High Dose Steroids as First-Line Treatment Increased the Risk of In-Hospital Infections in Patients With Anti-NMDAR Encephalitis

Does the Use of Intravenous Immunoglobulin Improve Clinical Outcomes in Adults With Autoimmune Encephalitis? A Systematic Review

BACKGROUND

Autoimmune encephalitis is an immune-mediated inflammatory condition affecting the central nervous system. Current best-practice guidelines recommend intravenous immunoglobulin (IVIG) for use if corticosteroids are ineffective, but the evidence surrounding the efficacy of IVIG in autoimmune encephalitis is yet to be evaluated.

OBJECTIVES

Perform a systematic review of the available literature to evaluate the efficacy of IVIG in autoimmune encephalitis and the impact of IVIG on clinical outcomes.

METHODS

This systematic review was written following PRISMA-S guidelines. Papers eligible for inclusion were primary research including adults aged 16 years and above, with a suspected or confirmed diagnosis of autoimmune encephalitis, treated using IVIG. Each included study was assessed for quality.

RESULTS AND CONCLUSION

From 2533 records, 27 studies met the inclusion criteria. The use of IVIG is associated with improved short-term and long-term neurological outcomes. There is evidence that IVIG may be more effective when used in combination with corticosteroids. The use of IVIG is significantly associated with reduced seizure incidence in patients. Where recorded, adverse effects related to IVIG were few. There is insufficient data available on how IVIG impacts mortality rates, discharge rates, and its effects according to different types of autoimmune encephalitis. Out of the included papers, there was 1 randomized controlled trial (RCT), 3 nonrandomized trials and 23 cohort studies. 25 of 27 papers were deemed to have a high or serious risk of bias. Heterogeneous study design and the quality of studies were major limiting factors for this review, highlighting the need for further research.

Clinical features and factors associated with outcomes of antibody-negative autoimmune encephalitis in patients requiring intensive care

BACKGROUND AND OBJECTIVES

Antibody-negative autoimmune encephalitis (AE) is a form of encephalitis characterized by the absence of detectable autoimmune antibodies, despite immunological evidence. However, data on management of patients with antibody-negative AE in the intensive care unit (ICU) are limited. This study aimed to explore the characteristics and subtypes of antibody-negative AE, assess the effects of immunotherapy, and identify factors independently associated with poor functional outcomes in patients requiring intensive care.

METHODS

This retrospective, single-center study analyzed consecutive adult patients diagnosed with antibody-negative AE and admitted to the ICU of a large tertiary hospital between 2019 and 2023. Multivariate regression analysis was used to identify factors linked to poor functional outcomes six months after ICU admission, as defined by a modified Rankin Scale score of 3-6. Generalized linear mixed models were applied to evaluate the effect of immunotherapy on longitudinal changes in the Clinical Assessment Scale in Autoimmune Encephalitis and modified Rankin Scale scores.

RESULTS

Of the 1220 patients with severe encephalitis admitted to the ICU, 107 were diagnosed with antibody-negative AE and included in the analysis. Six months after ICU admission, 67 patients (62.6%) had poor functional outcomes, including 28 deaths (26.2%). Factors independently associated with poor outcomes were high-dose corticosteroid therapy (odds ratio [OR] 8.734, 95% confidence interval [CI] 2.483-30.717), older age at onset (OR 1.063, 95% CI 1.028-1.099), acute respiratory failure at ICU admission (OR 10.931, 95% CI 2.062-57.751), and dyskinesia/dystonia (OR 14.109, 95% CI 1.336-148.957). The generalized linear mixed model also indicated that high-dose corticosteroid therapy was associated with poorer longitudinal outcomes.

CONCLUSIONS

While high-dose corticosteroids are frequently used to treat AE, their risks may outweigh their benefits in severe antibody-negative AE cases. Older patients and those with dyskinesia/dystonia or respiratory failure, may require more careful monitoring and timely intervention for improved outcomes. However, prospective validation of these findings is necessary to confirm their applicability and guide future treatment strategies.

Monocyte-to-lymphocyte ratio is a prognostic predictor for patients with non-small cell lung cancer treated with stereotactic body radiation therapy

Background

The monocyte-to-lymphocyte ratio (MLR), a systemic inflammation biomarker, has been shown to predict patient outcomes in several types of cancer. This study aimed to determine the association between MLR and local control (LC) and cause-specific survival (CSS) rates in patients with non-small cell lung cancer (NSCLC) treated with stereotactic body radiation therapy (SBRT).

Materials and methods

The median age of the 194 included participants (144 men, 50 women) was 80 (range, 50-96) years. The median follow-up period was 19 (range, 1-108) months. The LC and CSS rates were calculated using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazard regression models were used to estimate the LC and CSS rates.

Results

Local recurrence was observed in 25 patients during the follow-up. Univariate Cox proportional hazards regression analysis revealed that MLR, performance status, and tumor diameter were significant factors for LC. Multivariate analysis showed MLR and tumor diameter as significant factors (p = 0.041 and 0.031, respectively). The 1- and 2-year LC rates for the lower and higher MLR groups were 97.5% and 97.5%, and 89.7% and 81.2%, respectively. During the follow-up period, 14 patients died due to NSCLC. Although MLR tended to predict CSS in univariate analysis (p = 0.086), none of the parameters was significant in predicting CSS. However, MLR as a continuous variable was a significant factor for CSS in the univariate analysis (p = 0.004).

Conclusions

Our data suggest that MLR is correlated with LC and CSS rates in NSCLC patients treated with SBRT.

