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Castellazzi M, Candeloro R, Trevisan C, Permunian S, Buscemi G, Ghisellini S, Negri G, Gilli G, Ferri C, Bellini T, Pizzicotti S, Pugliatti M. Sex Differences in Albumin Quotient and Cerebrospinal Fluid Total Protein Content Do Not Depend on Anthropometric Factors. J Pers Med 2024; 14:362. [PMID: 38672989 PMCID: PMC11051272 DOI: 10.3390/jpm14040362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/19/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
(1) Background: Cerebrospinal fluid (CSF)/serum albumin quotient (QAlb) and CSF total protein (TP) are more elevated in males than females, and this has been hypothesised to be due to anthropometric differences between the sexes. This study aimed to investigate QAlb and CSF TP as a function of body height, weight, and body mass index (BMI). (2) Methods: A total of 207 patients were included in the study and analysed blinded to clinical diagnosis. (3) Results: Multivariable linear regressions were run to predict log-transformed Qalb and log-transformed CSF TP value from age, sex, weight, and height (first model) or from age, sex, and BMI (second model). In both models, age (β = 0.004, 95% CI = 0.002 to 0.006) and sex (β = -0.095, 95% CI = -0.169 to -0.021, and β = -0.135, 95% CI = -0.191 to -0.079) were significant predictors for QAlb, but weight, height, and BMI were not. Similarly, age (β = 0.004, 95% CI = 0.003 to 0.006) and sex (β = -0.077, 95% CI = -0.142 to -0.013, and β = -0.109, 95% CI = -0.157 to -0.060) were significant predictors for CSF TP, while anthropometric characteristics were not. No differences in QAlb and CSF TP were found when grouping males and females by BMI status. (4) Conclusions: Our data suggest that anthropometric characteristics could not explain the sex-related differences in QAlb and CSF TP.
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Affiliation(s)
- Massimiliano Castellazzi
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (S.P.); (G.B.); (G.G.); (T.B.); (M.P.)
- University Strategic Center for Studies on Gender Medicine, University of Ferrara, 44121 Ferrara, Italy
| | - Raffaella Candeloro
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (S.P.); (G.B.); (G.G.); (T.B.); (M.P.)
| | - Caterina Trevisan
- Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Samantha Permunian
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (S.P.); (G.B.); (G.G.); (T.B.); (M.P.)
| | - Gaia Buscemi
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (S.P.); (G.B.); (G.G.); (T.B.); (M.P.)
| | - Sara Ghisellini
- Chemical-Clinical Analysis Laboratory, “S. Anna” University Hospital, 44124 Ferrara, Italy; (S.G.); (G.N.); (S.P.)
| | - Giovanna Negri
- Chemical-Clinical Analysis Laboratory, “S. Anna” University Hospital, 44124 Ferrara, Italy; (S.G.); (G.N.); (S.P.)
| | - Giada Gilli
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (S.P.); (G.B.); (G.G.); (T.B.); (M.P.)
| | - Caterina Ferri
- Department of Neuroscience, “S. Anna” University Hospital, 44124 Ferrara, Italy;
| | - Tiziana Bellini
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (S.P.); (G.B.); (G.G.); (T.B.); (M.P.)
- University Strategic Center for Studies on Gender Medicine, University of Ferrara, 44121 Ferrara, Italy
| | - Stefano Pizzicotti
- Chemical-Clinical Analysis Laboratory, “S. Anna” University Hospital, 44124 Ferrara, Italy; (S.G.); (G.N.); (S.P.)
| | - Maura Pugliatti
- Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (R.C.); (S.P.); (G.B.); (G.G.); (T.B.); (M.P.)
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Madden J, Spadaro A, Koyfman A, Long B. High risk and low prevalence diseases: Guillain-Barré syndrome. Am J Emerg Med 2024; 75:90-97. [PMID: 37925758 DOI: 10.1016/j.ajem.2023.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023] Open
Abstract
INTRODUCTION Guillain-Barré syndrome (GBS) is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of GBS, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION GBS is a rare immune-mediated neurologic disorder with peripheral nerve injury. It most commonly presents weeks after a bacterial or viral infection, though there are a variety of associated inciting events. The diagnosis is challenging and often subtle, as only 25-30% of patients are diagnosed on their initial healthcare visit. Clinicians should consider GBS in patients with progressive ascending weakness involving the lower extremities associated with hyporeflexia, but the cranial nerves, respiratory system, and autonomic system may be involved. While the ED diagnosis should be based on clinical assessment, further evaluation includes laboratory testing, cerebrospinal fluid (CSF) analysis, and potentially neuroimaging. Not all patients demonstrate albumino-cytological dissociation on CSF testing. Several criteria exist to assist with diagnosis, including the National Institute of Neurological Disorders and Stroke criteria and the Brighton criteria. Management focuses first on assessment of the patient's hemodynamic and respiratory status, which may require emergent intervention. Significant fluctuations in heart rate and blood pressure may occur, and respiratory muscle weakness may result in the need for airway protection. Neurology consultation is recommended, and definitive treatment includes PLEX or IVIG. CONCLUSIONS An understanding of GBS can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Joshua Madden
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Fries FL, Kleiser B, Schwarz P, Tieck MP, Laichinger K, Mengel A, Ziemann U, Kowarik MC. Diagnosis of Froin's Syndrome by Parallel Analysis of Ventriculoperitoneal Shunt and Lumbar Cerebrospinal Fluid in a Patient with Cervical Spinal Stenosis. J Clin Med 2023; 12:5012. [PMID: 37568414 PMCID: PMC10419929 DOI: 10.3390/jcm12155012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
Elevated protein levels in cerebrospinal fluid (CSF) can occur in various pathologies and are sometimes difficult to interpret. We report a 62-year-old male patient with subacute neurological deterioration, progressive tetraparesis, and cytoalbumin dissociation in the lumbar CSF. The patient had a pre-existing cervical spinal stenosis with mild tetraparesis. Based on the initial cytoalbumin dissociation (protein 938 mg/dL, 4 leucocytes/µL), Guillain-Barré syndrome was initially considered. For further diagnosis, a CSF sample was taken from a pre-existing ventriculoperitoneal shunt, which showed a normal protein and cell count considering the patient's age (protein 70 mg/dL, 1 leucocyte/µL). In conclusion, we suggest that intermediate aggravation of tetraparesis was due to pneumonia with septic constellation, and the cytoalbumin dissociation was interpreted as Froin's syndrome (FS) due to spinal stenosis. In this unique case, we were able to prove the -often suspected- case of FS by parallel analysis of ventriculoperitoneal shunt and lumbar CSF. The triad of xanthochromia, high protein levels, and marked coagulation was first described by Georges Froin and occurs in various processes leading to severe spinal stenosis. The altered composition of lumbar CSF might be due to impaired CSF circulation; however, the exact mechanisms of this phenomenon require further investigation.
