The impact of disease modifying therapies on cognitive functions typically impaired in multiple sclerosis patients: a clinician's review

Objective

Over the last few decades clinicians have become aware that cognitive impairment might be a major cause of disability, loss of employment and poor quality of life in patients suffering from multiple sclerosis [MS].The impact of disease modifying therapies [DMTs] on cognition is still a matter of debate. Theoretically, DMTs could exert a substantial beneficial effect by means of reducing neuroinflammation and brain atrophy, which are established correlates of cognitive dysfunction. The aim of the study was to review the evidence concerning the effect of DMTs on cognitive functions.

Methods

PubMed, Scopus, and the European Committee for Treatment and Research in Multiple Sclerosis [ECTRIMS] Library were searched for articles concerning the pediatric and adult populations of patients with multiple sclerosis, including clinical trials and RWD, where psychometric results were analyzed as secondary or exploratory endpoints.

Results

We reviewed a total of 44 studies that were found by our search strategy, analyzed the psychological tests that were applied, the length of the follow-up, and possible limitations. We pointed out the difficulties associated with assessing of DMTs' effects on cognitive functions, and pitfalls in cognitive tools used for evaluating of MS patients.

Conclusion

There is a need to highlight this aspect of MS therapies, and to collect adequate data to make informed therapeutic decisions, to improve our understanding of MS-related cognitive dysfunction and provide new therapeutic targets.

Prevalence and prognostic value of prodromal symptoms in relapsing-remitting multiple sclerosis

INTRODUCTION

Several studies have suggested the possibility that disease prodromes might occur months or even years before a multiple sclerosis diagnosis.

OBJECTIVES

To describe the profile of prodromal symptoms and the possible relationship between the occurrence of individual symptoms and clinical course characteristics in patients with relapsing-remitting multiple sclerosis (RRMS), and to assess their role as predictors of further disease course.

MATERIAL AND METHODS

The cohort included 564 patients with RRMS. Patients were stratified based on their current EDSS score, and the annual EDSS growth rate was calculated. Logistic Regression Analysis was used to study the relationship between prodromal symptoms and disease progression.

RESULTS

The most commonly reported prodromal symptom was fatigue (42%). The following symptoms were significantly more common in women than in men: headache (39.7% vs. 26.5%, p < 0.05), excessive sleepiness (19.1% vs. 11.1%, p < 0.05) and constipation (18.0% vs. 11.1%, p < 0.05). Prodromal urinary and cognitive disturbances, fatigue and pain complaints were significantly more common in patients with the highest annual EDSS increase (p < 0.05). Multivariate analysis revealed some potential predictors of long-term disability progression: hesitancy in starting urination predicted EDSS increase by 0.6 point (p < 0.05), while deterioration in everyday functioning because of cognitive disturbances, and pain complaints, were associated with an EDSS increase of 0.5 (p < 0.05), and 0.4 (p < 0.05), respectively.

CONCLUSIONS

Prodromal pain, urinary and cognitive complaints (especially when these lead to deterioration of everyday functioning) were associated with a higher EDSS increase rate, and may thus be regarded as possible predictors of worse clinical outcomes in RRMS patients.

Case Report: Baló's Concentric Sclerosis-Like Lesion in a Patient With Relapsing-Remitting Multiple Sclerosis Treated With Dimethyl Fumarate

Baló's concentric sclerosis (BCS) is a rare demyelinating disorder characterized by acute or subacute neurological symptoms associated with characteristic lesions of concentric onion skin appearance on MRI images and in pathology. The connection between BCS and classic MS is still a subject of debates. Our report presents a case of a patient who developed a symptomatic Baló-like lesion following several years of classical relapsing-remitting multiple sclerosis treated with dimethyl fumarate.

Acute disseminated encephalomyelitis in a patient vaccinated against SARS-CoV-2

Acute disseminated encephalomyelitis (ADEM) is a demyelinating disease, and there are some data that link this event with various vaccinations. We report a young female admitted to the hospital with headache, fever, back pain, nausea, vomiting, and urinary retention. Two weeks prior, she received the first dose of SARS‐CoV‐2 mRNA vaccine. Brain and spinal cord magnetic resonance imaging (MRI) showed distinctive for ADEM widespread demyelinating lesions. The patient was successfully treated with methylprednisolone.

Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease: Current Insights into the Disease Pathophysiology, Diagnosis and Management

Myelin oligodendrocyte glycoprotein (MOG)-associated disease (MOGAD) is a rare, antibody-mediated inflammatory demyelinating disorder of the central nervous system (CNS) with various phenotypes starting from optic neuritis, via transverse myelitis to acute demyelinating encephalomyelitis (ADEM) and cortical encephalitis. Even though sometimes the clinical picture of this condition is similar to the presentation of neuromyelitis optica spectrum disorder (NMOSD), most experts consider MOGAD as a distinct entity with different immune system pathology. MOG is a molecule detected on the outer membrane of myelin sheaths and expressed primarily within the brain, spinal cord and also the optic nerves. Its function is not fully understood but this glycoprotein may act as a cell surface receptor or cell adhesion molecule. The specific outmost location of myelin makes it a potential target for autoimmune antibodies and cell-mediated responses in demyelinating processes. Optic neuritis seems to be the most frequent presenting phenotype in adults and ADEM in children. In adults, the disease course is multiphasic and subsequent relapses increase disability. In children ADEM usually presents as a one-time incident. Luckily, acute immunotherapy is very effective and severe disability (ambulatory and visual) is less frequent than in NMOSD. A critical element of reliable diagnosis is detection of pathogenic serum antibodies MOG with accurate, specific and sensitive methods, preferably with optimized cell-based assay (CBA). MRI imaging can also help in differentiating MOGAD from other neuro-inflammatory disorders. Reports on randomised control trials are limited, but observational open-label experience suggests a role for high-dose steroids and plasma exchange in the treatment of acute attacks, and for immunosuppressive therapies, such as steroids, oral immunosuppressants and rituximab as maintenance treatment. In this review, we present up-to-date clinical, immunological, radiographic, histopathological data concerning MOGAD and summarize the practical aspects of diagnosing and managing patients with this disease.

With a subarachnoid haemorrhage, the outcome is never enough

INTRODUCTION

In the current edition, Nastasovic et al. present the results of a prospective study on patients with aneurysm subarachnoid haemorrhage (SAH) regarding the association of selected variables and outcomes three months after the incident.

CLINICAL REFLECTIONS

The independent predicting factors of an unfavourable aneurysm SAH outcome are aneurysm re-rupture, high systolic blood pressure (SBP), and increased heart rate.

CLINICAL IMPLICATIONS

The article findings confirm easily monitored parameters that could be potentially useful in clinical approaches to this critical illness.

Association of platelet-derived microvesicles and their phenotypes with carotid atherosclerosis and recurrent vascular events in patients after ischemic stroke

INTRODUCTION

Platelet-derived microvesicles (pMVs) exhibit procoagulant and proinflammatory properties and play a role in the development and progression of atherosclerosis. The study examined the association between the total number of pMVs and their phenotypes with carotid atherosclerosis and recurrent vascular events (VEs) in patients in the convalescent phase of ischemic stroke (IS).

MATERIALS AND METHODS

The study group consisted of 72 patients with IS secondary to large artery atherosclerosis (LAA) (n = 40) and small arteries occlusion (SAO) (n = 32) and 69 matched cardiovascular disease risk-factor (RF) controls. Total pMV number, defined as CD61+ microvesicles (MVs), and their phenotypes, defined as the surface expression of proinflammatory (CD40L, CD62P, CD31) and procoagulant (PS, PAC-1) markers, were characterized and quantified using flow cytometry. The mean common carotid intima-media thickness (CCA mean IMT), maximal common carotid IMT (CCA max IMT) and maximal bifurcation IMT (BIF max IMT) were measured bilaterally using B-mode, color Doppler ultrasonography. All study subjects were observed for one-year to establish the occurrence of VEs.

RESULTS

No differences in pMV parameters between LAA and SAO stroke subjects and between stroke subgroups and controls were found. Stroke patients with carotid atherosclerosis exhibited higher concentration of CD62P+/CD61+ and PAC-1+/CD61+ MVs compared to patients without the atherosclerosis. Positive associations between total number of pMVs, AnV+ MVs and AnV+/CD61+ MVs and atherosclerotic thickening of carotid intima-media in stroke patients were found. Elevated concentration of AnV+/CD61+, PAC-1+/CD61+, CD61P+/CD61+ and CD31+/CD61+ MVs, were revealed in stroke patients who suffered from recurrent VE in one-year follow-up period. Negative correlation of pMVs and CD62P+/CD61+ MVs concentration as well as percentage of total CD61+ in AnV+ population of MVs and time elapsed from IS in convalescent stroke subjects was revealed.

CONCLUSION

Our results confirm positive correlations between total pMV number, the number of PAC-1+/CD61+ and CD62+/CD61+ MVs and carotid atherosclerosis in stroke subjects. Some pMV parameters may exhibit a predictive value for the next VE in groups with a history of stroke. pMVs and some of their phenotypes decline over time elapsed from stroke in convalescent stroke subjects.

Free thyroxine and TSH interact with secreted protein acidic and rich in cysteine-like 1 in ischemic stroke

The role of the thyroid gland in ischemic stroke pathology is not well understood. As thyroid hormones modulate the extracellular matrix, we explored the possible link between them and secreted protein acidic and rich in cysteine like 1 (SC1) - one of the extracellular matrix molecules. In the 81 patients with acute ischemic stroke, serum SC1 levels were much higher compared with 30 control subjects: 4.47 vs 2.43ng/mL (p<0.001). Serum levels of free thyroxine (fT4) were higher in stroke subjects compared to those of controls (p=0.03). In stroke patients, TSH concentration was lower than in the control group (p=0.03). SC1 levels positively correlated with fT4 levels (p=0.02) and negatively with TSH (p=0.03) in stroke patients. Our results confirmed the association between thyroid hormones and SC1 - extracellular matrix protein.

