Abnormal Dynamic Pupillometry Relates to Neurologic Disability and Retinal Axonal Loss in Patients With Multiple Sclerosis

Purpose

To assess alterations in quantitative dynamic pupil responses to light in relation to neurologic disability and retinal axonal loss in patients with multiple sclerosis (MS).

Methods

Twenty-five patients with relapsing-remitting MS and 25 healthy subjects were included in this cross-sectional study. Pupillary responses were measured with an infrared dynamic pupillometry unit, and peripapillary retinal nerve fiber layer (RNFL) thickness was measured with spectral-domain optical coherence tomography. Neurologic disability was assessed by the Expanded Disability Status Scale (EDSS). Patients with a history of optic neuritis (ON) within 6 months were excluded. Only the right eyes were assessed, except in 11 patients with a history of unilateral ON in whom both eyes were further analyzed to evaluate the effect of previous ON.

Results

The initial pupil diameter (P = 0.003) and pupil contraction amplitude (P = 0.027) were lower in patients with MS compared with healthy controls. Initial pupil diameter correlated with EDSS score (ρ = −0.458; P = 0.021), and RNFL correlated with contraction latency (ρ = −0.524; P = 0.007). There were no significant differences in any of the pupil parameters between eyes with and without a history of ON, and between the ON and fellow eyes of the 11 patients with previous unilateral ON.

Conclusions

Dynamic pupillometry reveals significant alterations in pupillary light reflex responses associated with neurologic disability and retinal axonal loss, independent of previous ON.

Translational Relevance

Dynamic pupillometry is a simple, noninvasive tool that may be useful in detecting autonomic dysfunction in patients with MS.

Progressive Loss of Corneal and Retinal Nerve Fibers in Patients With Multiple Sclerosis: A 2-Year Follow-up Study

Purpose

To determine longitudinal alterations in corneal nerve fiber morphology, dendritic cell (DC) density, and retinal nerve fiber layer (RNFL) thickness over 2 years in patients with multiple sclerosis (MS).

Methods

Thirty-one consecutive patients with relapsing-remitting MS (RRMS) underwent assessment of the Kurtzke Expanded Disability Status Scale (EDSS), Multiple Sclerosis Severity Score (MSSS), corneal confocal microscopy to quantify corneal subbasal nerve morphology and DC density, and spectral-domain optical coherence tomography to quantify RNFL thickness at baseline and after 2 years.

Results

There was a significant reduction in corneal nerve fiber area (CNFA) (P = 0.003), nerve fiber width (CNFW) (P = 0.005), and RNFL thickness (P = 0.004) with an increase in EDSS (P = 0.01) over 2 years. The change in corneal nerve fiber density (CNFD) correlated with the change in EDSS (ρ = -0.468; P = 0.008), MSSS (ρ = -0.442; P = 0.01), DC density (ρ = -0.550; P = 0.001), and RNFL (ρ = 0.472; P = 0.007). The change in corneal nerve fiber length (CNFL) correlated with the change in EDSS (ρ = -0.445; P = 0.01) and MSSS (ρ = -0.490; P = 0.005). Furthermore, there was a significant decrease in CNFL (P < 0.001), CNFA (P = 0.02), CNFW (P = 0.04), corneal total branch density (P = 0.01), and RNFL thickness (P = 0.02) and a significant increase in DC density (P = 0.04) in patients with worsening EDSS (n = 15).

Conclusions

Corneal confocal microscopy can be used to detect progressive corneal nerve fiber loss that relates to a progression of disability in patients with RRMS.

Translational Relevance

Corneal confocal microscopy acts as a sensitive imaging biomarker for progressive nerve degeneration in patients with MS.

Use of Corneal Confocal Microscopy to Detect Corneal Nerve Loss and Increased Dendritic Cells in Patients With Multiple Sclerosis

Importance

Multiple sclerosis (MS) is characterized by demyelination, axonal degeneration, and inflammation. Corneal confocal microscopy has been used to identify axonal degeneration in several peripheral neuropathies.

Objective

To assess corneal subbasal nerve plexus morphologic features, corneal dendritic cell (DC) density, and peripapillary retinal nerve fiber layer (RNFL) thickness in patients with MS.