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Affiliation(s)
- Franca Laura Fries
- Department of Neurodegeneration, Center of Neurology, Hertie-Institute for Clinical Brain Research, University of Tuebingen, 72076 Tuebingen, Germany
- German Center for Neurodegenerative Diseases, University of Tuebingen, 72076 Tuebingen, Germany
| | - Benedict Kleiser
- Department of Epileptology, Hertie-Institute for Clinical Brain Research, University of Tuebingen, 72076 Tuebingen, Germany
| | - Patricia Schwarz
- Department of Neurology and Stroke, Hertie-Institute for Clinical Brain Research, University of Tuebingen, 72076 Tubingen, Germany; (P.S.); (M.P.T.); (K.L.); (A.M.); (U.Z.); (M.C.K.)
| | - Maria P. Tieck
- Department of Neurology and Stroke, Hertie-Institute for Clinical Brain Research, University of Tuebingen, 72076 Tubingen, Germany; (P.S.); (M.P.T.); (K.L.); (A.M.); (U.Z.); (M.C.K.)
| | - Kornelia Laichinger
- Department of Neurology and Stroke, Hertie-Institute for Clinical Brain Research, University of Tuebingen, 72076 Tubingen, Germany; (P.S.); (M.P.T.); (K.L.); (A.M.); (U.Z.); (M.C.K.)
| | - Annerose Mengel
- Department of Neurology and Stroke, Hertie-Institute for Clinical Brain Research, University of Tuebingen, 72076 Tubingen, Germany; (P.S.); (M.P.T.); (K.L.); (A.M.); (U.Z.); (M.C.K.)
| | - Ulf Ziemann
- Department of Neurology and Stroke, Hertie-Institute for Clinical Brain Research, University of Tuebingen, 72076 Tubingen, Germany; (P.S.); (M.P.T.); (K.L.); (A.M.); (U.Z.); (M.C.K.)
| | - Markus C. Kowarik
- Department of Neurology and Stroke, Hertie-Institute for Clinical Brain Research, University of Tuebingen, 72076 Tubingen, Germany; (P.S.); (M.P.T.); (K.L.); (A.M.); (U.Z.); (M.C.K.)
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Fautsch KJ, Block DR, Graff-Radford J, Wang F, Craver EC, Hodge DO, Cutsforth-Gregory JK, Kilgore KP, Petersen RC, Knopman DS, Flanagan E, Toledano M, Mielke MM, Bhatti MT, Chen JJ. Population-Based Evaluation of Total Protein in Cerebrospinal Fluid. Mayo Clin Proc 2023; 98:239-251. [PMID: 36737114 PMCID: PMC10134077 DOI: 10.1016/j.mayocp.2022.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 08/23/2022] [Accepted: 10/07/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To present a normal range of cerebrospinal fluid (CSF) protein levels in a community-based population and to evaluate factors that contribute to CSF protein level variability. PATIENTS AND METHODS Samples of CSF protein were obtained from participants aged 32 to 95 years who underwent lumbar puncture (LP) between November 1, 2007, and October 1, 2017, as part of the Mayo Clinic Study of Aging, a longitudinal, population-based study of residents of Olmsted County, Minnesota. RESULTS A total of 633 participants (58.1% male; 99.1% White; mean ± SD age, 70.9±11.6 years) underwent LP with recorded CSF protein level. Mean ± SD CSF protein level was 52.2±18.4 mg/dL (to convert to mg/L, multiply by 10), with a 95% reference interval of 24.0 to 93.4 mg/dL (range, 14.0-148.0 mg/dL). Spinal stenosis and arterial hypertension were associated with higher CSF protein levels on univariable analysis (P<.001). Increasing age, male sex, and diabetes were all independently associated with higher CSF protein levels on multivariable analysis (P<.001). In the 66 participants with repeated LPs within 2.5 years, the coefficient of repeatability was 26.1 mg/dL. Eleven participants (16.7%) had a CSF protein level difference of 20 mg/dL or more between serial LPs, and 4 (6.1%) had a difference of 25 mg/dL or more. There was a trend toward greater CSF protein level variability in patients with spinal stenosis (P=.054). CONCLUSION This large population-based study showed that CSF protein level can vary significantly among individuals. Elevated CSF protein level was independently associated with older age, male sex, and diabetes and is higher than listed in many laboratories. These findings emphasize the necessity of evidence-based reevaluation and standardization of CSF protein metrics.
