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Theodorsdottir A, Nielsen HH, Ravnborg MH, Illes Z. Patient reported outcomes in a secondary progressive MS cohort related to cognition, MRI and physical outcomes. Mult Scler Relat Disord 2023; 71:104550. [PMID: 36842312 DOI: 10.1016/j.msard.2023.104550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/20/2022] [Revised: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patient-reported outcomes (PROs) are increasingly being used as outcomes in secondary progressive multiple sclerosis (SPMS) trials. We examined how PROs reflect disease burden in SPMS. METHODS In this observational prospective study, 65 SPMS patients were examined by five different PROs (Fatigue Scale Motor Cognition (FSMC), Multiple Sclerosis Impact Scale version 2 (MSIS-29v2), 36-Item Short Form Health Survey version 2 (SF-36v2), EQ-5D-5L and Work Productivity and Activity Impairment Questionnaire: Multiple Sclerosis version 2.0 (WPAI:MS)); two different rating scales, Multiple Sclerosis Impairment Scale (MSIS) and Expanded Disability Status Scale (EDSS); functional tests of mobility (Timed-25-Foot Walk (T-25FW), 6-Spot Step Test (6-SST) and (9-Hole Peg Test (9-HPT)); cognitive tests (Symbol Digital Modalities Test (SDMT) and Brief Visuospatial Memory Test-Revised (BVMT-R)); and multimodal Magnetic Resonance Imaging (MRI). RESULTS When the PROs were divided into physical and psychological subscores, the PRO physical subscores of FSMC, MSIS-29v2 and SF-36v2 correlated with physical rating scales (EDSS, MSIS) and physical measures of upper (9-HPT) and lower extremity function (T-25FW and 6-SST)) (p = 0.04-0.0001). 9-HPT correlated the least with physical subscores of PROs but showed the strongest correlation with activity impairment (subscore of WPAI:MS). In contrast, psychological PRO subscores of FSMC, MSIS-29v2 and SF-36v2 did not reflect the cognitive outcomes (SDMT and BVMT-R), although the cognitive scores correlated with disease burden indicated by MRI lesion volumes. The psychological PRO subscores did not correlate with fatigue, physical and MRI outcomes either. CONCLUSION Correlation between PRO physical subscores and physical outcomes supports PROs as potentially useful clinical endpoints in SPMS. The results of this study indicate that patients with SPMS highly perceive their mobility on function of their lower extremities, while they perceive their daily activities highly dependent on function of the upper extremities. Psychological subscores of MS specific PROs may be less suitable as surrogate markers for the cognitive status and should be considered as a mental quality of life measurement independent of disease burden.
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Affiliation(s)
- A Theodorsdottir
- Department of Neurology, Odense University Hospital, J.B. Winsloewsvej 4, 5000 Odense C, Denmark; OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, J.B. Winsloewsvej 4, 5000 Odense C, Denmark.