Design, Setting, and Participants

This single-center, cross-sectional comparative study was conducted at a tertiary referral university hospital between May 27, 2016, and January 30, 2017. Fifty-seven consecutive patients with relapsing-remitting MS and 30 healthy, age-matched control participants were enrolled in the study. Corneal subbasal nerve plexus measures and DC density were quantified in images acquired with the laser scanning in vivo corneal confocal microscope, and peripapillary RNFL thickness was measured with spectral-domain optical coherence tomography.

Main Outcomes and Measures

Corneal nerve fiber density, nerve branch density, nerve fiber length, DC density, peripapillary RNFL thickness, and association with the severity of neurologic disability as assessed by the Kurtzke Expanded Disability Status Scale (score range, 0-10; higher scores indicate greater disability) and Multiple Sclerosis Severity Score (score range, 0.01-9.99; higher scores indicate greater severity).

Results

Of the 57 participants with MS, 42 (74%) were female and the mean (SD) age was 35.4 (8.9) years; of the 30 healthy controls, 19 (63%) were female and the mean (SD) age was 34.8 (10.2) years. Corneal nerve fiber density (mean [SE] difference, -6.78 [2.14] fibers/mm2; 95% CI, -11.04 to -2.52; P = .002), nerve branch density (mean [SE] difference, -17.94 [5.45] branches/mm2; 95% CI, -28.77 to -7.10; P = .001), nerve fiber length (mean [SE] difference, -3.03 [0.89] mm/mm2; 95% CI, -4.81 to -1.25; P = .001), and the mean peripapillary RNFL thickness (mean [SE] difference, -17.06 [3.14] μm; 95% CI, -23.29 to -10.82; P < .001) were reduced in patients with MS compared with healthy controls. The DC density was increased (median [interquartile range], 27.7 [12.4-66.8] vs 17.3 [0-28.2] cells/mm2; P = .03), independent of a patient's history of optic neuritis. Nerve fiber density and RNFL thickness showed inverse associations with the Expanded Disability Status Scale (ρ = -0.295; P = .03 for nerve fiber density and ρ = -0.374; P = .004 for RNFL thickness) and the Multiple Sclerosis Severity Score (R = -0.354; P = .007 for nerve fiber density and R = -0.283; P = .03 for RNFL thickness), whereas other study measures did not.

Conclusions and Relevance

These data suggest that corneal confocal microscopy demonstrates axonal loss and increased DC density in patients with MS. Additional longitudinal studies are needed to confirm the use of corneal confocal microscopy as an imaging biomarker in patients with MS.

What is the most accurate method for the treatment of diminutive colonic polyps?: Standard versus jumbo forceps polypectomy

Different methods such as standard, hot, and jumbo forceps are used in endoscopic treatment of diminutive colon polyps. In the current study, it was aimed to compare efficacy and safety of standard and jumbo forceps polypectomy methods in treatment of diminutive colon polyps of ≤5 mm. Polyps with ≤5 mm which were excised during colonoscopy by using standard or jumbo forceps were evaluated. Standard and jumbo forceps polypectomy methods were randomly performed in 212 consecutive patients with diminutive colorectal polyp. One-bite polypectomy and complete resection rates were also determined among polypectomy methods. Results of 161 standard forceps polypectomy and 102 jumbo forceps polypectomy were retrospectively evaluated. Both one-bite polypectomy and complete resection rates were significantly higher in the jumbo forceps polypectomy group than the standard forceps polypectomy group (P < 0.001). In the subgroup analysis performed according to polyp sizes, complete resection rate among polyps with 3-mm diameter was determined as 100%. However, numbers of bites in 4-mm and 5-mm polyps were higher in the standard forceps polypectomy group, and complete resection rate was lower than in the jumbo forceps polypectomy group (P < 0.001). Both endoscopic treatment methods may be employed in treatment of diminutive colon polyps with ≤5 mm. However, jumbo forceps polypectomy is a more effective treatment method in 4- to 5-mm polyps with high one-bite polypectomy and complete resection rate.

