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Stepien KM, Schmidt WM, Bittner RE, O'Toole O, McNamara B, Treacy EP. Long-term outcomes in a 25-year-old female affected with lipin-1 deficiency. JIMD Rep 2019; 46:4-10. [PMID: 31240148 PMCID: PMC6498837 DOI: 10.1002/jmd2.12016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 01/04/2019] [Indexed: 12/19/2022] Open
Abstract
Lipin-1 is a phosphatidic acid phosphohydrolase (EC 3.1.3.4) that catalyzes the dephosphorylation of phosphatidic acid to diacylglycerol and inorganic phosphate. Deficiency of this enzyme causes potentially fatal severe, recurrent episodes of rhabdomyolysis triggered by infection. The defect has only recently been recognized so little is known about the long-term outcome in adult patients with this disorder. We report the course and outcome of a 25-year-old female patient with lipin-1 deficiency after a recent episode of rhabdomyolysis requiring intensive care admission with a peak creatine kinase of 500 000 IU/L. One-year post discharge from intensive care, the patient has residual drop foot bilaterally consistent with bilateral common peroneal neuropathies in addition to a background residual distal myopathy.
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Affiliation(s)
- Karolina M. Stepien
- Mark Holland Metabolic Unit, Adult Inherited Metabolic DiseasesSalford Royal NHS Foundation TrustSalfordUnited Kingdom
| | - Wolfgang M. Schmidt
- Neuromuscular Research DepartmentCenter for Anatomy and Cell Biology, Medical University of ViennaViennaAustria
| | - Reginald E. Bittner
- Neuromuscular Research DepartmentCenter for Anatomy and Cell Biology, Medical University of ViennaViennaAustria
| | - Orna O'Toole
- Department of NeurologyMercy University HospitalCorkIreland
| | - Brian McNamara
- Department of Clinical NeurophysiologyCork University HospitalCorkIreland
| | - Eileen P. Treacy
- University College DublinDublinIreland
- Paediatrics DepartmentTrinity CollegeDublinIreland
- National Centre for Inherited Metabolic DiseasesThe Mater Misericordiae University HospitalDublinIreland
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2
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Abstract
Autoimmune epilepsy is increasingly recognized as a distinct clinical entity, driven in large part by the recent discovery of neural autoantibodies in patients with isolated or predominant epilepsy presentations. Detection of neural autoantibodies in high-risk epilepsy patients supports an immune-mediated cause of seizures and, if applicable, directs the search for an underlying cancer when the paraneoplastic association of the associated antibody is compelling. Early diagnosis of autoimmune epilepsy is crucial, as prompt initiation of immunosuppressive treatment increases the likelihood of achieving either seizure freedom or a substantial reduction in seizure frequency. A practical clinical approach that incorporates risk scores to guide patient selection on the basis of clinical features, neural autoantibodies, and a treatment trial of immunotherapy is suggested. Elucidating an immunological basis of epilepsy provides neurologists with wider treatment options (incorporating immune-suppressive treatment), in addition to standard antiepileptic drugs, which often improves patient outcomes.
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Affiliation(s)
- Amy M L Quek
- Division of Neurology, Department of Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Orna O'Toole
- Department of Neurology, Mercy University Hospital, Grenville Place, Cork, Ireland
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3
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Abstract
Autoimmune movement disorders are rare but potentially treatable entities. They can present with an excess or paucity of movement and may have other associated neurological symptoms. These disorders were originally recognized by their classic clinical presentations and the cancers associated with them. Recent emphasis has been targeted on associated, and sometimes causative, antibodies. Although some disorders have stereotypical presentations, the spectrum of abnormalities reported in association with antibodies is widening. Determining whether antibodies are incidental or pathogenic and, hence, foregoing or commencing immunotherapy treatment can be challenging for practicing neurologists. Physicians often have to make the decision to empirically treat patients while awaiting test results. Due to the lack of randomized controlled trials, the ideal immunotherapy treatments and regimens are unknown. Patients with intracellularly targeted antibodies tend to fare less well, while those with extracellularly targeted antibody disorders often respond to treatments reducing antibody production. This review aims to summarize reported adult-onset autoimmune movement disorders to date, and to provide a template for the workup and treatment of suspected disorders. Rarer antibodies that are not yet fully characterized, or reported in a few cases only, will not be covered in detail as these are not likely to be readily commercially available. Childhood disorders will be only be mentioned briefly in the discussion, as there is a separate article in this issue on autoimmune neurologic diseases in children.