| | - H H Nielsen
- Department of Neurology, Odense University Hospital, J.B. Winsloewsvej 4, 5000 Odense C, Denmark; Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000 Odense C, Denmark; BRIDGE - Brain Research - Inter Disciplinary Guided Excellence, Department of Clinical Research, J.B. Winsloewsvej 19, 3., 5000 Odense C, Denmark
| | - M H Ravnborg
- Filadelfia Epilepsy Hospital, Kolonivej 1, 4293 Dianalund, Denmark
| | - Z Illes
- Department of Neurology, Odense University Hospital, J.B. Winsloewsvej 4, 5000 Odense C, Denmark; Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000 Odense C, Denmark; BRIDGE - Brain Research - Inter Disciplinary Guided Excellence, Department of Clinical Research, J.B. Winsloewsvej 19, 3., 5000 Odense C, Denmark
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2
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Mueller C, Elben S, Day GS, Alves P, Hebert J, Tang-Wai DF, Holtmann O, Iorio R, Perani D, Titulaer MJ, Hansen N, Bartsch T, Johnen A, Illes Z, Borm L, Willison AG, Wiendl H, Meuth SG, Kovac S, Bölte J, Melzer N. Review and meta-analysis of neuropsychological findings in autoimmune limbic encephalitis with autoantibodies against LGI1, CASPR2, and GAD65 and their response to immunotherapy. Clin Neurol Neurosurg 2022; 224:107559. [PMID: 36549220 DOI: 10.1016/j.clineuro.2022.107559] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 09/20/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES It is assumed that autoimmune limbic encephalitis (ALE) demonstrates distinct neuropsychological manifestations with differential responses to immunotherapy according to which associated autoantibody (AAB), if any, is identified. Towards investigating whether this is the case, this study aims to summarize respective findings from the primary literature on ALE with AABs binding to cell surface neural antigens and ALE with AABs against intracellular neural antigens. METHODS We chose ALE with AABs against leucine-rich, glioma inactivated protein 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) as the most frequent cell surface membrane antigens, and ALE with AABs to Embryonic Lethal, Abnormal Vision, Like 1 (ELAVL) proteins (anti-Hu) and glutamic acid decarboxylase 65 (GAD65) as the most frequent intracellular neural antigens. The PubMed and Scopus databases were searched on March 1st, 2021 for neuropsychological test and -screening data from patients with ALE of these AAB-types. Findings were reviewed according to AAB-type and immunotherapy status and are presented in a review section and are further statistically evaluated and presented in a meta-analysis section in this publication. RESULTS Of the 1304 initial hits, 32 studies on ALE with AABs against LGI1, CASPR2, and GAD65 reporting cognitive screening data could be included in a review. In ALE with AABs against LGI1, CASPR2 and GAD65, memory deficits are the most frequently reported deficits. However, deficits in attention and executive functions including working memory, fluency, and psychological function have also been reported. This review shows that ALE patients with AABs against both LGI1 and CASPR2 show higher percentages of neuropsychological deficits compared to ALE patients with AABs against GAD65 before and after initiation of immunotherapy. However, the methodologies used in these studies were heterogenous, and longitudinal studies were not comparable. Moreover, 21 studies including ALE patients with AABs against LGI1 and GAD65 were also suitable for meta-analysis. No suitable study on ALE with AABs against ELAVL proteins could be identified. Meta-Analyses could be executed for cognitive screening data and only partially, due to the small number of studies. However, in statistical analysis no consistent effect of AAB or immunotherapy on performance in cognitive screening tests could be found. CONCLUSION Currently, there is no definite evidence supporting the notion that different AAB-types of ALE exhibit distinct neuropsychological manifestations and respond differently to immunotherapy. Overall, we could not identify evidence for any effect of immunotherapy on cognition in ALE. More systematic, in-depth and longitudinal neuropsychological assessments of patients with different AAB-types of ALE are required in the future to investigate these aspects.
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Affiliation(s)
- Christoph Mueller
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Saskia Elben
- Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Gregory S Day
- Department of Neurology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, United States.
| | - Pedro Alves
- Serviço de Neurologia, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria, CHULN, Lisboa, Portugal; Laboratório de Estudos de Linguagem, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal.
| | - Julien Hebert
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada.
| | - David F Tang-Wai
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada; Memory Clinic, Toronto Western Hospital (University Health Network), Toronto, Canada.
| | - Olga Holtmann
- Institute of Medical Psychology and Systems Neuroscience, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Daniela Perani
- Division of Neuroscience, University Vita-Salute San Raffaele, Via Olgettina, 58, 20132 Milano, MI, Italy.
| | - Maarten J Titulaer
- Department of Neurology, Neuropsychology and Immunology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy, University of Göttingen, Von-Siebold-Str. 5, 37075 Göttingen, Germany.
| | - Thorsten Bartsch
- Department of Neurology, University Medical Center Schleswig-Holstein, Rosalind-Franklin-Straße 10, 24105 Kiel, Germany.
| | - Andreas Johnen
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Zslot Illes
- Department of Neurology with Institute of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
| | - Leah Borm
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Fliednerstraße 21, 48149 Münster, Germany.
| | - Alice G Willison
- Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Jens Bölte
- Institute of Psychology, Westfälische Wilhelms-University of Münster, Fliednerstraße 21, 48149 Münster, Germany.