Effects of multiple sclerosis on female sexuality: a controlled study

AIM

The aim of this study was to investigate the effects of multiple sclerosis (MS) on female sexuality.

METHODS

Present study included 142 females (70 MS patients, 72 healthy controls). MS patients were evaluated by Expanded Disability Status Scale (EDSS) for functional status, by Beck Depression Inventory (BDI) for severity of depression, by Visual Analog Scale (VAS) for severity of pain, and by Female Sexual Function Inventory (FSFI) for sexual function.

MAIN OUTCOME MEASURES

FSFI, BDI, EDSS, and VAS were the main outcome measures.

RESULTS

The number of weekly sexual intercourse, total FSFI, and FSFI subscale scores were lower in MS women compared with controls. FSFI total and FSFI subscale scores were statistically significantly lower in MS women with BDI score ≥ 17 compared with those with BDI score <17. A negative correlation was found between total FSFI score and BDI, EDSS, VAS, age, and duration of complaint, but a positive correlation was found with education level in MS women.

CONCLUSIONS

Sexual functions are negatively affected in MS women. Sexual functions in MS women seem to be associated with enhanced disability, pain, duration of the disease, and degree of concomitant depression. Therefore, women with MS should also be evaluated in terms of sexual function during routine follow-ups.

Impact of an information video before colonoscopy on patient satisfaction and anxiety

BACKGROUND/AIMS

Anxiety is a common problem in patients undergoing invasive medical procedures. Colonoscopy is a demanding procedure and requires a patient's good cooperation for successful results. We aimed to examine the effects of adding an information video to our usual preprocedural information.

MATERIALS AND METHODS

A total of 227 patients were assessed in this study (120 male, 107 female). The patients were divided into two groups as video (n=124) or verbal (n=103). When the patients in the polyclinic with indications for colonoscopy were selected, a text about the procedure and related complications was given to them. A colonoscopy appointment was scheduled for the patients 3-4 weeks following the procedure. On the appointment day, the patients selected randomly in groups of 10 as either verbal or video sections were taken into the communication room 1-5 hours before the procedure. The patients' anxiety was measured afterwards using the Spielberger State-Trait Anxiety Inventory questionnaire. In addition, patients answered individual questions. After the colonoscopy, the patients were asked if they would undergo colonoscopy again for health reasons and whether the procedure was similar to, better, or worse than they had expected (following the information sessions).

RESULTS

It was noted in univariate and multiple logistic regression analyses that low State-Trait Anxiety Inventory-State levels (p≤0.001 and p=0.016, respectively) and communication by video (p<0.001, p=0.007, respectively) had a significant impact on communication success.

CONCLUSIONS

An information video shown to patients preparing for colonoscopy had an impact on the success of the procedure and on anxiety.

A Neuro-Behçet's Case Operated with the Intracranial Mass Misdiagnosis

Behçet's disease (BD) is an inflammatory systemic disorder with oral and genital ulcers, as well as ophthalmologic and cutaneous symptoms. Neurological manifestations in BD represent between 2.2% to 50% of the cases. The 25-year-old male patient, diagnosed with BD three years earlier, was admitted to our clinic with complaints of recurrent headaches. Tumor-like-parenchimal involvement was detected on a cranial magnetic resonance imaging. The lesion was removed surgically and then he suffered from right hemiparesis and epilepsy. Pathological examination of the lesion noted a demyelinating non-tumoural etiology. A neuro-Behğet's case with parenchymal involvement has been examined in light of the literature, in terms of a tumor and a demyelinating disease differential diagnosis.

Does presence of common bile duct stones in patients with acute biliary pancreatitis affect the severity of illness or laboratory findings?

BACKGROUND/AIMS

To determine the effect of stone within the common bile duct, on the severity of acute biliary pancreatitis.

MATERIAL AND METHODS

This is a prospective and cross sectional study which was conducted at a tertiary care hospital including 103 patients. Serum biochemical values and white blood cell counts at the first 12th and 72nd hours of presentation were evaluated. The patients were grouped according to the presence or absence of common bile duct stones which were diagnosed by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. Besides, the patients were classified as mild and severe acute pancreatitis according to the data provided by computed tomography (Balthazar scoring) and clinical assessment and blood samples.