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Affiliation(s)
- Kalli J Fautsch
- Department of Ophthalmology, Mayo Clinic, Rochester, MN; University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | - Darci R Block
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Feng Wang
- Department of Ophthalmology, Mayo Clinic, Rochester, MN
| | - Emily C Craver
- Department of Quantitative Health Sciences/Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - David O Hodge
- Department of Quantitative Health Sciences/Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | | | | | | | | | | | | | - Michelle M Mielke
- Department of Neurology, Mayo Clinic, Rochester, MN; Department of Quantitative Health Sciences, Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - M Tariq Bhatti
- Department of Ophthalmology, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN
| | - John J Chen
- Department of Ophthalmology, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN.
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Aladawi M, Elfil M, Abu-Esheh B, Abu Jazar D, Armouti A, Bayoumi A, Piccione E. Guillain Barre Syndrome as a Complication of COVID-19: A Systematic Review. Can J Neurol Sci 2022; 49:38-48. [PMID: 33949300 PMCID: PMC8267336 DOI: 10.1017/cjn.2021.102] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/04/2021] [Accepted: 04/28/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND In January 2020, the first case of Guillain Barre syndrome (GBS) due to COVID-19 was documented in China. GBS is known to be postinfectious following several types of infections. Although causality can only be proven through large epidemiological studies, we intended to study this association by a thorough review of the literature. METHODS We searched PubMed, EMBASE, and Google scholar and included all papers with English or Spanish full text and original data of patients with GBS and recent COVID infection. Variables of interest were demographics, diagnostic investigations, and the latency between arboviral and neurological symptoms. Further variables were pooled to identify GBS clinical and electrophysiological variants, used treatments, and outcomes. The certainty of GBS diagnosis was verified using Brighton criteria. RESULTS We identified a total of 109 GBS cases. Ninety-nine cases had confirmed COVID-19 infection with an average age of 56.07 years. The average latency period between the arboviral symptoms and neurologic manifestations for confirmed COVID-19 cases was 12.2 d. The predominant GBS clinical and electromyography variants were the classical sensorimotor GBS and acute demyelinating polyneuropathy respectively. Forty cases required intensive care, 33 cases required mechanical ventilation, and 6 cases were complicated by death. CONCLUSIONS Studies on COVID-19-related GBS commonly reported sensorimotor demyelinating GBS with frequent facial palsy. The time between the onset of infectious and neurological symptoms suggests a postinfectious mechanism. Early diagnosis of GBS in COVID-19 patients is important as it might be associated with a severe disease course requiring intensive care and mechanical ventilation.
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Affiliation(s)
- Mohammad Aladawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Baha Abu-Esheh
- Department of Neurology, Mercy Hospital, Oklahoma City, Oklahoma, USA
| | - Deaa Abu Jazar
- Department of Neurology, University of Texas Medical Branch – Galveston, Galveston, Texas, USA
| | - Ahmad Armouti
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Ahmed Bayoumi
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Ezequiel Piccione
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Castellazzi M, Pizzicotti S, Lombardo I, Alfiero S, Morotti A, Pellegatti P, Negri G, Natali L, Ferri C, Fainardi E, Bellini T, Pugliatti M. Sexual dimorphism in the cerebrospinal fluid total protein content. Clin Chem Lab Med 2021; 58:1885-1890. [PMID: 32598300 DOI: 10.1515/cclm-2020-0419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/18/2020] [Indexed: 11/15/2022]
Abstract
Objectives Cerebrospinal fluid (CSF) is a clear, colorless body fluid filling the central nervous system. The determination of the CSF total protein (TP) content represents an important screening test of various pathologies. We aimed to address the effect of sex and age on CSF-TP content and the use of the current upper reference limits (URLs). Methods CSF-TP content was analysed in a selected population of 1,252 patients (648 women and 604 men; age 18-89 years) who underwent lumbar puncture as a part of the diagnostic work-up. Samples presenting (i) more than 5 white blood cells (WBC)/µL, (ii) discolorations and (iii) reduced glucose were not included. Results The CSF-TP content median values were significantly higher in men than in women (46 vs. 37 mg/dL) even after adjusting for age and different hospital inpatients. CSF-TP content positively correlated with age both in men and in women with a constant difference between sexes of 8.5 mg/dL. Applying the most used URLs (mainly 45 and 50 mg/dL, but also 60 mg/dL), men received a laboratory report suggestive of altered CSF-TP content more frequently than women. The use of age- and sex-calibrated CSF-TP URLs reduced, but not eliminated, this sex-gap. Conclusions Using the current URLs, a condition of "elevated CSF-TP content" may be overestimated in men or, conversely, underestimated in women, regardless of the age and of the diagnosis. These results highlighted the need to apply CSF-TP URLs values normalized for both sex and age.