Predictive value of serum transthyretin for outcome in acute ischemic stroke

Introduction

The impact of choroid plexus with its blood–cerebrospinal fluid barrier in the ischemic stroke pathology is poorly explored. Transthyretin (TTR) is a protein synthesized in liver and just in choroid plexus.

Objectives

The current study was designed to assess the prognostic value of serum TTR for functional outcome (at the time of hospital discharge) and long-term (one-year) overall mortality in ischemic stroke patients.

Patients and methods

We conducted a prospective observational study. Patients (n = 81) with acute (< 24 hours of symptoms onset) ischemic stroke consecutively admitted to Stroke Unit were included. An unfavorable outcome was defined as a modified Rankin Scale (mRS) score ≥ 3. The relationships between serum TTR levels and clinical outcome were analyzed using multivariate analysis. One-year mortality was analyzed by Kaplan–Meier survival curves stratified by mean value of TTR.

Results

Compared with patients with mRS <3, patients with an unfavorable outcome at hospital discharge had significantly lower TTR levels on admission (P < 0.0001). In non-survivals serum TTR levels were significantly lower compared with patients who survive one year of observation (P = 0.009). Using multivariate analysis, transthyretin emerged as an independent predictor for unfavorable outcome at the day of hospital discharge (adjusted odds ratio = 0.96; 95% CI: 0.9–0.99, P <0.05). A one-year mortality of patients with the lower TTR levels was significantly higher than in patients with TTR levels above mean value (P = 0.02).

Conclusions

Serum level of TTR at admission was a predictor of functional outcome after ischemic stroke and was also associated with one-year mortality in stroke survivals.

Pulsatility index in carotid arteries is increased in levothyroxine-treated Hashimoto disease

The aim of this case-control study was to evaluate carotid hemodynamic variables and traditional cardiovascular risk factors in women with Hashimoto thyroiditis (HT). The study group consisted of 31 females with HT on levothyroxine (L-T4) and 26 euthyroid women with HT without L-T4 matched for age and body mass index (BMI) as controls. Carotid intima-media thickness (CIMT), carotid extra-media thickness (CEMT), and pulsatility indexes in common carotid artery (PI CCA) and in internal carotid artery (PI ICA) were measured. BMI, waist circumference, lipid profile, fasting glucose and insulin levels, and parameters of thyroid function [TSH, free thyroxine (FT4) and antithyroperoxidase antibodies (TPOAbs)] were assessed. The study and the control groups did not differ in age, BMI, waist circumference, lipid profile, fasting glucose, and insulin levels. Results are expressed as median (IQR). Treated HT group had higher FT4 levels than nontreated [17.13 (5.11) pmol/l vs. 14.7 (2.27) pmol/l; p=0.0011] and similar TSH [1.64 (2.08) IU/ml vs. 2.07 (3.14) IU/ml; p=0.5915]. PI CCA and PI ICA were higher in the study group than in controls (p=0.0224 and p=0.0477, respectively). The difference remained statistically significant for PI ICA and PI CCA after adjustment for other variables (coefficient=0.09487; standard error=0.04438; p=0.037 and coefficient=0.1786; standard error=0.0870; p=0.0449, respectively). CIMT and CEMT were similar in both groups (p=0.8746 and p=0.0712, respectively). Women with HT on L-T4 replacement therapy have increased PI in common and internal carotid arteries than nontreated euthyroid HT patients. Therefore, it seems that hypothyroidism, but not autoimmune thyroiditis per se, influences arterial stiffness.

Population-based Stroke Atlas for outcome prediction: method and preliminary results for ischemic stroke from CT

BACKGROUND AND PURPOSE

Knowledge of outcome prediction is important in stroke management. We propose a lesion size and location-driven method for stroke outcome prediction using a Population-based Stroke Atlas (PSA) linking neurological parameters with neuroimaging in population. The PSA aggregates data from previously treated patients and applies them to currently treated patients. The PSA parameter distribution in the infarct region of a treated patient enables prediction. We introduce a method for PSA calculation, quantify its performance, and use it to illustrate ischemic stroke outcome prediction of modified Rankin Scale (mRS) and Barthel Index (BI).

METHODS

The preliminary PSA was constructed from 128 ischemic stroke cases calculated for 8 variants (various data aggregation schemes) and 3 case selection variables (infarct volume, NIHSS at admission, and NIHSS at day 7), each in 4 ranges. Outcome prediction for 9 parameters (mRS at 7th, and mRS and BI at 30th, 90th, 180th, 360th day) was studied using a leave-one-out approach, requiring 589,824 PSA maps to be analyzed.

