Subgroup comparison according to clinical phenotype and serostatus in autoimmune encephalitis: a multicenter retrospective study

BACKGROUND AND PURPOSE

Autoimmune encephalitides (AE) include a spectrum of neurological disorders whose diagnosis revolves around the detection of neuronal antibodies (Abs). Consensus-based diagnostic criteria (AE-DC) allow clinic-serological subgrouping of AE, with unclear prognostic implications. The impact of AE-DC on patients' management was studied, focusing on the subgroup of Ab-negative-AE.

METHODS

This was a retrospective multicenter study on patients fulfilling AE-DC. All patients underwent Ab testing with commercial cell-based assays (CBAs) and, when available, in-house assays (immunohistochemistry, live/fixed CBAs, neuronal cultures) that contributed to defining final categories. Patients were classified as Ab-positive-AE [N-methyl-d-aspartate-receptor encephalitis (NMDAR-E), Ab-positive limbic encephalitis (LE), definite-AE] or Ab-negative-AE (Ab-negative-LE, probable-AE, possible-AE).

RESULTS

Commercial CBAs detected neuronal Abs in 70/118 (59.3%) patients. Testing 37/48 Ab-negative cases, in-house assays identified Abs in 11 patients (29.7%). A hundred and eighteen patients fulfilled the AE-DC, 81 (68.6%) with Ab-positive-AE (Ab-positive-LE, 40; NMDAR-E, 32; definite-AE, nine) and 37 (31.4%) with Ab-negative-AE (Ab-negative-LE, 17; probable/possible-AE, 20). Clinical phenotypes were similar in Ab-positive-LE versus Ab-negative-LE. Twenty-four/118 (20.3%) patients had tumors, and 19/118 (16.1%) relapsed, regardless of being Ab-positive or Ab-negative. Ab-positive-AE patients were treated earlier than Ab-negative-AE patients (P = 0.045), responded more frequently to treatments (92.3% vs. 65.6%, P < 0.001) and received second-line therapies more often (33.3% vs. 10.8%, P = 0.01). Delays in first-line therapy initiation were associated with poor response (P = 0.022; odds ratio 1.02; confidence interval 1.00-1.04).

CONCLUSIONS

In-house diagnostics improved Ab detection allowing better patient management but was available in a patient subgroup only, implying possible Ab-positive-AE underestimation. Notwithstanding this limitation, our findings suggest that Ab-negative-AE and Ab-positive-AE patients share similar oncological profiles, warranting appropriate tumor screening. Ab-negative-AE patients risk worse responses due to delayed and less aggressive treatments.

Variation of a carotenoid-based trait in relation to oxidative stress and endocrine status during the breeding season in the Eurasian kestrel: a multi-factorial study

Carotenoid-based skin colorations vary seasonally in many bird species and are thought to be honest sexually selected signals. In order to provide more insight in the potential signal function and underlying mechanisms of such colorations we here quantified patterns of variation of leg coloration in adult male and female Eurasian kestrels (Falco tinnunculus tinnunculus) over the breeding season, and evaluated the relationship between coloration and levels of carotenoids, androgens and estrogens, oxidative damage and plasma non-enzymatic antioxidant capacity. We studied both reproducing wild and non-reproducing captive birds to test for the effect of diet and breeding effort. Males were more colored than females only during mating, and independently of diet, suggesting that leg-color is a sexually selected trait. Seasonal variation in leg color was associated with circulating carotenoids, but concentrations of these molecules were not related to antioxidant capacity, body condition or oxidative damage. These results indicate that carotenoid-based colorations may not be an honest signal of health status in this species. Production of carotenoid rich eggs coincided with low levels of circulating carotenoids in females, indicating that carotenoids might be a limited resource for laying female kestrels. Finally, young rearing males had higher levels of oxidative damage than females, and wild birds of both sexes had higher levels of these parameters than captive birds. These results may indicate that parental effort and physical activity are costly, independently from hormonal status. Since androgens did not explain carotenoid variation we suggest that multiple interacting factors can regulate carotenoid levels along the season.

