Chronic Neurology in COVID-19 Era: Clinical Considerations and Recommendations From the REPROGRAM Consortium

With the rapid pace and scale of the emerging coronavirus 2019 (COVID-19) pandemic, a growing body of evidence has shown a strong association of COVID-19 with pre- and post- neurological complications. This has necessitated the need to incorporate targeted neurological care for this subgroup of patients which warrants further reorganization of services, healthcare workforce, and ongoing management of chronic neurological cases. The social distancing and the shutdown imposed by several nations in the midst of COVID-19 have severely impacted the ongoing care, access and support of patients with chronic neurological conditions such as Multiple Sclerosis, Epilepsy, Neuromuscular Disorders, Migraine, Dementia, and Parkinson disease. There is a pressing need for governing bodies including national and international professional associations, health ministries and health institutions to harmonize policies, guidelines, and recommendations relating to the management of chronic neurological conditions. These harmonized guidelines should ensure patient continuity across the spectrum of hospital and community care including the well-being, safety, and mental health of the patients, their care partners and the health professionals involved. This article provides an in-depth analysis of the impact of COVID-19 on chronic neurological conditions and specific recommendations to minimize the potential harm to those at high risk.

Human neural stem cell transplantation in ALS: initial results from a phase I trial

Background

We report the initial results from a phase I clinical trial for ALS. We transplanted GMP-grade, fetal human neural stem cells from natural in utero death (hNSCs) into the anterior horns of the spinal cord to test for the safety of both cells and neurosurgical procedures in these patients. The trial was approved by the Istituto Superiore di Sanità and the competent Ethics Committees and was monitored by an external Safety Board.

Methods

Six non-ambulatory patients were treated. Three of them received 3 unilateral hNSCs microinjections into the lumbar cord tract, while the remaining ones received bilateral (n = 3 + 3) microinjections. None manifested severe adverse events related to the treatment, even though nearly 5 times more cells were injected in the patients receiving bilateral implants and a much milder immune-suppression regimen was used as compared to previous trials.

Results

No increase of disease progression due to the treatment was observed for up to18 months after surgery. Rather, two patients showed a transitory improvement of the subscore ambulation on the ALS-FRS-R scale (from 1 to 2). A third patient showed improvement of the MRC score for tibialis anterior, which persisted for as long as 7 months. The latter and two additional patients refused PEG and invasive ventilation and died 8 months after surgery due to the progression of respiratory failure. The autopsies confirmed that this was related to the evolution of the disease.

Conclusions

We describe a safe cell therapy approach that will allow for the treatment of larger pools of patients for later-phase ALS clinical trials, while warranting good reproducibility. These can now be carried out under more standardized conditions, based on a more homogenous repertoire of clinical grade hNSCs. The use of brain tissue from natural miscarriages eliminates the ethical concerns that may arise from the use of fetal material.

Trial registration

EudraCT:2009-014484-39.

Botulinum toxin injection into the forearm muscles for wrist and fingers spastic overactivity in adults with chronic stroke: a randomized controlled trial comparing three injection techniques

OBJECTIVE

To compare the outcome of manual needle placement, electrical stimulation and ultrasonography-guided techniques for botulinum toxin injection into the forearm muscles of adults with arm spasticity.

DESIGN

Randomized controlled trial.

SETTING

University hospital.

SUBJECTS

Sixty chronic stroke patients with wrist and fingers spasticity.

INTERVENTION

After randomization into three groups, each patient received botulinum toxin type A in at least two of these muscles: flexor carpi radialis and ulnaris, flexor digitorum superficialis and profundus (no fascicles selection). The manual needle placement group underwent injections using palpation; the electrical stimulation group received injections with electrical stimulation guidance; the ultrasonography group was injected under sonographic guidance. A sole injector was used.

MAIN MEASURES

All patients were evaluated at baseline and four weeks after injection.

OUTCOMES

Modified Ashworth Scale; Tardieu Scale; wrist and fingers passive range of motion.

RESULTS

One month after injection, Modified Ashworth Scale scores improved more in the electrical stimulation group than the manual needle placement group (wrist: P = 0.014; fingers: P = 0.011), as well as the Tardieu angle (wrist: P = 0.008; fingers: P = 0.015) and passive range of motion (wrist: P = 0.004). Furthermore, Modified Ashworth Scale scores improved more in the ultrasonography group than in the manual needle placement group (wrist: P = 0.001; fingers: P = 0.003), as well as the Tardieu angle (wrist: P = 0.010; fingers: P = 0.001) and passive range of motion (wrist: P < 0.001; proximal interphalangeal joints: P = 0.009). No difference was found between the ultrasonography and electrical stimulation groups.

CONCLUSIONS

Instrumental guidance may improve the outcome of botulinum toxin injections into the spastic forearm muscles of stroke patients.