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Affiliation(s)
- Massimiliano Castellazzi
- Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
- Interdepartmental Research Center for the Study of Multiple Sclerosis and Inflammatory and Degenerative Diseases of the Nervous System, University of Ferrara, Ferrara, Italy
| | - Stefano Pizzicotti
- Chemical-Clinical Analysis Laboratory, "S. Anna" University Hospital, Ferrara, Italy
| | - Ilenia Lombardo
- Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Sarah Alfiero
- Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Patrizia Pellegatti
- Chemical-Clinical Analysis Laboratory, "S. Anna" University Hospital, Ferrara, Italy
| | - Giovanna Negri
- Chemical-Clinical Analysis Laboratory, "S. Anna" University Hospital, Ferrara, Italy
| | - Lara Natali
- Chemical-Clinical Analysis Laboratory, "S. Anna" University Hospital, Ferrara, Italy
| | - Caterina Ferri
- Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Enrico Fainardi
- Interdepartmental Research Center for the Study of Multiple Sclerosis and Inflammatory and Degenerative Diseases of the Nervous System, University of Ferrara, Ferrara, Italy
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Tiziana Bellini
- Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
- University Center for Studies on Gender Medicine, University of Ferrara, Ferrara, Italy
| | - Maura Pugliatti
- Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
- Interdepartmental Research Center for the Study of Multiple Sclerosis and Inflammatory and Degenerative Diseases of the Nervous System, University of Ferrara, Ferrara, Italy
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Yoshihara T, Zaitsu M, Ito K, Hanada R, Chung E, Yazawa R, Sakata Y, Furusho K, Tsukikawa H, Chiyoda T, Matsuki S, Irie S. Cerebrospinal Fluid Protein Concentration in Healthy Older Japanese Volunteers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168683. [PMID: 34444430 PMCID: PMC8391590 DOI: 10.3390/ijerph18168683] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/13/2021] [Accepted: 08/15/2021] [Indexed: 11/23/2022]
Abstract
The concentration of cerebrospinal fluid total protein (CSF-TP) is important for the diagnosis of neurological emergencies. Recently, some Western studies have shown that the current upper reference limit of CSF-TP is quite low for older patients. However, little is reported about the concentration of CSF-TP in the older Asian population. In this study, we retrospectively analyzed the CSF-TP concentrations in healthy older Japanese volunteers. CSF samples in 69 healthy Japanese volunteers (age range: 55–73 years) were collected by lumbar puncture, and the data of CSF were retrospectively analyzed. The mean (standard deviation) CSF-TP was 41.7 (12.3) mg/dL. The older group (≥65 years old) had higher CSF-TP concentration than the younger group (55–64 years old). The 2.5th percentile and 97.5th percentile of CSF-TP were estimated as 22.5 and 73.2 mg/dL, respectively, which were higher than the current reference range in Japan (10–40 mg/dL). Conclusions: The reference interval of CSF-TP in the older population should be reconsidered for the precise diagnosis of neurological emergencies.
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Affiliation(s)
- Tatsuya Yoshihara
- SOUSEIKAI Fukuoka Mirai Hospital Clinical Research Center, Kashiiteriha 3-5-1, Higashi-ku, Fukuoka 813-0017, Japan; (K.F.); (H.T.); (S.M.); (S.I.)
- Correspondence: ; Tel.: +81-92-662-3608
| | - Masayoshi Zaitsu
- Department of Public Health, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu-machi, Shimotsuga-gun, Tochigi 321-0293, Japan;
| | - Kazuya Ito
- SOUSEIKAI Clinical Epidemiological Research Center, Kashiiteriha 3-5-1, Higashi-ku, Fukuoka 813-0017, Japan;
- College of Healthcare Management, Takayanagi 960-4, Setaka-machi, Miyama 835-0018, Japan
| | - Ryuzo Hanada
- SOUSEIKAI Sumida Hospital, 1-29-1, Honjo, Sumida-ku, Tokyo 130-0004, Japan; (R.H.); (R.Y.); (Y.S.); (T.C.)
| | - Eunhee Chung
- SOUSEIKAI Global Clinical Research Center, Kashiiteriha 3-5-1, Higashi-ku, Fukuoka 813-0017, Japan;
| | - Rie Yazawa
- SOUSEIKAI Sumida Hospital, 1-29-1, Honjo, Sumida-ku, Tokyo 130-0004, Japan; (R.H.); (R.Y.); (Y.S.); (T.C.)
| | - Yukikuni Sakata
- SOUSEIKAI Sumida Hospital, 1-29-1, Honjo, Sumida-ku, Tokyo 130-0004, Japan; (R.H.); (R.Y.); (Y.S.); (T.C.)
| | - Koki Furusho
- SOUSEIKAI Fukuoka Mirai Hospital Clinical Research Center, Kashiiteriha 3-5-1, Higashi-ku, Fukuoka 813-0017, Japan; (K.F.); (H.T.); (S.M.); (S.I.)
| | - Hiroshi Tsukikawa
- SOUSEIKAI Fukuoka Mirai Hospital Clinical Research Center, Kashiiteriha 3-5-1, Higashi-ku, Fukuoka 813-0017, Japan; (K.F.); (H.T.); (S.M.); (S.I.)
| | - Takeshi Chiyoda
- SOUSEIKAI Sumida Hospital, 1-29-1, Honjo, Sumida-ku, Tokyo 130-0004, Japan; (R.H.); (R.Y.); (Y.S.); (T.C.)
| | - Shunji Matsuki
- SOUSEIKAI Fukuoka Mirai Hospital Clinical Research Center, Kashiiteriha 3-5-1, Higashi-ku, Fukuoka 813-0017, Japan; (K.F.); (H.T.); (S.M.); (S.I.)
| | - Shin Irie
- SOUSEIKAI Fukuoka Mirai Hospital Clinical Research Center, Kashiiteriha 3-5-1, Higashi-ku, Fukuoka 813-0017, Japan; (K.F.); (H.T.); (S.M.); (S.I.)