RESULTS

Among the 103 patients with acute biliary patients, radial endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography revealed stones and/or sludge within the common bile duct or ampulla in 41 (39.8%) patients. There was not any persistent common bile duct stone in 62 (60.2%) patients. Severe pancreatitis developed in 9 (22%) of 41 patients who were determined to have stones by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography, and in 13 (21%) of 62 patients who were not. There was no difference in the incidence of progressing to severe acute biliary patients between patients with and without common bile duct stones (p=0.45).

CONCLUSION

Presence of common bile duct stones do not correlate with the severity of acute biliary pancreatitis.

Combined use of endosonography and endoscopic retrograde cholangiopancreatography in the same session

BACKGROUND/AIMS

The diagnostic value of endoscopic ultrasound in common bile duct stones is high. In this investigation, we evaluated the feasibility of endoscopic ultrasound preceding endoscopic retrograde cholangiography in the same session and the potential benefits in increasing the therapeutic endoscopic retrograde cholangiography ratio in the treatment of choledocholithiasis.

METHODS

One hundred and sixty-five consecutive patients who presented with elevated ALP and bilirubin levels and were referred for endoscopic retrograde cholangiography of biliary stones diagnosed with magnetic resonance cholangiopancreatography were evaluated. During the evaluation period (mean: 2 weeks), 50 patients with reductions in ALP and bilirubin by at least half relative to baseline values were enrolled into the study. Endoscopic ultrasound was performed prior to endoscopic retrograde cholangiography. Time spent to perform endoscopic ultrasound was noted. For the presence of common bile duct stone, we used retrograde cholangiography findings as the standard of reference.

RESULTS

Median endoscopic ultrasound time was 10.66 minutes (SD±1.52). Bile duct stones were revealed with retrograde cholangiography in 34 patients (68%). Sensitivity, specificity (with 95% confidence intervals [CIs]), positive predictive value and negative predictive value of endoscopic ultrasound were calculated. In identifying common bile duct stones on endoscopic ultrasound, sensitivity, specificity, positive predictive value, and negative predictive value were statistically determined as 91.2% (95% CI), 88.3% (95% CI), 91%, and 81.3%, respectively.

CONCLUSIONS

Our results indicate that in the presence of local experience and availability of endoscopic ultrasound, it is feasible to perform endoscopic ultrasound prior to endoscopic retrograde cholangiography. The sensitivity, specificity, positive predictive value, and negative predictive value for detecting choledocholithiasis in suspected cases are high. Endoscopic ultrasound preceding endoscopic retrograde cholangiography in the same session has the potential to decrease diagnostic endoscopic retrograde cholangiography and increase therapeutic endoscopic retrograde cholangiography. Need to perform magnetic resonance cholangiopancreatography in the presence of easily accessible endoscopic ultrasound should be questioned.

Endoscopic sphincterotomy alone in the management of low-grade biliary leaks due to cholecystectomy

AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is important in the diagnosis and management of postoperative bile leaks. Endoscopic sphincterotomy (ES) alone, ES with stent or nasobiliary drain (NBD) placement and stent or NBD without ES are the methods of choice. In the present study, we aimed to show the efficacy of ES alone in the management of low-grade (LGL) cystic duct stump (CDS) leaks due to cholecystectomy.

METHODS

Between September 2005 and January 2008, ES was carried out on 31 patients with LGL from the CDS due to cholecystectomy who were referred to the endoscopy unit of Izmir Ataturk Training and Research Hospital. Biliary leakage was detected by biliary discharge from a tube drain inserted during the operation. In cases of retaining common bile duct stones, balloon extraction was carried out. If bile discharge continued, a stent was introduced for cessation of the leak as a second procedure.

RESULTS

The success rate of ES alone was 87.1% (27 of 31 patients). In four patients (12.9%), ES alone was inadequate, therefore a stent was placed. The biliary leak ceased gradually and stopped in all patients at a mean of 11 (7-21) days. Balloon extraction of retained stones was carried out in six patients (19.6%). In two (6.5%) patients, mild hemorrhage and in two patients self-limited pancreatitis was seen (6.5%) as complications.

