Prognostic implication of neutrophil-lymphocyte ratio (NLR) in myocarditis: results from a multicentre, multinational study

Background

Neutrophil–lymphocyte ratio (NLR) is an accessible inflammatory biomarker. Recently, baseline NLR has been shown to be independently associated with incident cardiovascular (CV) events and all-cause mortality. However, whether this applies to acute myocarditis (AM) has not been evaluated. The aim of the present study was to investigate the prognostic value of NLR in patients with AM.

Methods

All consecutive patients with a diagnosis of AM admitted to three tertiary referral cardiac centres in two countries between October 2006 and June 2020 were included in the study. Diagnosis was confirmed by either cardiac magnetic resonance or endomyocardial biopsy. The outcome measure was all-cause mortality. Patients were divided into two groups according to NLR value defined in previous studies (i.e., 2.5).

Results

A total of 287 patients with AM were included in the study. Baseline characteristics were comparable in both groups. Approximately two thirds of patients were males (n=194, 68%) with a mean age of 39±16 years. The main clinical presentation was predominantly infarct-like (n=215, 75%), followed by heart failure (HF) (n=46, 16%) and arrhythmic (n=26, 9%). Patients admitted with a HF presentation were more prevalent in the group with elevated NLR, while no difference was found in the other clinical presentations. For all patients, ECG features were comparable between groups. However, patients with elevated NLR presented with slightly higher LVEF (55±11% vs 50±13% respectively, p=0.003). Over a median follow-up of 54 months, higher NLR was associated with worse prognosis (Figure 1, p=0.02). Patients with high NLR have a 7-fold higher risk of adverse events during follow-up (Hazard Ratio 7.83, 95% confidence interval 1.02–59.89, p=0.047).

Conclusions

NLR is a promising and accessible inflammatory biomarker. In patients with AM, elevated NLR is associated with worse prognosis. Further research is advocated to confirm these data in larger populations.

Funding Acknowledgement

Type of funding sources: None.

Kaiser Permanente's Good Health & Great Hair Program: Partnering With Barbershops and Beauty Salons to Advance Health Equity in West Baltimore, Maryland

CONTEXT

The Good Health & Great Hair program was developed by Kaiser Permanente in partnership with a network of trusted neighborhood barbershops and beauty salons in West Baltimore, Maryland.

PROGRAM

The initiative aimed to increase health awareness and knowledge and reduce health disparities by making no-cost health care services available beyond traditional health care settings in predominantly Black, historically redlined neighborhoods in West Baltimore.

IMPLEMENTATION

This initiative, established by an integrated health care system, is the first to utilize mobile health clinics into a holistic community health outreach program in partnership with barbershops and beauty salons to provide medical and social services to underserved populations. In addition to the mobile health clinics, key features of this program included lay first responder trainings on topics of physical and behavioral health, on-site medical and social services offered by community partners, and culturally relevant mental health programming. The majority of participants (n = 1823) were male (58%), Black (86%), and between the ages of 45 and 64 years (51%).

EVALUATION

Data presented include the number of clinical and social services provided. More than 8000 clinical and social services were provided between September 2016 and March 2020. Blood pressure (n = 2317), diabetes (n = 469), tobacco (n = 448), and cholesterol (n = 443) were the most accessed clinical screening services. The median number of clinical services provided per client was 2. Fitness (n = 1496), job search support (n = 1123), mental health (n = 603), and health insurance (n = 455) were the most accessed social services.

DISCUSSION

The initiative delivered critical health and social support services through a partnership with an established integrated health care system, community barbershops and beauty salons, a mobile health team, and social supports. This novel program utilized a mobile health clinic to provide extensive clinical services complemented by on-site social services. Patterns of service utilization and lessons learned could inform the design of similar programs.

Test of charge conjugation invariance

We report on the first determination of upper limits on the branching ratio (BR) of eta decay to pi0pi0gamma and to pi0pi0pi0gamma. Both decay modes are strictly forbidden by charge conjugation (C) invariance. Using the Crystal Ball multiphoton detector, we obtained BR(eta-->pi0pi0gamma)<5 x 10(-4) at the 90% confidence level, in support of C invariance of isoscalar electromagnetic interactions of the light quarks. We have also measured BR(eta-->pi0pi0pi0gamma)<6 x 10(-5) at the 90% confidence level, in support of C invariance of isovector electromagnetic interactions.