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany; Department of Neurology, Medical Faculty, Heinrich-Heine University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
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Jørgensen LØ, Hyrlov KH, Elkjaer ML, Weber AB, Pedersen AE, Svenningsen ÅF, Illes Z. Cladribine modifies functional properties of microglia. Clin Exp Immunol 2020; 201:328-340. [PMID: 32492189 PMCID: PMC7419928 DOI: 10.1111/cei.13473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 03/29/2020] [Revised: 05/04/2020] [Accepted: 05/18/2020] [Indexed: 01/13/2023] Open
Abstract
Cladribine (CdA), an oral prodrug approved for the treatment of relapsing multiple sclerosis, selectively depletes lymphocytes. CdA passes the blood–brain barrier, suggesting a potential effect on central nervous system (CNS) resident cells. We examined if CdA modifies the phenotype and function of naive and activated primary mouse microglia, when applied in the concentrations 0·1–1 μM that putatively overlap human cerebrospinal fluid (CSF) concentrations. Primary microglia cultures without stimulation or in the presence of proinflammatory lipopolysaccharide (LPS) or anti‐inflammatory interleukin (IL)‐4 were treated with different concentrations of CdA for 24 h. Viability was assessed by MTT [3‐(4,5‐dimethylthiazol‐2‐yl)‐2,5‐diphenyltetrazolium bromide] assay. Phagocytotic ability and morphology were examined by flow cytometry and random migration using IncuCyte Zoom and TrackMate. Change in gene expression was examined by quantitative polymerase chain reaction (qPCR) and protein secretion by Meso Scale Discovery. We found that LPS and IL‐4 up‐regulated deoxycytidine kinase (DCK) expression. Only activated microglia were affected by CdA, and this was unrelated to viability. CdA 0·1–1 μM significantly reduced granularity, phagocytotic ability and random migration of activated microglia. CdA 10 μM increased the IL‐4‐induced gene expression of arginase 1 (Arg1) and LPS‐induced expression of IL‐1β, tumor necrosis factor (TNF), inducible nitric oxide synthase (iNOS) and Arg1, but protein secretion remained unaffected. CdA 10 μM potentiated the increased expression of anti‐inflammatory TNF receptor 2 (TNF‐R2) but not TNF‐R1 induced by LPS. This suggests that microglia acquire a less activated phenotype when treated with 0·1–1 μM CdA that putatively overlaps human CSF concentrations. This may be related to the up‐regulated gene expression of DCK upon activation, and suggests a potential alternative mechanism of CdA with direct effect on CNS resident cells.