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Abstract
What is in the Literature focuses on peripheral neuropathies with new and practical information related to the diagnosis, treatment, and management. Diagnostic and treatment guidelines are available for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) but not all clinicians follow them resulting in erroneous diagnoses and prolonged treatment. Secondary axonal loss in CIDP causes increased connective tissue in muscle. Antibodies to proteins at the node of Ranvier are found in a small percentage of patients with CIDP. The differential diagnosis for CIDP-like neuropathies includes amyloid neuropathy and POEMS (polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes) and amyloidosis. Upper limits for cerebral spinal fluid protein are 0.45 g/L and cell count <10/µL, but both may be too low. Hyperactive reflexes may occur in Guillain-Barré syndrome and should not exclude the diagnosis. In severely affected Guillain-Barré syndrome patients, a second dose of intravenous immune globulin within 4 weeks of onset is not likely to be effective.
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Berek K, Bsteh G, Auer M, Di Pauli F, Zinganell A, Berger T, Deisenhammer F, Hegen H. Cerebrospinal Fluid Findings in 541 Patients With Clinically Isolated Syndrome and Multiple Sclerosis: A Monocentric Study. Front Immunol 2021; 12:675307. [PMID: 34220821 PMCID: PMC8248497 DOI: 10.3389/fimmu.2021.675307] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background Reports on typical routine cerebrospinal fluid (CSF) findings are outdated owing to novel reference limits (RL) and revised diagnostic criteria of Multiple Sclerosis (MS). Objective To assess routine CSF parameters in MS patients and the frequency of pathologic findings by applying novel RL. Methods CSF white blood cells (WBC), CSF total protein (CSF-TP), CSF/serum albumin quotient (Qalb), intrathecal synthesis of immunoglobulins (Ig) A, M and G, oligoclonal IgG bands (OCB) were determined in patients with clinically isolated syndrome (CIS) and MS. Results Of 541 patients 54% showed CSF pleocytosis with a WBC count up to 40/μl. CSF cytology revealed lymphocytes, monocytes and neutrophils in 99%, 41% and 9% of patients. CSF-TP and Qalb were increased in 19% and 7% applying age-corrected RL as opposed to 34% and 26% with conventional RL. Quantitative intrathecal IgG, IgA and IgM synthesis were present in 65%, 14% and 21%; OCB in 95% of patients. WBC were higher in relapsing than progressive MS and predicted, together with monocytes, the conversion from CIS to clinically definite MS. Intrathecal IgG fraction was highest in secondary progressive MS. Conclusions CSF profile in MS varies across disease courses. Blood-CSF-barrier dysfunction and intrathecal IgA/IgM synthesis are less frequent when the novel RL are applied.
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Affiliation(s)
- Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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10
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Stolte B, Nonnemacher M, Kizina K, Bolz S, Totzeck A, Thimm A, Wagner B, Deuschl C, Kleinschnitz C, Hagenacker T. Nusinersen treatment in adult patients with spinal muscular atrophy: a safety analysis of laboratory parameters. J Neurol 2021; 268:4667-4679. [PMID: 33899154 PMCID: PMC8563549 DOI: 10.1007/s00415-021-10569-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/29/2022]
Abstract
Background Nusinersen is an intrathecally administered antisense oligonucleotide (ASO) that improves motor function in patients with spinal muscular atrophy (SMA). In addition to efficacy, the safety of a therapy is the decisive factor for the success of the treatment. For some ASOs, various organ toxicities have been described, such as thrombocytopenia, renal and liver impairment, or coagulation abnormalities. However, systematic data on laboratory parameters under treatment with nusinersen are mainly available from studies in infants and children. Therefore, our aim was to assess the safety of nusinersen therapy in adult SMA patients. Methods Laboratory data from 404 nusinersen injections performed in 50 adult patients with SMA type 2 and type 3 were retrospectively analyzed. Results The total observation period was 76.9 patient-years, and patients received up to 12 injections. Our data provides no new safety concerns. In cerebrospinal fluid (CSF), the mean white blood cell count and lactate remained stable over time. Total CSF protein increased by 2.9 mg/dL. No change in mean platelet count was observed under therapy. Only one patient showed sporadic mild thrombocytopenia. Coagulation parameters and inflammatory markers were stable. The mean creatinine level decreased by 0.09 mg/dL. Analysis of mean liver enzyme levels revealed no relevant changes during treatment. Conclusion Our data demonstrate a favorable safety profile of nusinersen therapy in adult SMA patients under longer-term “real-world” conditions. In particular, we found no evidence of clinically relevant platelet declines, coagulopathies, or renal or hepatic organ toxicities, which are common concerns with the use of ASOs. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10569-8.