Paroxysmal eyelid movements: A confusing feature of generalized photosensitive epilepsy

BACKGROUND

Persistent, frequent, nonepileptic paroxysmal eyelid movements were observed in 19 children and adults with well-controlled generalized epilepsy.

METHODS

Patients were identified from five epilepsy centers.

RESULTS

Seventeen patients were female and two male. All had generalized photosensitive epilepsy requiring antiepileptic drugs (AEDs). In two children, paroxysmal eyelid movements began 2 to 4 years before their epilepsy was noted; in the remainder, it was noted when epilepsy was first diagnosed. Age at last follow-up was 8 to 38 years (average 21 years) with average follow-up of 9 years. All patients showed photosensitive generalized spike-wave discharges on EEG. Paroxysmal eyelid movements were a source of diagnostic confusion, but direct examination and video during EEG recording distinguished the attacks from absence seizures. In all cases, the epilepsy is completely or nearly completely controlled with AEDs, but the paroxysmal eyelid movements have not resolved with age. In 12 cases, there was a family history of the eyelid disorder without epilepsy. Videos of patients and an affected parent are available on the Neurology Web site.

CONCLUSION

There is an association between paroxysmal eyelid movements and photosensitive generalized epilepsy, creating diagnostic confusion.

The internet

The growing use of email and the world wide web (WWW), by the public, academics, and clinicians-as well as the increasing availability of high quality information on the WWW-make a working knowledge of the internet important. Although this article aims to enhance readers' existing use of the internet and medical resources on the WWW, it is also intelligible to someone unfamiliar with the internet. A web browser is one of the central pieces of software in modern computing: it is a window on the WWW, file transfer protocol sites, networked newsgroups, and your own computer's files. Effective use of the internet for professional purposes requires an understanding of the best strategies to search the WWW and the mechanisms for ensuring secure data transfer, as well as a compendium of online resources including journals, textbooks, medical portals, and sites providing high quality patient information. This article summarises these resources, available to incorporate into your web browser as downloadable "Favorites" or "Bookmarks" from www.jnnp.com, where there are also freely accessible hypertext links to the recommended sites.

Properties of the Lambda(1670)(1-)/2 resonance

Recently the Crystal Ball Collaboration measured precise new data for the near-threshold reaction K(-)p-->etaLambda, which is dominated by formation of the Lambda(1670)1 / 2(-). In this Letter, we present results of a unitary, multichannel analysis that incorporates the new Crystal Ball data. For our preferred fit, we obtain mass M = 1673+/-2 MeV, width Gamma = 23+/-6 MeV, and elasticity x = 0.37+/-0.07. This elasticity is significantly larger than previously recognized. Resonance parameters of our preferred fit are in striking agreement with the quark-model predictions of Koniuk and Isgur.

Lateralized postictal EEG delta predicts the side of seizure surgery in temporal lobe epilepsy

PURPOSE

The concordance of lateralized EEG postictal polymorphic delta activity (PPDA) to the side of seizure origin in temporal lobe epilepsy (TLE) has received limited study. Our objective was to study the lateralizing value of PPDA in patients with documented TLE.

METHODS

A cohort of consecutive adults with TLE, detailed presurgical evaluation before temporal lobectomy, and minimal follow-up of 2 years were included. One author masked the ictal rhythm of presurgical EEGs and randomly presented 20 s of preictal and the postictal EEG to two electroencephalographers who were blind to all clinical data. They independently assigned PPDA to one of three categories: not present, bilateral, or lateralized (defined as newly appearing or an amplitude >50% of the preictal record).

RESULTS

Eighty seizures from 29 patients were studied. Fifteen patients had a left, and 14 had a right temporal lobectomy. Twenty-three patients were seizure free or substantially improved (defined as simple partial or nocturnal seizures only). Lateralized PPDA was present in 64% of all EEGs and at least one record from 22 (76%) patients. Lateralized PPDA, when present, was concordant with the side of surgery in 96% of the EEGs.

CONCLUSIONS

Lateralized PPDA is highly predictive of the side of ultimate temporal lobectomy, and by inference the side of seizure origin.