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Affiliation(s)
- Conor Fearon
- Department of Neurology, Adelaide and Meath University Hospital, Tallaght, Dublin, Ireland
| | - Orna O'Toole
- Department of Neurology, Mercy University Hospital, Cork, Ireland
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4
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Barry A, Cronin O, Ryan AM, Sweeney B, O'Toole O, Allen AP, Clarke G, O'Halloran KD, Downer EJ. Impact of short-term cycle ergometer training on quality of life, cognition and depressive symptomatology in multiple sclerosis patients: a pilot study. Neurol Sci 2017; 39:461-469. [PMID: 29280019 DOI: 10.1007/s10072-017-3230-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
Abstract
In this pilot study, we investigate whether a routine cycle ergometry training programme has therapeutic potential in individuals with multiple sclerosis (MS) by improving quality of life (QOL) and depressive symptomatology, while ameliorating cognitive disturbances. Healthy volunteers and MS patients cycled for 30 min at 65-75% age-predicted maximal heart rate on a recumbent ergometer, with this session repeated twice a week for 8 weeks. QOL, depressive symptomatology and cognitive function were assessed pre- and post-exercise using the MS Quality of Life-54 (MSQOL-54) questionnaire, 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16) questionnaire and the Cambridge Neuropsychological Test Automated Battery (CANTAB), respectively. We determined that QOL was lower in MS patients, compared to healthy subjects, with a reduction in physical and mental health summary scores observed. Exercise improved both physical and mental health scores in MS patients. In support of this, exercise was shown to reduce depressive symptomatology in MS patients. Exercise was also associated with an improvement in visual sustained attention, executive function/cognitive flexibility and hippocampal-dependent visuospatial memory in patients. Overall, this study identifies a short-term exercise programme that improves physical and mental health, while reducing depressive symptomatology and cognitive dysfunction in MS.
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Affiliation(s)
- Alison Barry
- Department of Physiology, School of Medicine, Western Gateway Building, University College Cork, Cork, Ireland
| | - Owen Cronin
- Department of Medicine, Cork University Hospital, Cork, Ireland
| | - Aisling M Ryan
- Department of Neurology, Cork University Hospital, Cork, Ireland
| | - Brian Sweeney
- Department of Neurology, Cork University Hospital, Cork, Ireland
| | | | - Andrew P Allen
- Department of Psychiatry and Neurobehavioral Science, APC Microbiome Institute, University College Cork, Cork, Ireland
| | - Gerard Clarke
- Department of Psychiatry and Neurobehavioral Science, APC Microbiome Institute, University College Cork, Cork, Ireland
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, Western Gateway Building, University College Cork, Cork, Ireland
| | - Eric J Downer
- Department of Physiology, School of Medicine, Trinity Biomedical Sciences Institute, Trinity College Dublin, University of Dublin, Dublin 2, Ireland.
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Elkider M, O'Toole O. What can smudge the 'tough body' corpus callosum? Neth J Med 2017; 75:219. [PMID: 28653952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- M Elkider
- Department of Neurology, Mercy University Hospital, Cork, Ireland
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6
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Barry A, Cronin O, Ryan AM, Sweeney B, Yap SM, O'Toole O, Allen AP, Clarke G, O'Halloran KD, Downer EJ. Impact of Exercise on Innate Immunity in Multiple Sclerosis Progression and Symptomatology. Front Physiol 2016; 7:194. [PMID: 27313534 PMCID: PMC4889582 DOI: 10.3389/fphys.2016.00194] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/16/2016] [Indexed: 12/21/2022] Open
Abstract
Multiple Sclerosis (MS), an idiopathic progressive immune-mediated neurological disorder of the central nervous system (CNS), is characterized by recurrent episodes of inflammatory demyelination and consequent axonal deterioration. It accounts for functional deterioration and lasting disability among young adults. A body of literature demonstrates that physical activity counteracts fatigue and depression and may improve overall quality of life in MS patients. Furthermore, much data indicates that exercise ameliorates chronic neuroinflammation and its related pathologies by tipping cytokine profiles toward an anti-inflammatory signature. Recent data has focused on the direct impact of exercise training on the innate immune system by targeting toll-like receptors (TLRs), signaling pattern recognition receptors that govern the innate immune response, shedding light on the physiological role of TLRs in health and disease. Indeed, TLRs continue to emerge as players in the neuroinflammatory processes underpinning MS. This review will highlight evidence that physical activity and exercise are potential immunomodulatory therapies, targeting innate signaling mechanism(s) to modulate MS symptom development and progression.