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Affiliation(s)
- L Ø Jørgensen
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Neurobiology Research Unit, Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - K H Hyrlov
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Neurobiology Research Unit, Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - M L Elkjaer
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Neurobiology Research Unit, Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - A B Weber
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Neurobiology Research Unit, Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - A E Pedersen
- Merck A/S, Søborg, Denmark.,Department of Odontology, University of Copenhagen, Copenhagen, Denmark
| | - Å Fex Svenningsen
- Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Neurobiology Research Unit, Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Z Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Neurobiology Research Unit, Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
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Byg KE, Illes Z, Sejbaek T, Kindt A, Ellingsen T, Nielsen H. SAT0511 CYTOKINES, CHEMOKINES AND INFLAMMATORY BIOMARKERS IN NEUROSARCOIDOSIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Sarcoidosis is characterized by granulomatous inflammation, which in rare cases can affect the central nervous system, neurosarcoidosis (NS).Objectives:The aim of this study was to estimate levels of cytokines, chemokines, and vascular biomarkers in patients with NS.Methods:In this observational, cross-sectional study, cerebrospinal fluid (CSF) and plasma were collected from biopsy-proven sarcoidosis patients with clinical suspicion of NS. They were categorized into either a NS group (n=14) or a non-NS group (n=5) depending on fulfilment of NS criteria. The results were compared to a healthy control group (HC, n=11). Samples were analysed with Electrochemiluminescence, Mesoscale®.Results:The level of INF γ was significantly higher in NS group compared to non-NS group in CSF (median 11.3 pg/mL vs. 3.3 pg/mL) and in plasma (median 21.6 pg/mL vs. 4.5 pg/mL)In CSF and not in plasma, the level differs significantly in NS group compared to non-NS group, IL12/IL23p40 (median 54.05 pg/mL vs. 3.61 pg/mL), IL16 (median 8.7 pg/mL vs. 4.3 pg/mL), IL17A (median 1.37 pg/mL vs. 0.19 pg/mL), TNF β (median 0.37 pg/mL vs. 0.02 pg/mL), IL8 (median 55.4 pg/mL vs. 37.8 pg/mL), CCL11 (median 36.1 pg/mL vs. 16.4 pg/mL, CCL26 (median 6.7 pg/mL vs. 3.7 pg/mL), CXCL10 (median 4981 pg/mL vs. 771 pg/mL), CCL13 (median 24.5 pg/mL vs. 10.0 pg/mL), CCL22 (median 129.8 pg/mL vs. 22.6 pg/mL), CCL3 (median 54.1 pg/mL vs. 20.7 pg/mL), CCL17 (median 54.0 pg/mL vs. 6.9 pg/mL), ICAM1 (median 13901 pg/mL vs. 7327 pg/ml), and VCAM1 (median 18594 pg/mL vs. 12132 pg/mL)A cut-off level for each cytokine was set at 20% above the maximum values of both non-NS group and HC. Using this, the ratio of patients in NS group over were:-INF γ, 57% had level over 6.2 pg/mL in CSF, and 50% had level over 21.6 pg/mL in plasma.-IL12/IL23p40, 71% had level over 16.7 pg/mL in CFS.-CXCL10, 79% had level over 1614 pg/mL in CFS.-CCL22, 79% had level over 49.8 pg/mL in CFS.Conclusion:In NS patients, INF γ was elevated in both CSF and plasma, and multiple cytokines, chemokinves and vascular biomarkers were elevated in CSF.Disclosure of Interests:Keld-Erik Byg: None declared, Zsolt Illes: None declared, Tobias Sejbaek Grant/research support from: Biogen, grants, outside the submitted work., Consultant of: Personal fees from Novartis, outside the submitted work., Astrid Kindt: None declared, Torkell Ellingsen: None declared, Helle Nielsen: None declared
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Papp V, Iljicsov A, Rajda C, Magyari M, Koch‐Henriksen N, Petersen T, Jakab G, Deme I, Nagy F, Imre P, Lohner Z, Kovács K, Birkás AJ, Köves Á, Rum G, Nagy Z, Kerényi L, Vécsei L, Bencsik K, Jobbágy Z, Diószeghy P, Horváth L, Galántai G, Kasza J, Molnár G, Simó M, Sátori M, Rózsa C, Ács P, Berki T, Lovas G, Komoly S, Illes Z. A population‐based epidemiological study of neuromyelitis optica spectrum disorder in Hungary. Eur J Neurol 2019; 27:308-317. [DOI: 10.1111/ene.14079] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/21/2019] [Indexed: 11/27/2022]
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Abstract
OBJECTIVES Teriflunomide 14 mg is a once-daily oral disease-modifying treatment for relapsing-remitting multiple sclerosis. We examined adverse event (AE) profile and efficacy in real life. MATERIALS AND METHODS In this observational cohort study, we retrospectively examined 1521 blood samples and data of 102 patients followed for up to 28 months. RESULTS The number of female patients starting teriflunomide peaked in the fifth decade, 10 years later compared to male patients (P<.001), reflecting pregnancy concerns. Seventy-six percentages of patients shifted to teriflunomide from treatment with interferon-beta. Expanded disability status scale improved in 11% of patients (18.2±3.6 months follow-up) and remained constant in 67.5% (15±5.3 months follow-up). Of ten relapses, three occurred within 6 months after starting treatment. Seventeen patients (16.5%) discontinued teriflunomide: 53% because of AEs and 29% because of relapse. Levels of alanine aminotransferase (ALT) remained normal in 95.3% of the blood samples and remained below 1.5 times the upper limit of normal in 91% of the 4.7% abnormal samples. One-third of the patients had abnormal ALT values at least once. Haematological abnormalities were found in <4% of the blood samples, but at least one abnormal value was observed in up to 21% of the patients. CONCLUSIONS Efficacy and safety of teriflunomide in real-life setting support data obtained by the pivotal trials. Laboratory abnormalities are rare among the large number of samples, but patients may commonly have a single mild, abnormal value if frequently tested.