Measurement of pi(0)pi(0) production in the nuclear medium by pi(-) interactions at 0.408 GeV/c

We report on an investigation of the (pi(-),pi(0)pi(0)) reaction by means of measurements of the pi(0)pi(0) invariant mass distributions from pi(-) interactions on H, D, C, Al, and Cu targets at p(pi(-)) = 0.408 GeV/c. The sharp, strong peak in the pi(+)pi(-) invariant mass near 2m(pi) reported by the CHAOS Collaboration is not seen in our pi(0)pi(0) data. However, we do observe a change in the shape of the pi(0)pi(0) invariant mass spectrum for the different targets, indicating that the pi(0)pi(0) interaction diminishes in the nuclear medium as represented by nuclei D, C, Al, and Cu, compared to hydrogen.

Validation of a structured interview for the assessment of diabetes self-management

OBJECTIVE

The authors developed and validated a semi-structured interview; the Diabetes Self-Management Profile (DSMP), to measure self-management of type 1 diabetes. The DSMP includes the following regimen components: exercise, management of hypoglycemia, diet, blood glucose testing, and insulin administration and dose adjustment.

RESEARCH DESIGN AND METHODS

Families of youths with type 1 diabetes (n = 105) who were entering a controlled trial of intensive therapy (IT) versus usual care (UC) were administered the DSMP Analyses assessed the reliability and validity of the DSMP, including its associations with HbA1c and quality of life.

RESULTS

The DSMP total score has adequate internal consistency (Cronbach's alpha 0.76), 3-month test-retest reliability (Pearson correlation, r = 0.67), inter-interviewer agreement (r = 0.94), and parent-adolescent agreement (r = 0.61). DSMP total scores (r = -0.28) and 3 subscales correlated significantly with HbA1c (diet [r = -0.27], blood glucose testing [r = -0.37], and insulin administration and dose adjustment [r = -0.25 ]). Adolescents' reports of self-management did not differ from parental reports. Higher DSMP scores were associated with more favorable quality of life for mothers and youths.

CONCLUSIONS

The DSMP is a convenient measure that yields a reliable and valid assessment of diabetes self-management. Compared with extant similar measures, the DSMP is more strongly correlated with HbA1c.

Scalp EEG in temporal lobe epilepsy surgery

Electroencephalography (EEG) with standard scalp and additional noninvasive electrodes plays a major role in the selection of patients for temporal lobe epilepsy surgery. Recent studies have provided data supporting the value of interictal and postictal EEG in assessing the site of ictal onset. Scalp ictal rhythms are morphologically complex but at least one pattern (a five cycles/second rhythm maximum at the sphenoidal or anterior temporal electrode) occurs in >50% of patients and has a high predictive value and interobserver reliability for temporal lobe originating seizures. Thorough interictal and ictal scalp EEG evaluation, in conjunction with modern neuroimaging, is sufficient for proceeding to surgery without invasive recordings in some patients. Further studies are required to define the scalp ictal characteristics of mesial vs. lateral temporal lobe epilepsy.

Conventional versus intensive diabetes therapy in children with type 1 diabetes: effects on memory and motor speed

OBJECTIVE

Severe hypoglycemia may impair medial temporal-mediated cognitive skills, such as the ability to recall past events explicitly (delayed declarative memory). The objective of this study was to determine whether delayed declarative memory deficits are present in a group of diabetic children with an increased risk of severe hypoglycemia.

RESEARCH DESIGN AND METHODS

Nondiabetic children (n = 16) and children with type 1 diabetes who had been randomly assigned to either intensive (IT) (n = 13) or conventional (CT) (n = 12) diabetes therapy at the time of diagnosis participated in the study. All episodes of severe hypoglycemia were prospectively ascertained. All children were tested on memory tasks that have been closely linked to medial temporal functioning and on reaction time measures.

RESULTS

Our results demonstrated that the IT group had a threefold higher rate of severe hypoglycemia, performed less accurately on a spatial declarative memory task, and performed more slowly, but not less accurately, on a pattern recognition task than did the CT group or control subjects. In addition, both groups of type 1 diabetic children were significantly impaired on a motor speed task compared with their nondiabetic peers.

CONCLUSIONS

These results indicate a selective relative memory impairment associated with IT that is consistent with the effects of severe hypoglycemia and medial temporal damage or dysfunction. If larger prospective studies determine that severe hypoglycemia is the mediating factor for this memory impairment, extreme caution in imposing overly strict standards for glucose control in young patients with type 1 diabetes would be indicated because of the increased risk of hypoglycemia associated with IT regimens.