RESULTS

Outcomes predicted for different PSA variants are statistically equivalent, so the simplest and most efficient variant aiming at parameter averaging is employed. This variant allows the PSA to be pre-calculated before prediction. The PSA constrained by infarct volume and NIHSS reduces the average prediction error (absolute difference between the predicted and actual values) by a fraction of 0.796; the use of 3 patient-specific variables further lowers it by 0.538. The PSA-based prediction error for mild and severe outcomes (mRS  =  [2]-[5]) is (0.5-0.7). Prediction takes about 8 seconds.

CONCLUSIONS

PSA-based prediction of individual and group mRS and BI scores over time is feasible, fast and simple, but its clinical usefulness requires further studies. The case selection operation improves PSA predictability. A multiplicity of PSAs can be computed independently for different datasets at various centers and easily merged, which enables building powerful PSAs over the community.

Enhanced platelet-derived microparticle formation is associated with carotid atherosclerosis in convalescent stroke patients

Platelets participate in the development and progression of atherosclerosis. During this process they interact with endothelial cells and leukocytes. Therefore, we investigated the associations between carotid atherosclerosis and platelet reactivity markers. The platelet surface expression of P-selectin (CD62P) and the activated GPIIb/IIIa receptor (corresponding to increased binding of PAC-1), as well as the fraction of platelet-derived microparticles (PMPs) prior to and after platelet stimulation with TRAP or ADP, were determined using flow cytometry in 94 subjects in the convalescent phase of ischaemic stroke and in 76 disease controls. The mean common carotid intima-media thickness (CCA(mean) IMT), maximal common carotid IMT (CCA(max) IMT) and maximal bifurcation IMT (BIF(max) IMT) were measured bilaterally using B mode, colour Doppler ultrasonography. In stroke subjects IMT within CCA and BIF were greater than in disease controls and the percentage of PMPs prior to and after ex vivo stimulation with agonists was significantly higher than in controls. Multiple regression analysis revealed that PMPs were positively and independently correlated with both CCA(mean) IMT (β = 0.23; p < 0.01) and stroke (β = 0.21; p<0.01), while PAC-1 binding to platelets activated with ADP was negatively and independently associated with CCA(mean) IMT (β = -0.29; p<0.001) and atherosclerotic carotid plaque presence (β = -0.28, p = 0.003). We found a positive association between enhanced PMP formation and atherosclerotic thickening of carotid intima-media or carotid plaque in patients after ischaemic stroke. We demonstrated that diminished expression of active GPIIb/IIIa in the ADP-activated platelets is associated with increased carotid IMT, independently of stroke.

The hyperdense posterior cerebral artery sign in CT is related to larger ischemic lesion volume

BACKGROUND

Hyperdensity of the middle cerebral artery (MCA) on unenhanced CT is a recognized sign associated with brain's early ischemia. The number of studies which showed a hyperdense posterior cerebral artery (HPCA) sign in posterior circulation infarct is relatively small. We investigated the prevalence of the HPCA sign, correlations with ischemic lesion volume, and stroke risk factors. We also determined the association with prothrombotic and inflammatory markers which have not been studied before.

MATERIAL/METHODS

In the group of 376 patients with a first acute stroke consecutively admitted to Emergency Department, early signs of brain infarction were visible in 221 (58%) cases. Fifty five (25%) subjects had ischemic lesions in the brain supplied by the posterior circulation. We analyzed the unenhanced CT scans, calculated the density of the posterior cerebral arteries, infarct volume, and assessed the relation of the HPCA sign to other factors.

RESULTS

The HPCA sign appeared on CT scans of 12 (22%) patients with evidence of the posterior circulation infarct. The density (in Hounsfield units) of the affected PCA was 46.5 comparing to 20.2 of an intact vessel (p<0.0001). The stroke volume was larger when the HPCA sign was observed (medians: 17.6 vs. 4.3 cm(3), p=0.02); in multivariate analysis this association was still significant (OR=1.07; 95% CI, 0.99-1.13). The C-reactive protein and fibrinogen levels were significantly higher (p=0.02 for both factors) in patients with the HPCA sign in the univariate analysis.

CONCLUSIONS

The HPCA may be considered as an additional marker of early brain infarct, especially with large lesion volume.

Low free triiodothyronine levels are related to poor prognosis in acute ischemic stroke

BACKGROUND

Neuroendocrine changes are important processes which accompany critical illness, however, the number of clinical studies concentrating on the role of thyroid gland hormones in stroke pathogenesis is relatively small. The aim of this prospective study was to investigate the relation between free triiodothyronine (fT3) levels and the prognosis of patients with stroke.

METHODS

The prospective study included 387 patients with acute (<24 h of symptoms onset) ischemic stroke consecutively admitted to Stroke Units. The subjects with known conditions that could interfere with thyroid gland metabolism were excluded. We analyzed: the routine blood tests, fT3, free thyroxine (fT4), thyroid-stimulating hormone (TSH) levels, unenhanced CT scans, initial clinical status (NIH Stroke Scale, NIHSS), 30- and 360- days outcome (modified Rankin Scale-mRS) and calculated the survival rate.