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Affiliation(s)
- Alison Barry
- Department of Physiology, School of Medicine, University College Cork Cork, Ireland
| | - Owen Cronin
- Department of Medicine, Cork University Hospital Cork, Ireland
| | - Aisling M Ryan
- Department of Neurology, Cork University Hospital Cork, Ireland
| | - Brian Sweeney
- Department of Neurology, Cork University Hospital Cork, Ireland
| | | | | | - Andrew P Allen
- Department of Psychiatry and Neurobehavioral Science, APC Microbiome Institute, University College Cork Cork, Ireland
| | - Gerard Clarke
- Department of Psychiatry and Neurobehavioral Science, APC Microbiome Institute, University College Cork Cork, Ireland
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, University College Cork Cork, Ireland
| | - Eric J Downer
- Department of Physiology, School of Medicine, Trinity Biomedical Sciences Institute, Trinity College Dublin, University of Dublin Dublin, Ireland
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Yap SM, MacEneaney P, Ryan C, O'Toole O. Alternating hemiparesis and orolingual apraxia as manifestations of methotrexate neurotoxicity in a paediatric case of acute lymphoblastic leukaemia. BMJ Case Rep 2016; 2016:bcr-2016-214677. [PMID: 27113788 DOI: 10.1136/bcr-2016-214677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 15-year-old girl with a recent diagnosis of acute lymphoblastic leukaemia was admitted to hospital with pancytopaenia after having received high-dose intrathecal methotrexate 1 day prior. During the next week she had intermittent episodes of alternating hemiparesis associated with speech arrest lasting minutes to hours at a time. The episodes were not associated with altered level of consciousness or headache. MRI of the brain showed features consistent with methotrexate encephalopathy. This report discusses the typical clinical and radiological features of methotrexate neurotoxicity in addition to differential diagnoses and the proposed pathophysiological mechanisms.
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Affiliation(s)
- Siew Mei Yap
- Department of Neurology, Mercy University Hospital, Cork, Ireland
| | - Peter MacEneaney
- Department of Radiology, Mercy University Hospital, Cork, Ireland
| | - Clodagh Ryan
- Department of Haematology, Mercy University Hospital, Cork, Ireland
| | - Orna O'Toole
- Department of Neurology, Mercy University Hospital, Cork, Ireland
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Mello S, O'Toole O, McNamara B. Utilization and Yield of Nerve Conduction Studies and Electromyography in Older Adults. Ir Med J 2016; 109:361. [PMID: 27685694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Older adults are at increased risk of both central and peripheral neurological disorders. Impaired nerve and muscle deficits contribute to morbidity and reduced quality of life. Our aim was to define the utilization and yield of nerve conduction studies (NCS) and electromyography (EMG) in older adults. We reviewed NCS and EMG records for all patients older than age 65 in the year 2012. Of 1,530 NCS and EMGs performed, 352 (23%) were in patients older than 65 (mean age 73.7, 52% male). 288 (83.7%) of NCS were abnormal as were 102 (71.8%) of EMGs. The likelihood of having an abnormal test result increased with increasing age. The most common diagnosis was peripheral neuropathy 231 (65.4%). The incidence of peripheral neuropathy is particularly high in this age group and detection is vital to prevent morbidity and improve quality of life.
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Affiliation(s)
- S Mello
- Cork University Hospital, Wilton, Cork
| | - O O'Toole
- Cork University Hospital, Wilton, Cork
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9
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McNicholas N, O'Dowd S, McNamara B, O'Toole O. An unusual presentation of Guillain-Barré syndrome in a young man with bilateral upper extremity weakness. BMJ Case Rep 2015; 2015:bcr-2015-210375. [PMID: 26351312 DOI: 10.1136/bcr-2015-210375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 30-year-old man attended the emergency department with a 4-day history of progressive, bilateral upper limb weakness. He had mild shortness of breath and occasional swallowing difficulties. One month prior to presentation, he had flu-like symptoms and diarrhoea. Examination revealed upper limb hypotonia, symmetrical distal arm weakness and hyporeflexia. Power and reflexes in the lower limbs were normal. Nerve conduction studies and lumbar puncture demonstrated features consistent with Guillain-Barré syndrome (GBS). The patient was treated with a 5-day course of intravenous immunoglobulins. He improved significantly over the next 2 weeks. Breathing and swallow function did not deteriorate and required no further intervention. He had a sustained improvement, and remained at baseline 1 year later. Work-up for underlying structural, infectious, inflammatory and paraneoplastic aetiologies were negative. Serum antiganglioside antibodies were positive for the anti-GT1a IgG isotype supporting the clinical diagnosis of the pharyngeal-cervical-brachial variant of GBS.