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Affiliation(s)
- Benjamin Stolte
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational and Behavioral Neuroscience, University Hospital Essen, Essen, Germany
| | - Michael Nonnemacher
- Institute for Medical Informatics, Biometrics and Epidemiology, University Hospital Essen, Essen, Germany
| | - Kathrin Kizina
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational and Behavioral Neuroscience, University Hospital Essen, Essen, Germany
| | - Saskia Bolz
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational and Behavioral Neuroscience, University Hospital Essen, Essen, Germany
| | - Andreas Totzeck
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational and Behavioral Neuroscience, University Hospital Essen, Essen, Germany
| | - Andreas Thimm
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational and Behavioral Neuroscience, University Hospital Essen, Essen, Germany
| | - Bernd Wagner
- Department of Clinical Chemistry, University Hospital Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany.,Center for Translational and Behavioral Neuroscience, University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational and Behavioral Neuroscience, University Hospital Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany. .,Center for Translational and Behavioral Neuroscience, University Hospital Essen, Essen, Germany.
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11
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Allen JA, Merkies ISJ, Lewis RA. Monitoring Clinical Course and Treatment Response in Chronic Inflammatory Demyelinating Polyneuropathy During Routine Care: A Review of Clinical and Laboratory Assessment Measures. JAMA Neurol 2021; 77:1159-1166. [PMID: 32338716 DOI: 10.1001/jamaneurol.2020.0781] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Identifying clinical change in many neurologic diseases, including chronic inflammatory demyelinating polyneuropathy (CIDP), can be challenging. At the same time, how change is defined heavily influences a patient's diagnostic and treatment pathway. It can be especially problematic when equivocal subjective observations are interpreted as clinically meaningful and then used to make diagnostic and treatment decisions. Change in clinical trials is strictly defined by a preselected metric, but there is a perception that formal outcomes collection during routine clinical care is neither feasible nor necessary. Given the importance placed on how change is interpreted, there is a need to select assessments that can be applied to routine care that are representative of the neurologic disease state. Observations For an outcome measure to be useful during clinical trials, it must have good reliability, validity, be responsive to change, and have clinical meaning. To be useful during routine clinical care, the assessment must additionally be easy to collect without the need for extensive training or equipment and should provide an immediately available result that can be rapidly quantified and interpreted. Chronic inflammatory demyelinating polyneuropathy is clinically heterogeneous and so is best evaluated with a diverse group of assessment tools. Assessing strength impairment, disability, and quality of life is ideally suited for everyday practice when caring for patients with CIDP. While electrophysiologic studies, imaging, cerebrospinal fluid, and nodal/paranodal antibodies can provide diagnostic data, they are less practical and helpful longitudinal assessment tools. Conclusions and Relevance Sound clinimetric outcome measures in CIDP are widely available and have the potential to help clinicians objectify treatment response and disease progression. Such data are critically important when justifying the need for ongoing or periodic immunotherapy, documenting relapse or deterioration, or providing reassurance of disease improvement, stability, or remission.
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Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis
| | - Ingemar S J Merkies
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, the Netherlands.,Department of Neurology, St Elisabeth Hospital, Willemstad, Curaçao
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California
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12
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Rath J, Zulehner G, Schober B, Grisold A, Krenn M, Cetin H, Zimprich F. Cerebrospinal fluid analysis in Guillain-Barré syndrome: value of albumin quotients. J Neurol 2021; 268:3294-3300. [PMID: 33651153 PMCID: PMC8357680 DOI: 10.1007/s00415-021-10479-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 11/23/2022]
Abstract
Background Albuminocytologic dissociation in cerebrospinal fluid (CSF) is a diagnostic hallmark of Guillain–Barré syndrome (GBS). Compared to CSF total protein (TP), the CSF/serum albumin quotient (Qalb) has the advantage of method-independent reference ranges. Whether the diagnostic yield differs between Qalb and CSF-TP is currently unknown. Methods We retrospectively analyzed the diagnostic yield (i.e., a value above the URL indicating blood–nerve barrier dysfunction) of Qalb and CSF-TP levels in patients with GBS. We evaluated two different equations (Reiber’s and Hegen’s) for age-adjusted URLs of Qalb and compared results to CSF-TP using the standard URL of 0.45 g/L as well as age-adjusted URLs (by decade of age). Additionally, multivariable logistic regression analysis was used to assess the effect of clinical factors on the diagnostic yield. Results We analyzed 110 patients [62% males; median age 48 (IQR 35–58)] with sensorimotor (68), motor (16), sensory (12) and localized (8) GBS as well as Miller Fisher syndrome (6). Qalb and CSF-TP were highly correlated (r = 0.95, p < 0.001). The diagnostic yield of Qalb was 65% with Reiber’s and 47% with Hegen’s age-adjusted URLs compared to 66% with the fixed CSF-TP URL of 0.45 g/L and 49% with age-adjusted CSF-TP URLs. A longer duration from clinical onset to lumbar puncture was associated with a higher diagnostic yield. Conclusion Qalb strongly correlates with CSF-TP in patients with GBS with a similar diagnostic yield for the detection of a blood–nerve barrier dysfunction. However, the diagnostic yield of both values is lower when using more recent age-adjusted URLs and at earlier timepoints.