CONCLUSION

Endoscopic retrograde cholangiopancreatography is essential in the management of postoperative biliary leaks. Endoscopic sphincterotomy alone can be the initial procedure in the treatment of LGL from the CDS due to cholecystectomy.

The relationship between chronic HCV infection and the level of plasma adiponectin

BACKGROUND/AIMS

Metabolic products (TNFalpha, adiponectin, resistin, etc.), which are effective in insulin sensitivity and in the regulation of inflammation, play an important role in the development of metabolic disorders and fatty liver disease. The aim of this study was to evaluate the effect of HCV infection alone on plasma adiponectin levels and insulin sensitivity when metabolic factors are minimized and to determine whether chronic HCV infection causes hepatosteatosis through its effect on these factors.

METHODS

This study was carried out between 2006-2007, at the Gastroenterology Clinic of Izmir Atatürk Training and Research Hospital, in 30 non-diabetic patients with chronic HCV infection and 30 healthy subjects as controls. BMI (<26 kg/m2), fasting plasma glucose level, and ultrasonography were normal in both groups. In the patient group, HCV RNA was > or =1.90 x 10(3) IU/ml, ALT and AST were two times normal, and histological fibrosis scores were 1-2 in liver biopsy. Serum adiponectin levels and HOMA-IR were compared.

RESULTS

Fasting blood glucose levels, body mass index and HOMA-IR of the two groups were similar and normal. The mean ALT value was significantly higher in the patient group [61.8 U/L vs 28.17 U/L (p<0.05)]. The mean viral load was determined as 5.6 x 10(5) IU/ml in the chronic HCV patient group. The mean plasma adiponectin concentrations were 71.07 microg/ml in chronic HCV patients and 82.07 microg/ml in the control group, and the difference was statistically insignificant (p>0.05).

CONCLUSIONS

In the absence of metabolic disorders such as obesity, diabetes mellitus and hepatosteatosis, chronic HCV infection does not affect insulin sensitivity or adiponectin concentration.

The association of nocturnal serum melatonin levels with major depression in patients with acute multiple sclerosis

The association of nocturnal serum melatonin levels was investigated in acute multiple sclerosis (MS) patients with major depression (MD). The sample comprised 13 patients with MD and 12 with no psychiatric disorders admitted to our clinic due to acute MS attacks. Psychiatric evaluation was performed with the Structured Clinical Interview for DSM-IV (SCD-I). The level of depressive symptoms was assessed with the Beck Depression Scale (BDS). Blood samples were taken from the patients to determine melatonin level at 03.30 h and 10.00 h before steroid treatment started. Melatonin levels were determined using the ELISA test. Nocturnal serum melatonin levels (21.2+/-17.1 pg/ml) of the patients with MD were significantly lower than those (51.5+/-18.3 pg/ml) of the patients without MD. A significant negative correlation was found between BDS scores and nocturnal serum melatonin levels. These findings suggest that a melatonin deficiency may be among the factors involved in the occurrence of depression in MS patients.

Mood and anxiety disorders in patients with multiple sclerosis

Objective. This study aims to investigate the current prevalences of mood and anxiety disorders, as well as the sociodemographic and clinical features associated with these disorders in multiple sclerosis (MS). Method. A total of 74 patients with relapsing-remitting MS (42 patients in exacerbation phase, 32 patients in remission phase) were included in the study. Mood and anxiety disorders were diagnosed by means of the Structured Clinical Interview for DSM-IV (SCID-I). The Expanded Disability Status Scale (EDSS) was used to determine degree of disability due to MS. Results. Forty-five (60.8%) patients met the criterion of at least one mood or anxiety disorder. Major depression (33.8%) was the most common psychiatric diagnosis. Generalized anxiety disorder (18.9%), specific phobia (18.9%) and obsessive-compulsive disorder (OCD) (14.9%) were other frequent psychiatric disorders. Major depression, panic disorder and OCD were significantly more common among patients in the exacerbation phase compared to patients in the remission phase. The predictors of any depressive disorder were presence of exacerbation phase of MS and higher disability level, and the predictors of any anxiety disorder were presence of exacerbation phase of MS and shorter disease duration. Conclusions. Our results suggest that the patients with relapsing-remitting MS, particularly during exacerbation phase have high prevalence of mood and anxiety disorders.