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Affiliation(s)
- N McNicholas
- Department of Neurology, Mercy University Hospital, Cork, Ireland
| | - S O'Dowd
- Department of Neurology, Mercy University Hospital, Cork, Ireland
| | - B McNamara
- Department of Neurophysiology, Mercy University Hospital, Cork, Ireland
| | - O O'Toole
- Department of Neurology, Mercy University Hospital, Cork, Ireland
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Crowley T, Fitzpatrick JM, Kuijper T, Cryan JF, O'Toole O, O'Leary OF, Downer EJ. Modulation of TLR3/TLR4 inflammatory signaling by the GABAB receptor agonist baclofen in glia and immune cells: relevance to therapeutic effects in multiple sclerosis. Front Cell Neurosci 2015; 9:284. [PMID: 26283920 PMCID: PMC4516894 DOI: 10.3389/fncel.2015.00284] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/10/2015] [Indexed: 12/11/2022] Open
Abstract
The GABAB receptor agonist, baclofen, is used to treat muscle tightness and cramping caused by spasticity in a number of disorders including multiple sclerosis (MS), but its precise mechanism of action is unknown. Neuroinflammation drives the central pathology in MS and is mediated by both immunoreactive glial cells and invading lymphocytes. Furthermore, a body of data indicates that the Toll-like receptor (TLR) family of innate immune receptors is implicated in MS progression. In the present study we investigated whether modulation of GABAB receptors using baclofen can exert anti-inflammatory effects by targeting TLR3 and(or) TLR4-induced inflammatory signaling in murine glial cells and human peripheral blood mononuclear cells (PBMCs) isolated from healthy control individuals and patients with the relapse-remitting (RR) form of MS. TLR3 and TLR4 stimulation promoted the nuclear sequestration of NF-κB and pro-inflammatory cytokine expression in murine glia, while TLR4, but not TLR3, promoted pro-inflammatory cytokine expression in PBMCs isolated from both healthy donors and RR-MS patients. Importantly, this effect was exacerbated in RR-MS patient immune cells. We present further evidence that baclofen dose-dependently attenuated TLR3- and TLR4-induced inflammatory signaling in primary glial cells. Pre-exposure of PBMCs isolated from healthy donors to baclofen attenuated TLR4-induced TNF-α expression, but did not affect TLR4-induced TNF-α expression in RR-MS patient PBMCs. Interestingly, mRNA expression of the GABAB receptor was reduced in PBMCs from RR-MS donors when compared to healthy controls, an effect that might contribute to the differential sensitivity to baclofen seen in healthy and RR-MS patient cells. Overall these findings indicate that baclofen differentially regulates TLR3 and TLR4 signaling in glia and immune cells, and offers insight on the role of baclofen in the treatment of neuroinflammatory disease states including MS.
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Affiliation(s)
- Tadhg Crowley
- Department of Anatomy and Neuroscience, University College Cork Cork, Ireland
| | | | - Teun Kuijper
- Department of Anatomy and Neuroscience, University College Cork Cork, Ireland
| | - John F Cryan
- Department of Anatomy and Neuroscience, University College Cork Cork, Ireland ; Alimentary Pharmabiotic Centre, University College Cork Cork, Ireland
| | | | - Olivia F O'Leary
- Department of Anatomy and Neuroscience, University College Cork Cork, Ireland ; Alimentary Pharmabiotic Centre, University College Cork Cork, Ireland
| | - Eric J Downer
- Department of Anatomy and Neuroscience, University College Cork Cork, Ireland ; School of Medicine, Discipline of Physiology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland
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Clardy SL, Lucchinetti CF, Krecke KN, Lennon VA, O'Toole O, Weinshenker BG, Boyd CD, Krieger S, McGraw C, Guo Y, Pittock SJ. Hydrocephalus in neuromyelitis optica. Neurology 2014; 82:1841-3. [PMID: 24759842 DOI: 10.1212/wnl.0000000000000428] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Stacey L Clardy
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Claudia F Lucchinetti
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Karl N Krecke
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Vanda A Lennon
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Orna O'Toole
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Brian G Weinshenker
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Clara D Boyd
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Stephen Krieger
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Corey McGraw
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Yong Guo
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY
| | - Sean J Pittock
- From the Mayo Clinic (S.L.C., C.F.L., K.N.K., V.A.L., B.G.W., Y.G., S.J.P.), Rochester, MN; Mercy University Hospital (O.O.), Cork, Ireland; Columbia University Medical Center (C.D.B.), New York; Corinne Goldsmith Dickinson Center for MS (S.K.), Icahn School of Medicine at Mount Sinai, New York; and the Albert Einstein College of Medicine (C.M.), Montefiore Medical Center, Bronx, NY.