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Affiliation(s)
- Jakob Rath
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Gudrun Zulehner
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Bernadette Schober
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Anna Grisold
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Martin Krenn
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Hakan Cetin
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Fritz Zimprich
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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13
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Hegen H, Ladstätter F, Bsteh G, Auer M, Berek K, Di Pauli F, Walde J, Wanschitz J, Zinganell A, Deisenhammer F. Cerebrospinal fluid protein in Guillain-Barré syndrome: Need for age-dependent interpretation. Eur J Neurol 2020; 28:965-973. [PMID: 33073472 PMCID: PMC7898894 DOI: 10.1111/ene.14600] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Elevated cerebrospinal fluid (CSF) total protein in patients with acute ascending paresis is indicative of Guillain-Barré syndrome (GBS). Recent studies showed that the outdated, but still widely used upper reference limit (URL) for CSF total protein of 0.45 g/L leads to false-positive results, mainly as a result of lack of age-adjustment. The objective of this study was to assess the frequency of increased CSF total protein in adult GBS patients according to a new age-dependent URL. METHODS Patients with GBS treated at the Medical University of Innsbruck between 2000 and 2018 were included in this study. Demographic, clinical, electrophysiological and CSF data were obtained from patients' medical charts. Frequency of increased CSF total protein depending on disease duration was compared using the conventional URL of 0.45 g/L and the age-dependent URL. RESULTS Ninety-seven patients with GBS aged 57 ± 18 years, comprising 38% women, underwent CSF sampling within a median of 6 days after symptom onset. The median CSF total protein concentration was 0.65 g/L and correlated with disease duration. Overall, 74% of patients had elevated CSF total protein levels using the conventional URL, as opposed to 52% applying the age-dependent URL. At 0-3, 4-7, 8-14 and >14 days after disease onset, elevated CSF total protein was found in 46%, 84%, 78% and 100% of patients using the conventional URL, and in 32%, 53%, 65% and 64% of patients using the age-dependent URL. In multivariate analysis, significant predictors of elevated CSF total protein were disease duration and the demyelinating GBS variant. Similar results were obtained for CSF/serum albumin quotient (Qalb ). CONCLUSION Fewer true-positives for CSF total protein and Qalb must be considered in suspected GBS, especially in the early disease course.
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Affiliation(s)
- Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Ladstätter
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Berek
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Janette Walde
- Department of Statistics, Faculty of Economics and Statistics, University of Innsbruck, Innsbruck, Austria
| | - Julia Wanschitz
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anne Zinganell
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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14
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Abstract
There is a growing realization that many patients are incorrectly diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP), with at least half of patients that carry a diagnosis of CIDP in the USA possibly having a different explanation for their neuropathy or having no neuropathy at all. Many misdiagnosed patients go on to receive costly and potentially harmful treatments for a disease that they do not have, while at the same time missing an opportunity to treat their true ailment. The cost of misdiagnosis on patients and society is not trivial. Many factors contribute to misdiagnosis. Particular points of vulnerability include the evaluation of "atypical" CIDP, interpretation of equivocal nerve conduction studies, over-reliance on elevations in cerebrospinal fluid protein concentration in indeterminate ranges, and placing excessive diagnostic weight on subjective changes following the initiation of immunotherapy. In addition to heighted awareness of the challenges, adherence to CIDP diagnostic guidelines, utilization of objective metrics to document clinical change, and referrals to CIDP centers of excellence are strategies that may improve diagnostic accuracy.
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Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, USA.
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15
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Bourque PR, Breiner A. Cerebrospinal Fluid in Posterior Reversible Encephalopathy Syndrome. Neurohospitalist 2019; 9:125. [PMID: 31244966 DOI: 10.1177/1941874419847364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Pierre R Bourque
- Department of Medicine (Neurology), University of Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ari Breiner
- Department of Medicine (Neurology), University of Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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16
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Bourque PR, Brooks J, Warman-Chardon J, Hegen H, Deisenhammer F, McCudden CR, Breiner A. Dataset for worldwide survey of cerebrospinal total protein upper reference values. Data Brief 2019; 23:103760. [PMID: 31193022 PMCID: PMC6514267 DOI: 10.1016/j.dib.2019.103760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/06/2019] [Accepted: 02/08/2019] [Indexed: 11/01/2022] Open
Abstract
This article reports data pertaining to a worldwide web-based survey referenced in the publication "Adult CSF Total Protein: Higher upper reference limits should be considered worldwide " (P.R. Bourque, et al., 2019). This survey was distributed to corresponding authors of the journal Neurology and the Journal of neurological sciences for the period of Jan-Dec 2017. The response rate was 36.9%. Additional results were collated through networking and national associations. There were 473 unique responses from clinical hospital laboratories in 69 countries: North America 178, South America 26, Europe 139, Africa 20, Asia 102 and Oceania 8. The upper reference limit for cerebrospinal fluid total protein ranged from 0.2 g/L to 0.8 g/L. 86.8% of the survey responses were 0.45 g/L or less. Data is presented separately for tertiary/academic and non-university/community centers.