Toxic hepatitis associated with paroxetine

Hepatotoxicity is a rare complication of paroxetine, a selective serotonin reuptake inhibitor. Regarded as safe in therapeutic use, there have been reports of cases of severe hepatic dysfunction with gross elevations of transaminase levels that may be related to this drug. We report here severe adverse cholestatic and hepatocellular injury in a patient taking paroxetine probably due to an immune-mediated hypersensitivity reaction.

Congenital morphological abnormalities of the distal vertebral arteries (CMADVA) and their relationship with vertigo and dizziness

BACKGROUND

The aim of our study was to identify congenital morphological abnormalities of distal vertebral arteries (CMADVA) and their association with cerebral hypoperfusion leading to vertigo, and the role of MR and MRA in the diagnosis of vertebrobasilar (VB) abnormalities.

MATERIAL/METHODS

768 patients who complained of dizziness and/or vertigo were included in the study and evaluated by MR and MRA. CMADVAs were determined in 88 of the cases with no other explanation for vertigo and dizziness. 150 patients without dizziness or vertigo were used as a control group. The 3D TOF (Time- of- flight) MR angiographic technique was used.

RESULTS

CMADVAs were detected in 88 of 768 patients (11.5%) with vertigo and/or dizziness. We also detected CMADVAs in 4 (2.7%) of 150 persons in the control group. The patients with abnormal vertebral artery findings were classified into ten categories. Lacunar infarcts in the brain stem were found in 8 patients after long-duration vertigo attacks. There was significant correlation between the control and vertigo groups in terms of CMADVA (p=0.0001). After excluding the control group, there was a significant relationship between CMADVA and vertigo and/or dizziness symptoms (p=0.0001).

CONCLUSIONS

We believe that vertigo and dizziness associated with CMADVA is a real entity that deserves greater attention. For this reason, the vertebrobasilar system in these patients should be examined for CMADVA with MRA. This would enable us to take preventive measures against brainstem ischemia or at least elucidate the etiology of vertigo in these patients.

Real-time sonography for screening of gallbladder motility in diabetic patients: relation to autonomic and peripheral neuropathy

OBJECTIVES

Diabetes mellitus is known as one of the factors causing the cholesterol gallstone. Gallstone incidence is about 30% in diabetic patients over 20 years of age. Pathophysiology is still not clear. The aim of the present study was to investigate gallbladder (GB) functions in diabetic patients and determine its relationship with peripheral and autonomic neuropathy.

DESIGN

Study was performed between October 2001 and may 2002 in fifty-one diabetic patients of similar age and weight. Diabetic patients (n=51) were chosen randomly among diabetic patients, who were being followed in Diabetes Out-patient clinics of Selcuk University, Meram Medical Faculty. Twenty-eight control subjects were chosen from healthy volunteers. We measured fasting and post-prandial gallbladder volumes and ejection fractions by real-time ultrasonography. The patients were divided into three groups; group A (n=18) had no diabetic autonomic and peripheral neuropathy, group B (n=13) had diabetic peripheral neuropathy, group C (n=13) had diabetic autonomic neuropathy.

RESULTS

No significant difference in any biochemical parameters between diabetic and control group could be found. Fasting gallbladder volume was significantly higher in the diabetic group (5.31 +/- 0.28 cm(3)) compared to control group (4.19 +/- 0.25 cm(3), p<0.01). But there was no difference within diabetic subgroups. Gallbladder ejection fraction was significantly reduced in diabetic patients in groups B and C (29.7 +/- 1.43%, 28.7 +/- 1.28%) compared to group A (44.8 +/- 2.4%; p<0.05, p<0.025 respectively).

CONCLUSIONS

Cholesterol crystal formation as a result of increased gallbladder volume and decreased ejection fraction in diabetic patients may result from hypotonicity and stasis and thus this may lead to gallstones.