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Affiliation(s)
- Stacey Clardy
- Department of Neuroimmunology, Mayo Clinic, Rochester, Minnesota
| | - Amy Lin Quek
- Mayo Clinic Rochester Alumni, Rochester, Minnesota
| | - Orna O'Toole
- Mayo Clinic Rochester Alumni, Rochester, Minnesota
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Pittock SJ, Lennon VA, McKeon A, Mandrekar J, Weinshenker BG, Lucchinetti CF, O'Toole O, Wingerchuk DM. Eculizumab in AQP4-IgG-positive relapsing neuromyelitis optica spectrum disorders: an open-label pilot study. Lancet Neurol 2013; 12:554-62. [DOI: 10.1016/s1474-4422(13)70076-0] [Citation(s) in RCA: 233] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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14
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Klein CJ, Lennon VA, Aston PA, McKeon A, O'Toole O, Quek A, Pittock SJ. Insights from LGI1 and CASPR2 potassium channel complex autoantibody subtyping. JAMA Neurol 2013; 70:229-34. [PMID: 23407760 DOI: 10.1001/jamaneurol.2013.592] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine, in patients identified as seropositive for neuronal voltage-gated potassium channel (VGKC) complex autoantibodies, the spectrum of clinical presentations and frequency of leucine-rich glioma-inactivated protein 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) as defined antigenic neuronal targets in the VGKC macromolecular complex. DESIGN Retrospective cohort study. SETTING Clinical practice, Mayo Clinic Neuroimmunology Laboratory and Department of Neurology. PATIENTS A total of 54 853 patients were evaluated, of whom 1992 were found to be VGKC complex IgG positive. RESULTS From June 1, 2008, to June 30, 2010, comprehensive service serologic evaluation performed on 54853 patients with unexplained neurologic symptoms identified 1992 patients (4%) who were positive for VGKC complex IgG (values ≥ 0.03 nmol/L). Among 316 seropositive patients evaluated clinically at our institution, 82 (26%) were seropositive for LGI1 IgG and/or CASPR2 IgG. Of these 82 patients, 27% had low (0.03-0.09 nmol/L), 51% had medium (0.10-0.99 nmol/L), and 22% had high (≥ 1.00 nmol/L) VGKC complex IgG values. Leucine-rich glioma-inactivated protein 1 IgG positivity was associated with higher VGKC complex IgG values (P< .001) and cortical presentations (P< .001); CASPR2 IgG was associated with peripheral motor excitability (P= .009). However, neither autoantibody was pathognomonic for a specific neurologic presentation or correlated significantly with cancer. Neurologic phenotypes were diverse. Cerebrocortical manifestations (including cognitive impairment and seizures) were recorded in 76% of patients with LGI1 IgG alone (n=46) and 29% with CASPR2 IgG alone (n=28). Peripheral motor hyperexcitability was found in 21% of patients with CASPR2 IgG alone and 6.5% of patients with LGI1 IgG alone. CONCLUSIONS The study emphasizes diverse and overlapping neurologic phenotypes across a range of VGKC complex IgG values and varying LGI1 IgG and CASPR2 IgG specificities. The frequent occurrence of LGI1 IgG and CASPR2 IgG in serum samples with low and medium VGKC complex IgG values supports the clinical significance of low values in clinical evaluation. Additional antigenic components of VGKC macromolecular complexes remain to be defined.