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Affiliation(s)
- M. L. Elkjaer
- Department of Neurology; Odense University Hospital; Odense Denmark
| | - T. Molnar
- Department of Anesthesiology and Intensive Care; University of Pecs; Pecs Hungary
| | - Z. Illes
- Department of Neurology; Odense University Hospital; Odense Denmark
- Department of Clinical Research; University of Southern Denmark; Odense Denmark
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Celicanin M, Blaabjerg M, Maersk-Moller C, Beniczky S, Marner L, Thomsen C, Bach FW, Kondziella D, Andersen H, Somnier F, Illes Z, Pinborg LH. Autoimmune encephalitis associated with voltage-gated potassium channels-complex and leucine-rich glioma-inactivated 1 antibodies - a national cohort study. Eur J Neurol 2017; 24:999-1005. [PMID: 28544133 DOI: 10.1111/ene.13324] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [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: 12/08/2016] [Accepted: 04/03/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to describe clinical and paraclinical characteristics of all Danish patients who tested positive for anti-voltage-gated potassium channels (VGKC)-complex, anti-leucine-rich glioma-inactivated 1 (LGI1) and anti-contactin-associated protein-2 antibodies in the serum/cerebrospinal fluid between 2009 and 2013 with follow-up interviews in 2015 and 2016. METHODS We evaluated antibody status, symptoms leading to testing, course of disease, suspected diagnosis and time of admission as well as diagnosis and treatment. All magnetic resonance imaging, electroencephalography and 18 F-fluorodeoxyglucose positron emission tomography scans were re-evaluated by experts in the field. RESULTS A total of 28/192 patients tested positive for VGKC-complex antibodies by radioimmunoassay and indirect immunofluorescence; 17 had antibodies to LGI1 and 6/7 of the available cerebrospinal fluids from these patients were seropositive. These 17 patients all had a clinical phenotype appropriate to LGI1 antibodies. The remaining 11 were LGI1 negative (n = 4) or not tested (n = 7). Of these, two had a phenotype consistent with limbic encephalitis. The remaining phenotypes were Guillain-Barré syndrome, Creutzfeldt-Jakob disease, neuromyotonia and anti-N-methyl-D-aspartate receptor encephalitis. Magnetic resonance imaging abnormalities were demonstrated in 69% of the LGI1-positive patients. Two patients with normal magnetic resonance imaging demonstrated temporal lobe hypermetabolism using 18 F-fluorodeoxyglucose positron emission tomography. Abnormal electroencephalography recordings were found in 86% of the patients. Upon follow-up (median 3.2 years), the median modified Rankin Scale score of anti-LGI1-positive patients was 2 and only two patients reported seizures in the past year. CONCLUSIONS Patients diagnosed with anti-LGI1 autoimmune encephalitis increased significantly from 2009 to 2014, probably due to increased awareness. In contrast to seropositive anti-VGKC-complex patients, all anti-LGI1-positive patients presented with a classical limbic encephalitis. The majority of patients recovered well.