RESULTS

A higher NIHSS score was in the 1 (st) fT3 levels tertile, whereas a lower in the 3 (rd) fT3 levels tertile (p=0.006). The 30- and 360-days mRS scores showed that patients in the lowest fT3 tertile had more severe neurological impairment than those in the highest tertile (p=0.001 and p=0.03, respectively). A 1-year mortality of the patients with the first tertile fT3 levels was significantly higher than that of the patients with the third tertile hormone levels (p=0.008). Additionally, subjects with fT3 level in the lowest tertile demonstrated higher WBC counts and the ventricular system on Computed Tomography of head performed on admission to hospital was statistically more frequent compressed than that in the patients with fT3 level in the highest tertile (p=0.02 and p=0.03, respectively).

CONCLUSION

In acute stroke patients lower free T3 levels are an important factor related to unfavorable outcome, i. e., severe disability and death.

Automatic segmentation of cerebrospinal fluid, white and gray matter in unenhanced computed tomography images

RATIONALE AND OBJECTIVES

Although segmentation algorithms for cerebrospinal fluid (CSF), white matter (WM), and gray matter (GM) on unenhanced computed tomographic (CT) images exist, there is no complete research in this area. To take into account poor image contrast and intensity variability on CT scans, the aim of this study was to derive and validate a novel, automatic, adaptive, and robust algorithm.

MATERIALS AND METHODS

Unenhanced CT scans of normal subjects from two different centers were used. The algorithm developed uses adaptive thresholding, connectivity, and domain knowledge and is based on heuristics on the shape of CT histogram. The slope of the intensity histogram corresponding to the three-dimensional largest connected region in a variable CSF intensity range is tracked to determine the critical intensity, which serves as an initial classifier of CSF-WM. Thresholds of CSF, WM, and GM are then optimally derived to minimize classification overlap. Multiple, null, and erroneous classifications are resolved by applying domain knowledge.

RESULTS

The ground-truth regions with the minimal partial volume effect were used to evaluate segmentation results using the statistical markers. Average sensitivity, Dice index, and specificity, respectively, for the first center were 95.7%, 97.0%, and 98.6% for CSF; 96.1%, 97.3%, and 98.8% for WM; and 95.2%, 94.3%, and 92.8% for GM. The results were consistent for the second data center.

CONCLUSIONS

The algorithm automatically identifies CSF, WM, and GM on unenhanced CT images with high accuracy, is robust to data from different scanners, does not require any parameter setting, and takes about 5 minutes in MATLAB to process a 512 × 512 × 30 scan. The algorithm has potential use in research and clinical applications.

Robust calculation of the midsagittal plane in CT scans using the Kullback-Leibler's measure

OBJECTIVE

The identification of the interhemispheric fissure (IF) is important in clinical applications for brain landmark identification, registration, symmetry assessment, and pathology detection. The IF is usually approximated by the midsagittal plane (MSP) separating the brain into two hemispheres. We present a fast accurate, automatic, and robust algorithm for finding the MSP for CT scans acquired in emergency room (ER) with a large slice thickness, high partial volume effect, and substantial head tilt.

MATERIALS AND METHODS

An earlier algorithm for MSP identification from MRI using the Kullback-Leibler's measure was extended for CT by estimating patient's head orientation using model fitting, image processing, and atlas-based techniques. The new algorithm was validated on 208 clinical scans acquired mainly in the ER with slice thickness ranging from 1.5 to 6 mm and severe head tilt.

RESULTS

The algorithm worked robustly for all 208 cases. An angular discrepancy (degrees) and maximum distance (mm) between the calculated MSP and ground truth have the mean value (SD) 0.0258 degrees (0.9541 degrees) and 0.1472 (0.7373) mm, respectively. In average, the algorithm takes 10 s to process of a typical CT case.

CONCLUSION

The proposed algorithm is robust to head rotation, and correctly identifies the MSP for a standard clinical CT scan with a large slice thickness. It has been applied in our several CT stroke CAD systems.

Anti-inflammatory cytokines in subclinical carotid atherosclerosis

Some studies have shown correlations between selected proinflammatory factors and carotid atherosclerosis. It has not been established whether anti-inflammatory cytokines are associated with carotid intima-media thickness (IMT), an ultrasound surrogate marker of atherosclerosis. Therefore, the authors studied the relationship between the carotid IMT and serum levels of interleukin (IL)-10 and transforming growth factor-beta1 in 76 subjects. They discovered that lower IL-10 levels were associated with increased mean IMT in common carotid arteries.

Predictive value of white blood cell count on admission for in-hospital mortality in acute stroke patients

OBJECTIVE

In the present study, we sought to determine the predictive value of white blood cell (WBC) count measured on admission for in-hospital death in acute stroke patients.