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O'Toole O, Murphy R, Tracy JA, McKeon A. Teaching NeuroImages: PET-CT hypermetabolism paralleling muscle hyperactivity in stiff-person syndrome. Neurology 2013; 80:e109. [DOI: 10.1212/wnl.0b013e3182840bad] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
OBJECTIVES To determine the characteristics of adult-onset autoimmune chorea, and compare paraneoplastic and idiopathic subgroups. METHODS Thirty-six adults with autoimmune chorea were identified at Mayo Clinic (Rochester, MN) from 1997 to 2012. Medical record and laboratory data were recorded. Nonparaneoplastic (n = 22) and paraneoplastic cases (n = 14) were compared. RESULTS Women accounted for 21 patients (58%). Median age at symptom onset was 67 years (range 18-87 years). We estimated the incidence for Olmsted County was 1.5 per million person-years. Symptom onset was subacute in all. Chorea was focal (20 patients) or generalized (16 patients). Although chorea predominated, other neurologic disorders frequently coexisted (29 patients); abnormal eye movements were uncommon (4 patients). No patient had NMDA receptor antibody or any immunoglobulin (Ig)G yielding a detectable immunofluorescence binding pattern restricted to basal ganglia. Two had synaptic IgG antibodies novel to the context of chorea (GAD65, 1; CASPR2, 1). In the paraneoplastic group, 14 patients had evidence of cancer. Of 13 with a histopathologically confirmed neoplasm, small-cell carcinoma and adenocarcinoma were most common; 6 patients had a cancer-predictive paraneoplastic autoantibody, with CRMP-5-IgG and ANNA-1 being most common. In the idiopathic group, 19 of the 22 patients had a coexisting autoimmune disorder (most frequently systemic lupus erythematosus and antiphospholipid syndrome); autoantibodies were detected in 21 patients, most frequently lupus and phospholipid specificities (19 patients). The paraneoplastic group was older (p = 0.001), more frequently male (p = 0.006), had more frequent weight loss (p = 0.02), and frequently had peripheral neuropathy (p = 0.008). CONCLUSIONS Autoimmune chorea is a rare disorder with rapid onset. Male sex, older age, severe chorea, coexisting peripheral neuropathy, and weight loss increase the likelihood of cancer.
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Affiliation(s)
- Orna O'Toole
- Department of Neurology, Mayo Clinic, College of Medicine, Rochester, MN, USA
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Abstract
BACKGROUND AND METHODS We conducted an all-Ireland population-based prospective epidemiological survey of motor neurone disease (MND) using the Northern Ireland and Republic of Ireland MND registers to examine the incidence and prevalence of the disease over the period 2004-2005. RESULTS AND CONCLUSIONS Incidence of MND was 1.9 per 100 000 person-years and rates were comparable in both the north and south of Ireland. Prevalence of MND was 5.0 per 100 000 population. When compared with previous published surveys of MND performed in the Republic of Ireland over the last 10 years, rates of disease have remained relatively constant. When standardized to the 1990 US population, the incidence of MND in Ireland was found to be consistent with other European prospective surveys of MND.
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Affiliation(s)
- C Donaghy
- Department of Neurology, Royal Victoria Hospital, Belfast, UK.
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O'Toole O, Ahlskog J, Matsumoto J, Pittock S, Bower J, Lennon V, Lachance D, Fealey R, McKeon A. Adult-Onset Autoimmune Chorea (S08.003). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.s08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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O'Toole O, Lefter S, McNamara B. EEG use in a tertiary referral centre. Ir Med J 2011; 104:202-204. [PMID: 21957686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The aim of this study was to retrospectively audit all electroencephalograms (EEGs) done over a 2-month period in 2009 by the Neurophysiology Department at Cork University Hospital. There were 316 EEGs performed in total, of which 176/316 (56%) were done within 24 hours of request. Out of 316 EEGs, 208 (66%) were considered 'appropriate' by SIGN and NICE guidelines; 79/208 (38%) had abnormal EEGs and 28 of these abnormal EEGs had epileptiform features. There were 108/316 (34%) 'inappropriate' requests for EEG; of these 15/108 (14%) were abnormal. Of the 67/316 (21%) patients who had EEGs requested based on a history of syncope/funny turns: none of these patients had epileptiform abnormalities on their EEGs. Our audit demonstrates that EEGs are inappropriately over-requested in our institution in particular for cases with reported 'funny turns' and syncope. The yield from EEGs in this cohort of patients was low as would be expected.
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Affiliation(s)
- O O'Toole
- Department of Neurology, Cork University Hospital, Wilton, Cork.
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Molloy A, Forde D, De Gascun C, Fanning N, Wyse G, O'Toole O. A virulent vasculopathy. BMJ Case Rep 2011; 2011:2011/mar24_1/bcr1120103481. [PMID: 22700078 DOI: 10.1136/bcr.11.2010.3481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Arteriopathy is an uncommon complication of primary varicella zoster virus (VZV) infection in the immunocompetent adult. We report a case of a 39-year-old woman known to be VZV negative prior to the event. She presented to the emergency department having experienced an episode of expressive aphasia and right upper limb paraesthesia lasting 15 min. The symptoms followed a 3-day period of general malaise, arthralgia and a generalised maculopapular itchy rash involving face and limbs. No immunocompromise was detected but an infectious contact was identified in the home. Imaging findings were consistent with a focal cerebritis/vasculopathy and VZV infection was confirmed with cerebrospinal fluid PCR analysis. Resolution of radiological signs occurred following prompt treatment with appropriate antivirals.