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Affiliation(s)
- M Celicanin
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - M Blaabjerg
- Department of Neurology, Roskilde University Hospital, Roskilde, Denmark
| | - C Maersk-Moller
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - S Beniczky
- Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark
| | - L Marner
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Copenhagen, Denmark
| | - C Thomsen
- Department of Diagnostic Radiology, Rigshospitalet, Copenhagen, Denmark
| | - F W Bach
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - D Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - H Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - F Somnier
- Department of Autoimmunology, Statens Serum Institut, Copenhagen, Denmark
| | - Z Illes
- Department of Neurology, University of Southern Denmark, Odense, Denmark
| | - L H Pinborg
- Neurobiology Research Unit, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
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Szabo P, Lantos J, Nagy L, Keki S, Volgyi E, Menyhei G, Illes Z, Molnar T. l-Arginine Pathway Metabolites Predict Need for Intra-operative Shunt During Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2016; 52:721-728. [PMID: 27839876 DOI: 10.1016/j.ejvs.2016.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 10/11/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVE/BACKGROUND Asymmetric dimethylarginine (ADMA) inhibits nitric oxide (NO) synthesis and is a marker of atherosclerosis. This study examined the correlation between pre-operative l-arginine and ADMA concentration during carotid endarterectomy (CEA), and jugular lactate indicating anaerobic cerebral metabolism, jugular S100B reflecting blood-brain barrier integrity, and with factors of surgical intervention. METHODS The concentration of l-arginine, ADMA, and symmetric dimethylarginine was measured in blood taken under regional anaesthesia from the radial artery of 55 patients prior to CEA. Blood gas parameters, concentration of lactate, and S100B were also serially measured in blood taken from both the radial artery and the jugular bulb before and after carotid clamping, and after release of the clamp. To estimate anaerobic metabolism, the jugulo-arterial ratio of CO2 gap/oxygen extraction was calculated. RESULTS Positive correlation was found between pre-operative ADMA levels and the ratio of jugulo-arterial CO2 gap/oxygen extraction during clamp and reperfusion (p = .005 and p = .01, respectively). An inverse correlation was found between the pre-operative l-arginine concentration and jugular lactate at each time point (both p = .002). The critical pre-operative level of l-arginine was determined by receiver operator curve analysis. If l-arginine was below the cutoff value of 35 μmol/L, jugular S100B concentration was higher 24 h post-operatively (p = .03), and jugular lactate levels were increased during reperfusion (p = .02). The median pre-operative concentration of l-arginine was lower in patients requiring an intra-operative shunt than in patients without need of shunt (median: 30.3 μmol/L [interquartile range 24.4-34.4 μmol/L] vs. 57.6 μmol/L [interquartile range 42.3-74.5 μmol/L]; p = .002). CONCLUSION High pre-operative ADMA concentration predicts poor cerebral perfusion indicated by elevated jugulo-arterial CO2 gap/oxygen extraction. Low pre-operative l-arginine concentration predicts the need for a shunt. The inverse correlation between pre-operative l-arginine concentration and both jugular lactate and S100B during carotid clamping suggests a protective role of the NO donor l-arginine.
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Affiliation(s)
- P Szabo
- Department of Anesthesiology and Intensive Care, University of Pecs, 7624 Ifjusag u 13, Pecs, Hungary
| | - J Lantos
- Department of Surgical Research and Techniques, University of Pecs, 7624 Szigeti u 12, Pecs, Hungary
| | - L Nagy
- Department of Applied Chemistry, University of Debrecen, 4032 Egyetem tér 1, Debrecen, Hungary
| | - S Keki
- Department of Applied Chemistry, University of Debrecen, 4032 Egyetem tér 1, Debrecen, Hungary
| | - E Volgyi
- Department of Anesthesiology and Intensive Care, University of Pecs, 7624 Ifjusag u 13, Pecs, Hungary
| | - G Menyhei
- Department of Vascular Surgery, University of Pecs, 7635 Ifjusag 13, Pecs, Hungary
| | - Z Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark; SDR, Boulevard 29, Odense 5000, Denmark
| | - T Molnar
- Department of Anesthesiology and Intensive Care, University of Pecs, 7624 Ifjusag u 13, Pecs, Hungary.