[Customer satisfaction in home care: methodological issues based on a survey carried out in Lazio]

Home care customer satisfaction has been, until now, rarely evaluated. After illustrating the main italian regional surveys on this issue, the article presents a customer satisfaction survey carried out in the district of Civitavecchia (Local Health Unit 'Rome F'), Lazio, regarding 30 home care beneficiaries. Methodological aspects emerging from the survey are basically focused on: advantages and disadvantages of quantitative and qualitative approaches (possibly associated each other); main criteria of eligibility of people selected for interviewing, both patients or caregivers; conditions that maximize answers reliability, including training on interviewers. Authors highlight opportunity of using such kind of survey, integrated with other different tools, into a systemic vision, for promoting management changes coming from suggested problems, aimed at total quality management.

Only high concentrations of ethanol affect GABAA receptors of rat cerebellum granule cells in culture

In the experiments described in the present report, we evaluated the effects of ethanol on the activity of GABAA receptors of cerebellar granule cells in culture. Only very high ethanol concentrations (100-300 mM) showed a clear and significant stimulatory effect on the activity of such receptors. This result was unexpected. In fact, previous reports from other groups would have suggested high ethanol sensitivity of at least one population of GABAA receptors expressed by granule cells.

[Comprehensive assessment in public health]

The Italian health system has been completely public for 25 years; it is now adopting a federal structure conferring to the single regions a leading role in public health management. Therefore clear evaluation methods and tools need to be adopted in order to guarantee equity-based decision making. Multidimensional evaluation, a method first developed in the geriatric setting, represents an extremely useful tool both to establish the best profile of assistance and to guide the management of different services. It is mainly used to evaluate health status and needs for assistance within non self-sufficient populations, largely composed of the elderly. Currently available assessment tools reveal different approaches, goals and level of accuracy. The authors have examined and compared 21 different multidimensional assessment tools adopted in Italy with a standardized method based on pre-established data collection and evaluation criteria. Both quantitative (number of items used for every single dimension or sub-dimension) and quali-quantitative aspects (level of detail for every single dimension or sub-dimension) are included in the analysis. Tools were also evaluated according to the degree of fulfilment of certain fixed requirements. In the authors' opinion, given a specific assistance setting and its users, once the goals and requirements of the evaluation instrument are clearly defined, adopting this methodology--defined as "Progressive exclusion method for easier visualization of criteria correspondence and quali-quantitative aspects", would help to identify the most suitable assessment tools to be used. The authors hope that, on a regional level, the public health system will make a greater use of homogeneous multidimensional comprehensive assessment tools in order to foster both a uniform approach towards the needs for assistance and transparent criteria of resources allocation in public health services.

Modulation by Zn(2+) and Cd(2+) of GABA(A) receptors of rat cerebellum granule cells in culture

This study aims to characterize more closely the different populations of GABA(A) receptors present on the cerebellar granule cells of the rat. The effects of two divalent cations, Zn(2+) and Cd(2+), on GABA-activated chloride currents were studied using the whole-cell patch-clamp technique. Zinc cations inhibit differently the peak and the steady-state current elicited by 10 micro M GABA. In fact, Zn(2+) appears to be more potent in inhibiting the steady-state component, with a lower IC(50). The inhibition of the peak component is of the competitive type, whereas the inhibition of the steady-state one is mixed, being partly competitive and partly allosteric. In addition, Cd(2+) has an inhibitory effect on GABA-activated chloride currents. In terms of the peak component, its effect is limited in extent with a maximal inhibition of only 26%, but with a high affinity (IC(50) as low as 0.03 micro M). The steady-state component is inhibited by 20% independently from the Cd(2+) concentration, in the 10(-2)-10(2) micro M range. In this case, the inhibitory mechanism appears to be of the competitive type for the peak component and of the allosteric type for the steady-state one. We suggest these data are a further confirmation that the rapidly and slowly desensitizing components of the GABA-activated chloride currents, corresponding respectively to the peak and the steady-state components, are made up of two different receptor populations.