Criterion-based validity of an intracarotid amobarbital recognition-memory protocol

PURPOSE

We tested whether the behavioral components of an Intracarotid Amobarbital Protocol (IAP) had criterion validity. It was hypothesized that a recognition-memory test designed for intracarotid injections and used to predict the risk of global amnesia before an elective temporal lobectomy should also identify persons who are severely amnesic due to other neurologic causes. Divergent validity predicts that speech tasks would be unaffected by amnesia. Test-retest reliability also was measured.

METHODS

Fifteen persons with severe amnesia were administered four alternate forms of a yes/no recognition-memory protocol and a speech protocol. No drug injection occurred. Standardized neuropsychological tests were used to divide the amnesic group into those with Global Amnesia (i.e., retain no ongoing memories), Severe Amnesia (i.e., memory impaired), and Amnesia Plus (severe amnesia plus other neuropsychologic deficits).

RESULTS

Two persons with Global Amnesia obtained scores at or below chance (i.e., failed) on the memory protocol. Unexpectedly, 12 of 13 severely amnesic persons obtained near-perfect memory scores. Amnesia had no impact on the speech protocol. Pass/Fail outcomes were highly correlated across all four sets.

CONCLUSIONS

A four-item IAP memory protocol showed good reliability and criterion validity in identifying the rare condition of Global Amnesia, but it was insensitive to other disabling, severe amnesic disorders. This IAP memory protocol might have validity in predicting a postsurgical Global Amnesic disorder, but it did not identify and therefore could not predict other more common severe amnesic disorders.

Lamotrigine associated with insomnia

PURPOSE

To review the incidence of lamotrigine (LTG)-associated insomnia in an adult tertiary care epilepsy outpatient clinic.

METHODS

The records of all patients who had received LTG were reviewed to identify patients who had experienced insomnia after introduction of this drug. Patients were included if they had experienced a sleep disturbance of sufficient severity to require a discontinuation of LTG or a dose reduction.

RESULTS

Among 109 patients exposed to LTG, seven (6.4%) had a sleep disturbance of a severity to required a change in therapy. The descriptions of the sleep disturbance were similar among the patients, and the LTG-induced insomnia appeared to be dose dependent. Unlike the few previous descriptions of LTG-induced insomnia in the literature, no factors predisposing to this adverse effect were identified.

CONCLUSIONS

The results of this retrospective review suggest an association between LTG and intolerable insomnia in a small proportion of patients. Physicians should inquire about sleep disturbances in patients treated with LTG.

Peripheral neuropathy with nucleoside antiretrovirals: risk factors, incidence and management

Distal symmetrical peripheral neuropathy is a common adverse experience in persons with HIV infection. This condition, which presents as a pain, numbness. burning and/or dysaethesia initially in the feet, is often multi-factorial in its origin. Nucleoside analogue reverse transcriptase inhibitors represent an important contributor to peripheral neuropathy. Specifically, around 10% of patients receiving stavudine or zalcitabine and 1 to 2% of didanosine recipients may have to discontinue therapy with these agents due to neuropathy. Prompt withdrawal of these therapies enables gradual resolution of signs and symptoms in most patients, although a period of symptom intensification may occur shortly after withdrawal. Risk factors for developing peripheral neuropathy during nucleoside analogue therapy include low CD4+ cell count (<100 cells/mm3), a prior history of an AIDS defining illness or neoplasm, a history of peripheral neuropathy, use of other neurotoxic agents including high alcohol (ethanol) consumption and nutritional deficiencies such as low serum hydroxocobalamin levels. Thus, patients at increased risk of peripheral neuropathy should potentially avoid the use of the neurotoxic nucleoside analogues or be more carefully monitored during therapy. Management of this problem includes patient education. prompt withdrawal of the likely causative agent (giving consideration not to leave the patient on a sub-optimal therapy regimen) and simple analgesia. with augmentation with tricyclic antidepressants or anticonvulsant agents when pain is severe. New agents that may assist in managing this condition include levacecarnine (acetyl-L-carnitine) and nerve growth factors such as recombinant human nerve growth factor.