Complex pattern of convulsive syncope in glossopharyngeal neuralgia: video/EEG report and short review

A 65-year-old woman presented with three "convulsive" events that were preceded by stabbing pain extending from the left submandible zone to the neck and ipsilateral ear. Video-electroencephalography captured a typical attack, where electrocardiography showed bradycardia for 17 seconds and asystole for at least 9 seconds. The patient lost consciousness while her head/gaze turned right. She then manifested tonic extension of her left limbs followed by adduction of her left limb and flexion of her right upper limb. Her gaze deviated upward and her left upper limb manifested swimming-like automatisms. The full episode lasted about 70 seconds, and the EEG showed progressive diffuse high-amplitude slowing. A diagnosis of convulsive syncope resulting from classic glossopharyngeal neuralgia was made. Carbamazepine led to steady remission. Glossopharyngeal neuralgia is a rare condition (incidence of 0.7/100.000/year), whereas the occurrence of syncope is about 20%, and that of convulsive syncope is about 5%.

[Mental retardation and psychiatric pathology. Statistical investigation and follow-up]

The Authors describe the organization and aims of the rehabilitation institute "G. Ferrero" of Alba, Cuneo district, Italy. Afterwards they present, analyse and compare 34 items regarding patients over 14 years of age that were present on the 30 November 1978 and 1988. The most important data are: 1) a large rise in average age and stay at the institute; 2) a similar rise in the mental retardation level; 3) the lack of link between handicap level and possibility for the subject to go back to the original family; 4) a considerable increase in the subjects with psychosis or cerebropathia; 5) the poor prognosis for psychotic subjects, that are affected 10 years after and almost never succeed in going back to their original family or in finding a job; 6) big changes that changing types of patients produced in the institute's aims and in treatment, with partial renunciation to rehabilitation and development of nursing and ergotherapy.

[Calcium folate in pregnancy. Therapeutic efficacy]

An open, randomised multicentre study was carried out to compare pregnant women, treated with calcium folinate (Citofolin Bracco S.p.A.) 15 mg/day per os starting from the 12th or 20th week of gestation, with an untreated group. The results obtained confirm the efficacy of calcium folinate treatment on the trends of parameters analysed (serum and endoerythrocytic folatemia, hemoglobin and sideremia) which remained within the normal range. Moreover, no adverse effects of any type were reported during the study.

[The effects of bisoprolol and atenolol on glucose metabolism in hypertensive patients with non-insulin-dependent diabetes mellitus]

Effects of bisoprolol and atenolol on glucose metabolism in hypertensive patients NIDDM. The aim of the study was to compare the antihypertensive efficacy and the effects on glucose metabolism of a new beta 1-selective beta-blocker with high beta 1 selectivity, bisoprolol and atenolol in 12 hypertensive patients (WHO classes I e II) suffering from untreated not insulin-dependent diabetes mellitus (NIDDM). According to a cross-over design after a placebo run-in period of 4 weeks, the patients were randomly allocated to receive bisoprolol 10 mg o.d. or atenolol 100 mg o.d. for 4 weeks, with a four-week wash-out period between the two active treatments. In basal condition and after each therapy an intravenous glucose tolerance test (i.v. GTT, 20 g) was performed, with evaluation of serum glucose and insulin at 0, 15, 30, 60, 90, 120 minutes and glycosuria during the test. At the same time blood pressure, heart rate (supine, upright), ECG, laboratory tests were assessed and subjective tolerability was evaluated. The glucose and insulin responses to the i.v. GTT did not significantly change to basal condition. Similarly glycosuria did not show significative increment during the test with both beta-blocking therapies. Blood pressure and heart rate values were significantly reduced (p less than 0.001) after bisoprolol and atenolol treatment. During the study no side effects were reported and laboratory tests and ECG remained substantially unchanged. These data confirm the antihypertensive efficacy of bisoprolol and atenolol and demonstrate the absence of important effects of these drugs on glucose metabolism in hypertensive patients with NIDDM.

Nicorandil, a new vasodilator drug, in patients with essential hypertension

In 12 mild to moderate hypertensive patients we investigated the acute antihypertensive efficacy of three different doses of nicorandil, a new vasodilating agent which probably acts by increasing the potassium efflux from smooth muscle cells and causing a cellular hyperpolarization. After a 3-day placebo period the patients were given, according to a double-blind Latin-square randomized design, 10, 20 and 30 mg nicorandil as a single acute dose every other day. Blood pressure and the heart rate were measured in both supine and upright positions at various times for 24 h after the dosing; fractional urine collections were obtained at the end of the placebo period and after each active dose. All doses of nicorandil similarly and significantly (P less than 0.01) reduced supine blood pressure, with a peak after 4-6 h (10 mg: -21/-8 mmHg; 20 mg: -20/-9 mmHg; 30 mg: -29/-17 mmHg), and the effect was still present, though reduced, after 24 h; no change in the heart rate was observed. The results from the upright position were similar. There were no significant changes in urine volume and electrolyte excretion during the nicorandil administration. The three different doses of nicorandil caused similar acute blood pressure reductions without change in the heart rate, nor in the urine volume and urinary sodium.