Antibiotic resistance in Streptococcus pneumoniae in six Latin American countries: 1993-1999 surveillance

The impact of invasive pneumococcal invasive disease is increased by the emergence of antibiotic resistance. We report regional and temporal variations in antibiotic resistance for 4,105 invasive Streptococcus pneumoniae isolates collected from Latin American children <5 years, between 1993 and 1999. Reduced susceptibility to penicillin was detected in 1,182 isolates (28.8%); 36% of these were resistant (> or = 2 microg/ml), including 12.6% with MIC > or = 4 microg/ml, occurring primarily in serotypes 14 and 23F. Reduced susceptibility to third-generation cephalosporins was detected in 12.1% of the collection. Mexico had the highest proportion of reduced susceptibility to penicillin (51.6%) and to third-generation cephalosporins (22%), whereas Brazil had the lowest at 20.9% and 0.7%, respectively. Isolates cultured from patients with pneumonia were more likely to have reduced susceptibility to third-generation cephalosporins than isolates from patients with meningitis (p < 0.0001). Susceptibility to trimethoprim-sulfamethoxazole, chloramphenicol, erythromycin, and vancomycin was tested by disk diffusion for 2.899 isolates. Reduced susceptibility was observed for 45.6%, 11.5%, 6.9%, and 0%, respectively. Thirty-one percent of the strains were resistant to > or = 2 drugs. High levels of antibiotic resistance in Latin America emphasize the need for the development of and adherence to rational antibiotic use guidelines. On-going surveillance will monitor the impact of these programs.

Erythropoietin prevents neuronal apoptosis after cerebral ischemia and metabolic stress

Erythropoietin (EPO) promotes neuronal survival after hypoxia and other metabolic insults by largely unknown mechanisms. Apoptosis and necrosis have been proposed as mechanisms of cellular demise, and either could be the target of actions of EPO. This study evaluates whether antiapoptotic mechanisms can account for the neuroprotective actions of EPO. Systemic administration of EPO (5,000 units/kg of body weight, i.p.) after middle-cerebral artery occlusion in rats dramatically reduces the volume of infarction 24 h later, in concert with an almost complete reduction in the number of terminal deoxynucleotidyltransferase-mediated dUTP nick-end labeling of neurons within the ischemic penumbra. In both pure and mixed neuronal cultures, EPO (0.1--10 units/ml) also inhibits apoptosis induced by serum deprivation or kainic acid exposure. Protection requires pretreatment, consistent with the induction of a gene expression program, and is sustained for 3 days without the continued presence of EPO. EPO (0.3 units/ml) also protects hippocampal neurons against hypoxia-induced neuronal death through activation of extracellular signal-regulated kinases and protein kinase Akt-1/protein kinase B. The action of EPO is not limited to directly promoting cell survival, as EPO is trophic but not mitogenic in cultured neuronal cells. These data suggest that inhibition of neuronal apoptosis underlies short latency protective effects of EPO after cerebral ischemia and other brain injuries. The neurotrophic actions suggest there may be longer-latency effects as well. Evaluation of EPO, a compound established as clinically safe, as neuroprotective therapy in acute brain injury is further supported.

Polymorphism of the apolipoprotein E gene and early carotid atherosclerosis defined by ultrasonography in asymptomatic adults