METHODS

WBC count was measured automatically in 400 consecutive acute stroke patients (67.5 +/- 12.9 years old; 226 female) on admission to hospital. Patients included into the study had symptoms starting less than 12 h prior to hospitalization and no known causes of inflammation. Logistic regression adjusted for age, gender, the presence of diabetes, hypertension, atrial fibrillation, previous stroke and ischemic heart disease was used for the calculation of odds ratio (OR) with 95% confidence interval (CI) for in-hospital mortality.

RESULTS

Stroke patients with WBC counts in the third tertile (over 9.7 x 10(3) microL(-1)) had more than eight times (OR: 8.26; 95% CI: 3.95-17.25; P < 0.0001) increased risk of in-hospital mortality as compared with the rest of the patients. The WBC count increment of every 1000 cell/microL was associated with OR for in-hospital death of 1.27 (95% CI: 1.17-1.39; P < 0.0001). There was also a significant correlation between patients' WBC count and their clinical condition and degree of disability at the time of admission to hospital.

CONCLUSION

An increased WBC count within the first 12 h of onset of an ischemic stroke is a strong prognostic factor for in-hospital mortality.

An evaluation of the reproducibility of the measurement of the intima-media thickness of carotid arteries

The intima-media thickness (IMT) of carotid arteries was demonstrated to be a reliable measure for early stages of atherosclerosis. B-mode ultrasound may be used to measure carotid IMT. The measurements of the IMT of the carotid artery (CA) conducted by different investigators can be comparable and enable the implementation of clinical trial successfully while maintaining a high reproducibility value. The objective of the study was to evaluate the reproducibility of the measurements made by the same investigator on two separate occasions (intraobserver variability) and the reproducibility of the off-line measurements between four sonographers in our laboratory (interobserver variability). The IMT of CA in 25 subjects (15 post stroke and 10 healthy persons) was investigated with the use of high-resolution ultrasonography. The CA subdivided into the common, bulbs and internal segments were scanned twice with a 3-week interval. Additionally three other readers with different levels of experience and skills in ultrasonography were asked to perform the same measurements in duplicate with at least a 3-week interval between. A high concurrence for intraobserver variability was detected with a correlation coefficient ranging from 0.92 to 0.95; p < 0.0001, and maximal bias 0.019 mm. Interobserver variability for all four readers also demonstrated a high correlation coefficient ranging from 0.72 to 0.83; p < 0.0001, and the maximal bias of measurements did not exceed 0.08 mm. The analogue measurements performed by the team demonstrate a reliable reproducibility in terms of the results of morphologic measurements. The differences obtained in the study were less than the error of the method (i.e. 0.1 mm) and should not influence clinical decision-making. Additionally, this study demonstrated that interobserver concurrence increases with the increasing experience of the investigators.

[Leukocytosis in the first day of acute ischemic stroke as a prognostic factor of disease progression]

It has been reported that white blood cells (WBC) may contribute to the initiation and further development of stroke. WBC count could have influence on hemorheology, thrombosis and induction of vasoconstriction in cerebral arteries. The aim of this work was to determine whether WBC count assessed in patients with acute stroke in the first day of the disease have a predictive value for the late clinical outcomes. Peripheral WBC count was measured at the admission to the hospital in 100 consecutive patients with acute stroke. Ischemic stroke was confirmed in all patients by head CT. Neurological status was evaluated with the use of modified Rankin's Scale. We assessed the following clinical outcomes: in-hospital mortality, the lack of neurological improvement on the 21st day of disease, and the need for hospital stay longer than 21 days. Odds ratio (OR) with 95% confidence interval (95% CI) adjusted for patient's age, gender, cardiovascular diseases, diabetes mellitus and previous stroke was calculated with the use of logistic regression. OR was evaluated both for the presence of WBC count > 10.000 cells/microliter and for each 1000 leukocytes/microliter increase. WBC count greater than 10.000 cells/microliter was associated with a more than seventy-fold greater risk for death (OR--75.18; 95% CI: 8.89-635.84; p = 0.0001), nearly eight times increased risk for the no-improvement status (OR--7.78; 95% CI: 2.51-24.17; p = 0.0004) and approximately four times increased risk for the prolonged hospital stay (OR--4.20; 95% CI: 1.50-11.72; p = 0.0062). Each 1000 cell/microliter increase in WBC count at the admission was associated with increased risk for in-hospital mortality (OR--2.24; 95% CI: 1.39-3.57; p = 0.0008), no neurological improvement (OR--1.43; 95% CI: 1.15-1.76; p = 0.0009) and the need for prolonged hospitalization (OR--1.26; 95% CI: 1.07-1.49; p = 0.0066). Increased WBC count within the first 12 hours of stroke is an independent and strong risk factor for mortality, no neurological improvement, and the need for prolonged hospitalization in the course of acute ischemic stroke.