Blood and CSF findings of cellular immunity in anti-NMDAR encephalitis

OBJECTIVES

To investigate the immunopathogenic mechanisms of anti-N-methyl-D-aspartate receptor encephalitis (NMDAR-E) by characterizing the changes of immune cells in both peripheral blood (PB) and cerebrospinal fluid (CSF) of patients with NMDAR-E.

METHODS

Cytology and flow cytometry were used to explore and compare different immunological parameters in PB and CSF of patients with NMDAR-E, viral encephalitis (VE) and healthy volunteers. Moreover, different models were established to assess the possibility of identifying NMDAR-E patients based on PB and CSF parameters.

RESULTS

The neutrophil counts and monocyte-to-lymphocyte ratios (MLR) in PB are higher in NMDAR-E patients than in both VEs and controls (P < 0.001, respectively), while the percentages of CD3 + T, CD4 + T lymphocytes, and the leukocytes count in CSF were lower in NMDAR-Es than in VEs (P < 0.01, respectively). The higher percentages of CD8 + T cells in blood and CSF were both correlated with more severe NMDAR-E (P < 0.05, respectively). The poor neurological status group had significantly higher PB leukocytes but lower CSF leukocyte count (P < 0.05). Longitudinal observations in patients with NMDAR-E showed a decreasing trend of leukocyte count, neutrophils count, neutrophil-to-monocyte ratios (NMR), and neutrophil-to-lymphocyte ratios (NLR) with the gradual recovery of neurological function.

CONCLUSIONS

The expression patterns of T lymphocyte subsets were different in patients with NMDAR-E and viral encephalitis. The changing trends of leukocyte and lymphocyte populations in peripheral blood and cerebrospinal fluid may provide clues for the diagnosis of different types of encephalitides, including NMDARE, and can be used as immunological markers to assess and predict the prognosis.

Prognostic value of cachexia index in patients with colorectal cancer: A retrospective study

Background

Current diagnostic criteria for cancer cachexia are inconsistent, and arguments still exist about the impact of cachexia on the survival of patients with colorectal cancer. In this study, we aim to investigate the prognostic value of a novel cachexia indicator, the cachexia index (CXI), in patients with colorectal cancer.

Methods

The CXI was calculated as skeletal muscle index (SMI) × serum albumin/neutrophil-lymphocyte ratio. The cut-off value of CXI was determined by the receiver operating characteristic (ROC) curves and Youden’s index. The major outcomes were major complications, overall survival (OS), and recurrence-free survival (RFS).

Results

A total of 379 patients (234 men and 145 women) were included. The ROC curves indicated that CXI had a significantly diagnostic capacity for the detection of major complications. Based on Youden’s index, there were 231 and 148 patients in the low and high CXI groups, respectively. Patients in the low CXI group had significantly older age, lower BMI, and a higher percentage of cachexia and TNM stage II+III. Besides, Patients in low CXI group were associated with a significantly higher rate of major complications, blood transfusion, and longer length of stay. Logistic regression analysis indicated that low CXI, cachexia, and coronary heart disease were independent risk factors for the major complications. Kaplan Meier survival curves indicated that patients with high CXI had a significantly more favorable OS than those with low CXI, while no significant difference was found in RFS between the two groups. Besides, there were no significant differences in OS or RFS between patients with and without cachexia. The univariate and multivariate Cox regression analysis indicated that older age, low CXI, and coronary heart disease instead of cachexia were associated with a decreased OS.

Conclusion

CXI was better than cachexia in predicting OS and could be a useful prognostic indicator in patients with colorectal cancer, and greater attention should be paid to patients with low CXI.

Risk Prediction Models for Early ICU Admission in Patients With Autoimmune Encephalitis: Integrating Scale-Based Assessments of the Disease Severity

Background

In patients with autoimmune encephalitis (AE), the prediction of progression to a critically ill status is challenging but essential. However, there is currently no standard prediction model that comprehensively integrates the disease severity and other clinical features. The clinical assessment scale in autoimmune encephalitis (CASE) and the modified Rankin Scale (mRS) have both been applied for evaluating the severity of AE. Here, by combining the two scales and other clinical characteristics, we aimed to investigate risk factors and construct prediction models for early critical care needs of AE patients.

Methods

Definite and probable AE patients who were admitted to the neurology department of Tongji Hospital between 2013 and 2021 were consecutively enrolled. The CASE and mRS scores were used to evaluate the overall symptom severity at the time of hospital admission. Using logistic regression analysis, we analyzed the association between the total scores of the two scales and critical illness individually and then we evaluated this association in combination with other clinical features to predict early intensive care unit (ICU) admission. Finally, we constructed four prediction models and compared their performances.

Results

Of 234 patients enrolled, forty developed critical illness and were early admitted to the ICU (within 14 days of hospitalization). Four prediction models were generated; the models were named CASE, CASE-plus (CASE + prodromal symptoms + elevated fasting blood glucose + elevated cerebrospinal fluid (CSF) white blood cell (WBC) count), mRS and mRS-plus (mRS + prodromal symptoms + abnormal EEG results + elevated fasting blood glucose + elevated CSF WBC count) and had areas under the ROC curve of 0.850, 0.897, 0.695 and 0.833, respectively. All four models had good calibrations. In general, the models containing “CASE” performed better than those including “mRS”, and the CASE-plus model demonstrated the best performance.

Conclusion

Overall, the symptom severity at hospital admission, as defined by CASE or mRS, could predict early ICU admission, especially when assessed by CASE. Adding other clinical findings, such as prodromal symptoms, an increased fasting blood glucose level and an increased CSF WBC count, could improve the predictive efficacy.