Clinical and autoptical studies have suggested a predisposing role of the allele E4 of apolipoprotein E (apoE) in the development of atherosclerosis and cardiovascular disease. To investigate the possible contribution of apoE allele polymorphism to the carotid intima-media thickness (IMT) as assessed by ultrasound, we studied 260 asymptomatic nondiabetic subjects (121 men, 139 women; mean +/- SD age, 53 +/- 7 years), randomly selected from the population register of the inhabitants of Trieste, Italy. B-mode ultrasound was used to quantify the maximum IMT at 12 sites on the near and far wall of the common, bifurcation, and internal carotid arteries. ApoE genotypes were determined from amplified apoE sequences by restriction isotyping. The frequencies of E2, E3, and E4 alleles were 0.073, 0.827, and 0.100, respectively. As expected, subjects with E4 allele had the highest levels of total serum cholesterol and LDL cholesterol, subjects with E2 allele had the lowest levels, and those with E3 genotype had intermediate levels. The echographic measurements of carotid IMT showed increasing values from E2 to E4 carriers. After adjustment for total and LDL cholesterol serum levels, triglycerides, ratio of LDL to HDL cholesterol, age, sex, and body mass index, ANCOVA showed that the common carotid IMT was significantly greater (P = .029) in subjects with E4 allele compared with E3 carriers. Our data confirm the influence of apoE4 on cholesterol levels and clearly show that apoE genotype affects carotid atherosclerosis in its early stages in middle-aged asymptomatic subjects.

Fibromuscular dysplasia. A case report with multivessel vascular involvement

A case of multivessel fibromuscular dysplasia involving the cervico-cephalic arteries, the right renal artery and the iliac arteries is reported. It was associated with reversible bilateral internal carotid arteries and vertebral arteries dissection, left thalamic infarct, right hemorrhagic cerebellar infarct, renovascular hypertension and intermittent claudication of the right lower limb. This report indicates that fibromuscular dysplasia is a systemic angiopathy. Renovascular hypertension may foster the appearance of complication such as dissection of the arteries affected by fibromuscular dysplasia. In the case investigated the dissection of cervico-cephalic arteries was followed by spontaneous healing and a favourable neurological outcome whereas at the iliac arteries a rapid deterioration was observed.

Il penogramma radioisotopico dinamico con nitroglicerina sublinguale nella diagnostica non invasiva dell'impotenza

Nuclear medicine techniques may be used to test vasculogenic impotence. Dynamic radioisotope penogram with 0.3 mg sublingual nitroglycerin was performed in 50 impotent patients. The penogram index (Ip) and the time required to reach peak activity (Tp) was calculated. Ip was useful to differentiate vasculogenic and psychogenic impotence. The radioisotope penogram is a simple, less invasive and valuable screening test in the identification of vasculogenic impotence.

Primary amenorrhoea and infertility due to a mutation in the beta-subunit of follicle-stimulating hormone

We report a woman with primary amenorrhoea and infertility associated with an isolated deficiency of pituitary follicle-stimulating hormone (FSH), but normal luteinizing hormone (LH) secretion. Ovulation was induced by administration of exogenous FSH and resulted in a successful pregnancy. Sequence analysis of the FSH beta-subunit gene indicated that she is homozygous for a two nucleotide frameshift deletion in the coding sequence. Her mother and son are heterozygous for this mutation. This deletion results in an alteration of amino acid codons 61-86 followed by a premature termination codon. The predicted truncated beta-subunit peptide lacks regions which are important for association with the alpha subunit and for binding to and activation of the FSH receptor. Abnormalities of FSH structure or function might be an under recognised but treatable cause of infertility.

Experimental herpes simplex virus encephalitis: Comparative effects of treatment with cytosine arabinoside and adenine arabinoside

Experimental herpesvirus encephalitis in weanling mice was treated with either cytosine arabinoside or adenine arabinoside to determine the comparative effectiveness of the two compounds on survival and on the concentration of virus in the brain. The uniformly fatal course of the encephalitis was not altered by any dosage of cytosine arabinoside. In contrast, treatment with adenine arabinoside resulted in long-term survival of the majority of the infected animals. The concentration of virus measured in the brains of animals treated with two different dosages of cytosine arabinoside indicated initial suppression of viral replication with a subsequent rise to levels higher than those in the untreated controls. In the brains of adenine arabinoside-treated animals, titers of virus gradually diminished to undetectable levels by the eighth day after institution of therapy.