Effect of calcium or 25OH vitamin D3 dietary supplementation on bone loss at the hip in men and women over the age of 60

Dietary supplements that prevent bone loss at the hip and that can be applied safely in the elderly are likely to reduce hip fractures. A daily dietary supplement of 750 mg calcium or 15 microg 25OH vitamin D3 on bone loss at the hip and other sites, bone turnover and calcium-regulating hormones were studied over 4 yr in elderly volunteers using a randomized, double-blind, placebo-controlled trial. Bone mineral density (BMD) was measured by dual x-ray absorptiometry and bone structure by radiographs. Calcium biochemistry and bone turnover markers were measured in blood and urine. The 316 women entering the trial had a mean age of 73.7 yr and the 122 men of 75.9 yr. Baseline median calcium intake was 546 mg/day, and median serum 25OH vitamin D3 was 59 nmol/L. On placebo, loss of BMD at total hip was 2% and femoral medulla expansion was 3% over 4 yr. Calcium reduced bone loss, secondary hyperparathyroidism, and bone turnover. 25OH vitamin D3 was intermediate between placebo and calcium. Fracture rates and drop-out rates were similar among groups, and there were no serious adverse events with either supplement. A calcium supplement of 750 mg/day prevents loss of BMD, reduces femoral medullary expansion, secondary hyperparathyroidism, and high bone turnover. A supplement of 15 microg/day 25OH vitamin D3 is less effective, and because its effects are seen only at low calcium intakes, suggests that its beneficial effect is to reverse calcium insufficiency.

Forced expiratory flows and volumes in infants. Normative data and lung growth

Forced expiratory flows (FEF) can be measured in infants from lung volumes initiated near total lung capacity. In order to establish reference values and to evaluate lung growth, we obtained measurements in 155 healthy subjects between 3 and 149 wk of age. Forced vital capacity (FVC) was highly correlated with body length; however, after accounting for length, age was also significant. When subjects were divided at the median age (40 wk) younger compared with older subjects had a significantly larger slope for length (3.7 versus 2.8; p = 0.002). The flow parameters (FEF(50), FEF(75), FEF(85), and FEF(25-75)) were highly correlated with length, and those infants whose mothers smoked had lower flows. For FEF(75), male subjects had lower flows than female subjects. The relationship between FEF and volume was assessed using FEV(0.5)/FVC, which decreased with increasing length. Smaller subjects emptied their lung volume proportionately faster. We conclude that our study provides reference values for this age group and demonstrates that smoke-exposed infants and male subjects have decreased FEF. In addition, our findings indicate that lung volume increases most rapidly during the first year of life and that airways are large relative to lung volume very early in life.

Patients' perception of stopping or continuing treatment of cervical dystonia with botulinum toxin type A

Despite widespread commercial acceptance of botulinum toxin (BTX) for idiopathic cervical dystonia (ICD), no follow up has been performed to determine when and why some patients stop therapy. It has been suggested that some patients who stop BTX treatment may do so because of permanent improvement. We surveyed 155 patients with ICD who were treated over 6 years with BTX to determine when and why patients stopped treatment with BTX, and what adverse events and changes in dose and/or frequency of treatments occurred in those who continued treatment. Of the 133 (86.6%) individuals returning the surveys, 104 continued on BTX treatment and 29 had stopped therapy. Of the 29 subjects no longer receiving BTX, 11 individuals had only received one or two injections. Prior surgical treatment for ICD did not influence their decision to stop therapy. Of those 104 of 133 continuing on BTX treatments, two thirds of the subjects reported the injections always help, whereas one quarter estimated one set of injections did not help. One third of those continuing treatment reported the first injection was most helpful, whereas another one third felt all injections were similarly effective. After an initial adjustment, BTX dosages and frequency of treatment remained stable in this group.

Does microdamage accumulation affect the mechanical properties of bone?

It has never been demonstrated that microcrack accumulation in bone leads to impaired mechanical properties. We hypothesized that microdamage accumulation is positively and linearly correlated with a reduction in bone's elastic modulus. We also tested the hypothesis that damage accumulates more rapidly in tensile cortices, but crack growth is greater in compressive cortices. Canine femurs (n = 26) were tested in four-point cyclic bending under load control until they had lost between 5 and 43% of their stiffness. Ten femurs were used as nonloaded controls. The loaded portion of the bone was stained en bloc with basic fuchsin to detect the presence of microdamage. The number of stained microcracks, their lengths and the area of damaged bone were measured under the microscope. Crack numerical density, surface density, mean crack length, and the percentage of damaged area were calculated. Significant microdamage accumulation was not detected until the bone had lost 15% of its elastic modulus. The relationship between crack density and stiffness loss was approximately quadratic, but the relationship between damaged area and stiffness loss was linear. There were significantly more microcracks in tensile cortices, but on average cracks were significantly longer in compressive cortices. We conclude that microcrack accumulation impairs the mechanical properties of bone by reducing its elastic modulus. We also conclude that damage accumulates more rapidly in tensile cortices, but crack growth is greater in compressive cortices.

