neurosurgical hand rest

doi: 10.3126/kumj.v6i3.1727  Kathmandu University Medical Journal (2008), Vol. 6, No. 3, Issue 23, 426-427

Metabolic abnormalities associated with mild cognitive impairment in Parkinson disease

OBJECTIVE

To use (18)F-fluorodeoxyglucose (FDG) and PET to investigate changes in regional metabolism associated with mild cognitive impairment (MCI) in Parkinson disease (PD). Cognitive abnormalities are common in PD. However, little is known about the functional abnormalities that underlie the manifestations of MCI in this disorder.

METHODS

We used FDG PET to measure regional glucose metabolism in patients with PD with multiple-domain MCI (MD-MCI; n = 18), with single-domain MCI (SD-MCI; n = 15), and without MCI (N-MCI; n = 18). These patients were matched for age, education, disease duration, and motor disability. Maps of regional metabolism in the three groups were compared using statistical parametric mapping (SPM). We also computed the expression of a previously validated cognition-related spatial covariance pattern (PDCP) in the patient groups and in an age-matched healthy control cohort (n = 15). PDCP expression was compared across groups using analysis of variance.

RESULTS

SPM revealed decreased prefrontal and parietal metabolism (p < 0.001) in MD-MCI relative to N-MCI, as well as an increase in brainstem/cerebellar metabolism (p < 0.001) in this group. In these regions, SD-MCI occupied an intermediate position between the two other groups. PDCP expression was abnormally elevated in the N-, SD-, and MD-MCI groups (p < 0.05), increasing stepwise with worsening cognitive impairment (p < 0.01).

CONCLUSIONS

Early cognitive decline in Parkinson disease as defined by mild cognitive impairment is associated with discrete regional changes and abnormal metabolic network activity. The quantification of these alterations with (18)F-fluorodeoxyglucose PET may allow for the objective assessment of the progression and treatment of this disease manifestation.

Thalamic metabolism and symptom onset in preclinical Huntington's disease

The neural basis for the transition from preclinical to symptomatic Huntington's disease (HD) is unknown. We used serial positron emission tomography (PET) imaging in preclinical HD gene carriers (p-HD) to assess the metabolic changes that occur during this period. Twelve p-HD subjects were followed longitudinally with [11C]-raclopride and [18F]-fluorodeoxyglucose PET imaging, with scans at baseline, 18 and 44 months. Progressive declines in striatal D2-receptor binding were correlated with concurrent changes in regional metabolism and in the activity of an HD-related metabolic network. We found that striatal D2 binding declined over time (P < 0.005). The activity of a reproducible HD-related metabolic covariance pattern increased between baseline and 18 months (P < 0.003) but declined at 44 months (P < 0.04). These network changes coincided with progressive declines in striatal and thalamic metabolic activity (P < 0.01). Striatal metabolism was abnormally low at all time points (P < 0.005). By contrast, thalamic metabolism was elevated at baseline (P < 0.01), but fell to subnormal levels in the p-HD subjects who developed symptoms. These findings were confirmed with an MRI-based atrophy correction for each individual PET scan. Increases in network expression and thalamic glucose metabolism may be compensatory for early neuronal losses in p-HD. Declines in these measures may herald the onset of symptoms in gene carriers.

‘Induction of inflammatory gene expression by THP-1 macrophages cultured in normocholesterolaemic hypertensive sera and modulatory effects of green tea polyphenols’

Hypertension is a disorder controlled by multiple genes and inflammation and vascular remodelling of arteries have been implicated in pathogenesis of this disease. Green tea polyphenols (GrTPs) are rich in antioxidants and are known to inhibit inflammatory responses. A significant time-dependent increase in mRNA expression of both IL-6 and MMP-9 were observed in THP-1 macrophages when cultured in normocholesterolaemic hypertensive sera (P<0.05).

Genetic aspects of restless legs syndrome

Restless legs syndrome (RLS), also known as Ekbom syndrome, is a common movement disorder with sensorimotor symptoms occurring during sleep and quiet wakefulness. The underlying cause for RLS is unknown but genetic influences play a strong part in the pathogenesis of RLS, particularly when the condition starts at a young age. This review explores the genetic basis of RLS and related phenotypic variations. Recently, three loci showing vulnerability to RLS have been described in French-Canadian and Italian families in chromosomes 12q, 14q and 9q, emphasising on an autosomal dominant mode of inheritance. These have been labelled RLS1, RLS2 and RLS3, respectively. However, specific causative mutations remain elusive and no linkage analysis has been identified so far in the candidate genes investigated in RLS.