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Affiliation(s)
- Pierre R Bourque
- Division of Neurology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Brooks
- Division of Neurology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Jodi Warman-Chardon
- Division of Neurology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Harald Hegen
- Department of Neurology, Neuroimmunology Laboratory, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Deisenhammer
- Department of Neurology, Neuroimmunology Laboratory, Medical University of Innsbruck, Innsbruck, Austria
| | - Chris R McCudden
- Department of Pathology & Laboratory Medicine, The Ottawa Hospital and University of Ottawa, Ontario, Canada
| | - Ari Breiner
- Division of Neurology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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17
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Bourque PR, Brooks J, McCudden CR, Warman-Chardon J, Breiner A. Age matters: Impact of data-driven CSF protein upper reference limits in Guillain-Barré syndrome. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e576. [PMID: 31355312 PMCID: PMC6624106 DOI: 10.1212/nxi.0000000000000576] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/28/2019] [Indexed: 11/17/2022]
Abstract
Objective We conducted a retrospective review of patients with a diagnosis of Guillain-Barré syndrome (GBS) to assess the diagnostic impact of applying age-adjusted upper limits for CSF total protein (CSF-TP) supported by a systematic literature review. Methods Cases coded as GBS or inflammatory neuropathy for the period 2001–2016 at The Ottawa Hospital were reviewed. Cases were included if they met the Brighton criteria for GBS with a diagnostic certainty level 1 or 2 and had contemporaneous CSF-TP data. We excluded cases with CSF pleocytosis >50 and cases with Miller-Fisher syndrome. Age-adjusted reference limits were compared with conventional 0.45 and 0.6 g/L upper limits. Results One hundred thirty-eight cases met the study criteria, with a mean age of 47 years. The mean interval from symptom onset to lumbar puncture was 7.9 days, and mean CSF-TP was 1.23 g/L. There was a strong correlation between rising CSF-TP and time to lumbar puncture. Age-adjusted CSF-TP had a significantly lower sensitivity of only 45% in the first week (32% in the first 3 days) compared with 70% in the first week for the 0.45 g/L limit. All upper limits gained high sensitivity after the first week. Conclusions The low sensitivity of CSF-TP for the diagnosis of GBS is exacerbated by age-adjusted upper limits. The main role of lumbar puncture in GBS in the first week may be to help exclude other inflammatory or neoplastic etiologies of acute neuropathy. After the first week, the magnitude of the CSF-TP rise reduces the effect of different upper reference limits.
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Affiliation(s)
- Pierre R Bourque
- The Ottawa Hospital (P.R.B., J.B., J.W.-C., A.B.), University of Ottawa; The Ottawa Hospital Research Institute (P.R.B., C.R.M., J.W.-C., A.B.); and Department of Pathology and Laboratory Medicine (C.R.M.), The Ottawa Hospital, Ottawa, Canada
| | - John Brooks
- The Ottawa Hospital (P.R.B., J.B., J.W.-C., A.B.), University of Ottawa; The Ottawa Hospital Research Institute (P.R.B., C.R.M., J.W.-C., A.B.); and Department of Pathology and Laboratory Medicine (C.R.M.), The Ottawa Hospital, Ottawa, Canada
| | - Christopher R McCudden
- The Ottawa Hospital (P.R.B., J.B., J.W.-C., A.B.), University of Ottawa; The Ottawa Hospital Research Institute (P.R.B., C.R.M., J.W.-C., A.B.); and Department of Pathology and Laboratory Medicine (C.R.M.), The Ottawa Hospital, Ottawa, Canada
| | - Jodi Warman-Chardon
- The Ottawa Hospital (P.R.B., J.B., J.W.-C., A.B.), University of Ottawa; The Ottawa Hospital Research Institute (P.R.B., C.R.M., J.W.-C., A.B.); and Department of Pathology and Laboratory Medicine (C.R.M.), The Ottawa Hospital, Ottawa, Canada
| | - Ari Breiner
- The Ottawa Hospital (P.R.B., J.B., J.W.-C., A.B.), University of Ottawa; The Ottawa Hospital Research Institute (P.R.B., C.R.M., J.W.-C., A.B.); and Department of Pathology and Laboratory Medicine (C.R.M.), The Ottawa Hospital, Ottawa, Canada
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18
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Breiner A, Bourque PR, Allen JA. Updated cerebrospinal fluid total protein reference values improve chronic inflammatory demyelinating polyneuropathy diagnosis. Muscle Nerve 2019; 60:180-183. [DOI: 10.1002/mus.26488] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Ari Breiner
- Department of Medicine, Division of NeurologyThe Ottawa Hospital, University of Ottawa 1053 Carling Ave, Room ES‐08, Ottawa M5G 2C4 Ontario Canada
- Ottawa Hospital Research Institute Ottawa Ontario Canada
| | - Pierre R. Bourque
- Department of Medicine, Division of NeurologyThe Ottawa Hospital, University of Ottawa 1053 Carling Ave, Room ES‐08, Ottawa M5G 2C4 Ontario Canada
- Ottawa Hospital Research Institute Ottawa Ontario Canada
| | - Jeffrey A. Allen
- Department of NeurologyNorthwestern University Chicago Illinois USA
- Department of NeurologyUniversity of Minnesota Minneapolis Minnesota USA
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A Survey of Cerebrospinal Fluid Total Protein Upper Limits in Canada: Time for an Update? Can J Neurol Sci 2019; 46:283-286. [PMID: 30915935 DOI: 10.1017/cjn.2019.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The antiquated standard reference range of 0.15-0.45 g/L for cerebrospinal fluid total protein (CSF-TP) is well entrenched in medical literature and laboratory operating procedures across the world. METHODS We conducted a web-based survey with a response rate of 34.9% through the listserv of the Canadian Neurological Sciences Federation. Additional laboratory reference data were collated by telephone interview of hospital laboratory technologists across Canada. RESULTS A total of 142 site responses were obtained: 64.1% from academic/tertiary hospitals and 35.9% from community hospitals. A strong majority (80.4%) of both types of institutions reported using a CSF-TP upper reference limit of 0.45 g/L or less. As a rule, no age adjustments were implemented in CSF-TP-level interpretation. CONCLUSIONS Recent well-powered laboratory reference studies have documented CSF-TP upper reference limits that are above 0.6 g/L starting at age 50, with incremental limits partitioned by subsequent decades of age. The conventional 0.45 g/L limit could lead to false positive results. Our survey suggests there is a need to consider a wide adoption of data-driven, rather than historical, reference values.
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