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Affiliation(s)
- A Molloy
- Department of Neurology, Cork University Hospital, Cork, Ireland.
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21
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Abstract
A 20 year old female presented with a 4 month history of right upper limb pain and paraesthesias. She had no systemic symptoms and no prior medical or family history of note. MRI revealed a right-sided intradural extramedullary mass extending from C7-T1 and displacing the spinal cord. While awaiting surgery her symptoms progressed to involve the right lower limb. She was re-imaged and the lesion now extended from C5 to T3 with spinal cord compression at C7-T1. The radiological features and recent rapid growth were felt to be in keeping with a large plexiform neurofibroma. The patient underwent emergency resection of the lesion and pathology revealed Hodgkin's Lymphoma (HL)-mixed cellularity type. A mediastinal mass was identified on further imaging and biopsy confirmed the diagnosis of HL-stage IV. The patient is currently undergoing treatment with ABVD chemotherapy. CNS-HL is extremely rare and may occur de novo or in association with systemic disease. Lesions may be parenchymal or dural based and are usually intracranial with an increased risk of CNS involvement in HL-mixed-cellularity type as in our patient. This is the first report in the literature of CNS-HL radiologically mimicking a paraspinal plexiform neurofibroma.
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Affiliation(s)
- Orna O'Toole
- Department of Neuropathology, Beaumont Hospital, Dublin, UK
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22
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Phelan PJ, Murphy RKJ, Farrell M, O'Toole O, Heffernan J, O'Brien D, Breathnach O, Conlon PJ. EBV-positive B cell cerebral lymphoma 12 years after sex-mismatched kidney transplantation: post-transplant lymphoproliferative disorder or donor-derived lymphoma? Nephrol Dial Transplant 2010; 25:2032-5. [PMID: 20348150 DOI: 10.1093/ndt/gfq170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We present a follow-up case report of possible transmission of lymphoma 12 years after deceased-donor renal transplantation from a male donor who was found at autopsy to have had an occult lymphoma. The female recipient underwent prompt transplant nephrectomy. However, 12 years later, she presented with cerebral B cell lymphoma. A donor origin for the cerebral lymphoma was supported by in situ hybridization demonstration of a Y chromosome in the lymphoma. There was a dramatic resolution of the cerebral lesions with tapering of immunosuppression and introduction of rituximab treatment. The finding of a Y chromosome in the cerebral lymphoma does not exclude a host contribution to lymphoma development.
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Affiliation(s)
- Paul J Phelan
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland.
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Lefter S, O'Toole O, Sweeney B. Epilepsy and driving: new European Union guidelines. Ir Med J 2010; 103:86-88. [PMID: 20666075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- S Lefter
- Department of Neurology, Cork University Hospital, Wilton, Cork.
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O'Toole O, Mahon C, Lynch K, Brett FM. Is the contribution of alcohol to fatal traumatic brain injuries being underestimated in the acute hospital setting? Ir Med J 2009; 102:207-209. [PMID: 19771999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Alcohol consumption in Ireland has nearly doubled during the period 1989-2001. To evaluate the relationship of alcohol to fatal head injuries in the acute hospital setting we created a data base of all fatal traumatic brain injuries in the Department of Neuropathology at Beaumont Hospital over a ten year period (1997-2006 inclusive). 498 cases were identified (351 males: 147 females). Fatalities were highest in males aged 19-25 years (N=101) and 51-70 years (N=109). Falls (N=210) and road traffic accidents (N=183) were the commonest modes of presentation. 36/210 (17%) falls had positive blood alcohol testing, 9/210 (4.3%) had documentation of alcohol in notes but no testing, 35/210 (16.7%) tested negative for alcohol and 130/210 (61.9%) were not tested. The RTA group (N=183) comprised drivers (n=79), passengers (n=47) and pedestrians (n=57). 65/79 (82.2%) of drivers were males aged 19-25 years. Blood alcohol was only available in 27/79 (34.1%) drivers and was positive in 13/27 (48.1%). 14/75 (18.7%) pedestrians were tested for alcohol, 4/14 (28.6%) were positive. Overall 142/183 (77.6%) of the RTA group were not tested. The contribution of alcohol to fatal traumatic brain injuries is probably being underestimated due to omission of blood alcohol concentration testing on admission to hospital. Absence of national guidelines on blood alcohol testing in the emergency department compounds the problem.