Bone mass and structure at the hip in men and women over the age of 60 years

Bone mass and structure at the proximal femur are important predictors of hip fracture. The aims of this study were to compare in a large sample of elderly men and women the precision of measurements of bone mass and structure at multiple sites at the proximal femur, to examine their interrelationships, to establish their relationships with age and body size, and to examine criteria for defining geometric and architectural variables in bone structure. Women (n = 336) and men (n = 141) over the age of 60 years were studied cross-sectionally. Bone mineral density (BMD) and content (BMC) at the proximal femur were measured in duplicate by dual-energy X-ray absorptiometry (DXA). Shaft and total upper femur (hip) sites in addition to femoral neck, Ward's triangle and trochanter were measured. Structural variables, measured from radiographs and from DXA images, including cortical thickness at calcar femorale, lateral cotex and midfemur, width of the femur and medulla, Singh grade, hip and femoral axis length, femoral head and neck width and the center of mass of the femoral neck. BMD and BMC had high reproducibility and there were significant differences in reproducibility across sites. Among sites, total upper femur and shaft had the highest reproducibility. Duplicate measurements substantially improved reliability of the measurement and are recommended when the value is close to a diagnostic level or when it will be used to establish rates of change. Reproducibility of structural variables was also high except for the lateral cortex, center of mass and Singh grade. Variance due to measurement error did not change with either age or gender. Women were significantly different from men, after controlling for differences in body size, in all variables except Singh grade and medulla width. BMD and BMC were negatively related to age and positively to body size. Structural variables examined in relation to age and body size fell into two categories. The first comprised variables that were not age-related but were body-size-related suggesting that they could be classified as geometric variables. The second comprised variables that were both body-size-related and age-related, suggesting that they could be classified as architectural variables. Using these criteria, calcar and lateral cortex were architectural variables, whereas shaft width, hip and femoral axis length, femoral head and neck width, and center of mass were geometric in both men and women. In women, shaft cortex width and medulla width were age-related, whereas in men they were not. Singh grade showed no consistent pattern with age or body size in women and men.

Trabecular bone volume and microdamage accumulation in the femoral heads of women with and without femoral neck fractures

Repetitive loading causes fragility and microdamage accumulation in the skeleton, but it is not clear whether microcracks accumulate with age in the human skeleton, or whether older women with femoral neck fractures have more microdamage than older women without fracture. This study tested the hypotheses that: (1) microcracks accumulate in the femoral head with age; and (2) older women with femoral neck fractures have significantly more microcracks than similar aged women without fractures. Nonosteoarthritic femoral heads from 9 young (16-66 years) and 12 old (73-88 years) female cadavers and those from 7 females with femoral neck fractures (56-90 years) were dissected. Midfrontal slabs were block stained with 1% basic fuchsin and 150-microm-thick specimens were measured histomorphometrically. Percent trabecular bone area (TbxAr) significantly decreased in older and fractured subjects compared with young subjects (p < or = 0.05). Microcrack density (CrxDn) was significantly higher in women older than 70 years compared with those younger than 70 (p = 0.005; Spearman's r = 0.41, p = 0.032), but was not different between older women with and without fractures. Osteocyte lacunar density (OtxDn) was significantly less in old and fractured subjects compared with young subjects (p < or = 0.01), and inversely correlated to crack density (r = -0.49, p = 0.011). CrxDn was higher in women with low TbxAr (Spearman's r = -0.56; p = 0.004), and varied inversely with OtxDn (Spearman's r = -0.47; p = 0.014). This is consistent with the idea that cracks accumulate more rapidly in women with low bone density. It is also consistent with the idea that the osteocyte network detects microcracks, and signals for their repair.

Lower respiratory illness in infants and young children with cystic fibrosis: evaluation of treatment with intravenous hydrocortisone

The purpose of our study was to assess the effect on pulmonary function of adding intravenous hydrocortisone to the standard treatment of infants with cystic fibrosis (CF) hospitalized for lower respiratory illnesses (LRI). Twenty CF infants were randomized and received 10 days of hydrocortisone (10 mg/kg/day) or placebo in addition to standard treatment with intravenous antibiotics, chest physiotherapy, and an aerosolized beta-agonist with cromolyn. Functional residual capacity (FRC) and forced expiratory flows (V'mak,FRC) were measured on admission, on Day 10 of hospitalization, and as outpatients 1-2 months following hospital discharge. Pulmonary function values were adjusted for differences in body length and expressed as Z-scores. Upon admission flows were decreased, and FRC was increased in both groups; there were no differences between the groups. The change in pulmonary function from admission to Day 10 of hospitalization was not different for the two groups. From admission to outpatient follow-up after hospitalization, there was a significant increase in flows for the steroid group, but not for the placebo group. In addition, the direction of change in FRC was significantly different for the two groups; the steroid group had a small decrease in FRC, while the placebo group had a small increase in FRC. These findings suggest that the addition of intravenous hydrocortisone to the standard treatment of CF infants hospitalized for a LRI may produce a greater or a more sustained improvement in lung function following hospitalization.