The range and nature of sleep dysfunction in untreated Parkinson's disease (PD). A comparative controlled clinical study using the Parkinson's disease sleep scale and selective polysomnography

In this study we have explored the nature and range of sleep dysfunction that occurs in untreated Parkinson's disease (PD) comparing data obtained from the use of the Parkinson's disease sleep scale (PDSS) in an untreated PD patient group compared to advanced PD and healthy controls. 25 untreated (drug-naive, DNPD) PD patients (mean age 66.9 years, range 53-80, 18 males) completed the validated Parkinson's disease sleep scale (PDSS), mean duration of PD was 2.1 years (1-10, up to 4 years in all except one patient with tremulous PD reporting tremor duration of 10 years) and mean Hoehn and Yahr score 1.9 (1-3). Data were compared to 34 advanced PD (mean age 70.2 years, range 51-88, 23 male), mean duration of PD 11 years (range 4-22), mean Hoehn and Yahr score 3.4 (3-5) and PDSS data obtained from 131 healthy controls (mean age 66.6 years, range 50-93, 56 males). Total PDSS scores and PDSS sub-items, except PDSS item 2, were highly significantly different (p<0.001) between DNPD, advanced PD and controls. Controls reported higher mean PDSS scores than both groups of patients, and advanced cases reported lower (mean+/-S.D.) PDSS scores (86.95+/-20.78) than drug-naive (105.72+/-21.5) (p<0.001). Logistic regression analysis showed that items PDSS8 (nocturia), PDSS11 (cramps), PDSS12 (dystonia), PDSS13 (tremor), and PDSS15 (daytime somnolence) were significantly impaired in DNPD compared to controls while PDSS7 (nighttime hallucinations) additionally separated advanced PD from DNPD. In a subgroup of 11 advanced PD cases (mean age 62 years, range=49-84 years, mean Hoehn and Yahr score 2.5, range=1-3) with high Epworth Sleepiness Scale (ESS) scores (mean 14.5), low item 15 PDSS score (mean 4.7) and complaints of severe daytime sleepiness, underwent detailed overnight polysomnography (PSG) studies, all showing abnormal sleep patterns. We conclude that nocturia, nighttime cramps, dystonia, tremor and daytime somnolence seem to be the important nocturnal disabilities in DNPD and some of these symptoms may be reminiscent of "off" period related symptoms even though patients are untreated. Furthermore, polysomnography in "sleepy" PD patients may help diagnose unrecognised conditions such as periodic limb movement of sleep (PLMS), obstructive sleep apnoea (OSA) and REM Sleep Behaviour Disorder.

Sleep-related problems of Parkinson's disease

OBJECTIVE

To define the epidemiology, characteristics and aetiology of nocturnal symptoms and sleep disorders in patients with Parkinson's disease (PD) and evaluate the available methods for their diagnosis and management.

METHODS

A review of the English-language literature pertaining to sleep disturbances associated with PD, using the Medline database and bibliographies in relevant articles.

RESULTS

Sleep-related problems specific to PD may occur early and even predate the diagnosis of the disease but are generally more frequent and more severe in patients with advanced PD. These problems can seriously compromise patients' quality of life and lead to impaired functioning in daily activities. Scales designed specifically for the assessment of sleep problems in patients with PD have recently been developed. Evidence base for the treatment of sleep disturbances in PD is poor, and only nocturnal akinesia, excessive day-time sleepiness and rapid eye movement behaviour disorder have been partially addressed.

CONCLUSIONS

Sleep disorders associated with PD are a common and under-recognised problem. The assessment of sleep should be part of the routine evaluation of patients with PD, and large-scale controlled therapeutic trials are necessary.

Decreased striatal D2 receptor binding in non-manifesting carriers of the DYT1 dystonia mutation

To determine whether reduced striatal D2 receptor binding reported in patients with idiopathic torsion dystonia is associated with the genotype, the authors used PET and [11C]-raclopride to assess non-manifesting carriers of the DYT1 mutation. D2 receptor binding was reduced by approximately 15% in caudate and putamen (p < 0.005). These results suggest that striatal D2 binding reductions are a trait feature of the DYT1 genotype.

Retrospective evaluation of cardio-pulmonary fibrotic side effects in symptomatic patients from a group of 234 Parkinson?s disease patients treated with cabergoline

BACKGROUND

Cardiac valvulopathy has been recently associated with the use of the ergot dopamine agonist (EDA) pergolide in Parkinson's disease (PD). Cabergoline a widely used, well-tolerated EDA which has also been recently implicated in relation to fibrotic side effects although the evidence base for this is not sound.

AIMS

In PD patients on chronic cabergoline therapy, do symptoms suggestive of serosal/cardiac fibrosis imply underlying fibrotic lesions?

METHODS

A retrospective data review of 234 PD cases from three UK centres, on chronic cabergoline monotherapy or adjunctive treatment to identify symptoms suggestive of pleuro-pulmonary, cardiac or retroperitoneal fibrosis. These causes were thereafter selectively examined by appropriate specialists with relevant investigations.

CONCLUSIONS

Out of 234 cases, 15 were identified with symptoms suggestive of respiratory, cardiac or abdominal systems involvement although subsequent investigations failed to reveal definite association with cabergoline except two cases with probable alveolitis and a possible association with cardiac murmur in one case. In spite of the deficiencies of a retrospective study, the results suggest a low risk of fibrotic side effects with cabergoline, particularly cardiac valvulopathy.