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Affiliation(s)
- O O'Toole
- Department of Neuropathology, Beaumont Hospital, Beaumont, Dublin
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O'Toole O, Traynor BJ, Brennan P, Sheehan C, Frost E, Corr B, Hardiman O. Epidemiology and clinical features of amyotrophic lateral sclerosis in Ireland between 1995 and 2004. J Neurol Neurosurg Psychiatry 2008; 79:30-2. [PMID: 17634215 DOI: 10.1136/jnnp.2007.117788] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND We conducted a prospective, population based study to examine trends in incidence and prevalence of amyotrophic lateral sclerosis (ALS) in Ireland from 1995 to 2004. METHODS The Irish ALS Register was used to identify Irish residents diagnosed with ALS between the 3 year period from 1 January 1995 to 31 December 1997 and the 3 year period from 1 January 2002 to 31 December 2004. RESULTS 465 Irish residents were diagnosed with ALS during the study periods. The annual incidence rate of ALS in Ireland remained stable over this time (2.0 cases per 100,000 person-years; 95% CI 1.9, 2.2). Median survival of Irish ALS patients was 16.4 months and did not change during the study period. Demographics and clinical features of the incident and prevalent Irish ALS cohorts were markedly different.
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Affiliation(s)
- O O'Toole
- Department of Neurology, Beaumont Hospital, and and RCSI, Dublin 9, Ireland
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Hosback S, Hardiman O, Nolan CM, Doyle MAC, Gorman G, Lynch C, O'Toole O, Jakeman P. Circulating insulin-like growth factors and related binding proteins are selectively altered in amyotrophic lateral sclerosis and multiple sclerosis. Growth Horm IGF Res 2007; 17:472-479. [PMID: 17697791 DOI: 10.1016/j.ghir.2007.06.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Revised: 05/04/2007] [Accepted: 06/15/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To provide a detailed profile of the peripheral IGF system in the neurological conditions; amyotrophic lateral sclerosis (ALS), post polio syndrome (PPS) and multiple sclerosis (MS). To determine whether subsets of patients within the disease groups could be identified in whom one or more components of the IGF regulatory system are altered compared to healthy control subjects matched for age, sex and BMI. DESIGN Three cohorts of patients were recruited, 28 with ALS, 18 with PPS and 23 with MS. Patients were individually matched to a healthy control based on sex, age (+/-3 yr), and BMI (+/-2.5 kg m(-2)). The concentration (ng/ml) of serum IGF-I, IGF-II, IGFBP-1, IGFBP-2 and IGFBP-3 and acid-labile subunit (microg/ml) was determined by IRMA. RESULTS In ALS patients, there was an increase of 11% in [IGF(TOTAL)] (p=0.042) ([IGF(TOTAL)]=[IGF-I]+[IGF-II]) and [IGFBP-1] was decreased by 34% (p=0.050) compared to matched controls. In "surviving" ALS patients, defined as those ALS patients with long disease duration (+2 SD from the mean survival time for Irish patients post diagnosis), there was an increase in [IGF-I] 36% (p=0.032) and a large decrease in [IGFBP-1] -58% (p=0.020) compared to controls. These differences were not evident in pre-agonal ALS patients. The concentration of serum IGF-I was 38% (p=0.018), acid-labile subunit 17% (p=0.044) and IGFBP-2 43% (p=0.035) higher in MS patients compared to controls. When stratified for interferon-beta (IFN-beta) use, we observed an increase in serum [IGF-I] 52% (p=0.013) and [IGF(TOTAL)] 19% (p=0.043) in MS patients undergoing IFN-beta treatment, but MS patients not undergoing IFN-beta treatment had similar IGF and IGFBP concentration to controls. Serum [IGFBP-3] 18% (p=0.033), [IGFBP-2] 86% (p=0.015) and (acid-labile subunit) 33% (p=0.012) was also higher in IFN-beta patients compared to controls. Stratified by stage of disease the most significant increase in components of the peripheral IGF system was attributed to relapsing-remitting MS patients treated with IFN-beta. All components of the peripheral IGF system in PPS patients were similar to controls. CONCLUSIONS The increase in circulating IGF-I and a reduction in regulatory binding protein IGFBP-1 in ALS patients with a "stable" disease profile suggest a potential change in peripheral IGF bioavailability in these subjects. In MS, we report a change in a number of components of the peripheral IGF system, the observed increase in IGF-I in patients treated with IFN-beta being of most significance as a potential therapeutic biomarker.
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Affiliation(s)
- Sharah Hosback
- Human Science Research Unit, University of Limerick, Ireland
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28
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O'Toole O. Appointment of Preregistration House Officers. West J Med 1973. [DOI: 10.1136/bmj.3.5871.106-e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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