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Meggyes M, Lajko A, Miko E, Illes Z, Szekeres-Bartho J, Szereday L. The significance of Galectin-9/TIM-3 pathway in mifepristone induced medical abortion in BALB/c mice. J Reprod Immunol 2015. [DOI: 10.1016/j.jri.2015.06.029] [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: 11/17/2022]
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10
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Inotai D, Szilvasi A, Benko S, Boros-Major A, Illes Z, Bors A, Kiss KP, Rajczy K, Gelle-Hossó A, Buhler S, Nunes JM, Sanchez-Mazas A, Tordai A. HLA genetic diversity in Hungarians and Hungarian Gypsies: complementary differentiation patterns and demographic signals revealed by HLA-A, -B and -DRB1 in Central Europe. ACTA ACUST UNITED AC 2015; 86:115-21. [PMID: 26149581 DOI: 10.1111/tan.12600] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [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: 02/11/2015] [Revised: 05/13/2015] [Accepted: 06/02/2015] [Indexed: 11/30/2022]
Abstract
Systematic analyses of human leukocyte antigen (HLA) profiles in different populations may increase the efficiency of bone marrow donor selection and help reconstructing human peopling history. We typed HLA-A, -B, and -DRB1 allele groups in two bone marrow donor cohorts of 2402 Hungarians and 186 Hungarian Gypsies and compared them with several Central-European, Spanish Gypsy, and Indian populations. Our results indicate that different European Gypsy populations share a common origin but diverged genetically as a consequence of founder effect and rapid genetic drift, whereas other European populations are related genetically in relation to geography. This study also suggests that while HLA-A accurately depicts the effects of genetic drift, HLA-B, and -DRB1 conserve more signatures of ancient population relationships, as a result of balancing selection.
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Affiliation(s)
- D Inotai
- Laboratory of Transplantation Immunogenetics, Hungarian National Blood Transfusion Service, Budapest, Hungary
| | - A Szilvasi
- Laboratory of Transplantation Immunogenetics, Hungarian National Blood Transfusion Service, Budapest, Hungary
| | - S Benko
- Laboratory of Transplantation Immunogenetics, Hungarian National Blood Transfusion Service, Budapest, Hungary
| | - A Boros-Major
- Laboratory of Transplantation Immunogenetics, Hungarian National Blood Transfusion Service, Budapest, Hungary
| | - Z Illes
- Laboratory of Transplantation Immunogenetics, Hungarian National Blood Transfusion Service, Budapest, Hungary
| | - A Bors
- Molecular Diagnostics, Hungarian National Blood Transfusion Service, Budapest, Hungary
| | - K P Kiss
- Molecular Diagnostics, Hungarian National Blood Transfusion Service, Budapest, Hungary
| | - K Rajczy
- Bone Marrow Donor Registry, Hungarian Blood Transfusion Service, Budapest, Hungary
| | - A Gelle-Hossó
- Bone Marrow Donor Registry, Hungarian Blood Transfusion Service, Budapest, Hungary
| | - S Buhler
- Laboratory of Anthropology, Genetics and Peopling History, Department of Genetics and Evolution - Anthropology Unit, University of Geneva, Geneva, Switzerland
| | - J M Nunes
- Laboratory of Anthropology, Genetics and Peopling History, Department of Genetics and Evolution - Anthropology Unit, University of Geneva, Geneva, Switzerland
| | - A Sanchez-Mazas
- Laboratory of Anthropology, Genetics and Peopling History, Department of Genetics and Evolution - Anthropology Unit, University of Geneva, Geneva, Switzerland
| | - A Tordai
- Laboratory of Transplantation Immunogenetics, Hungarian National Blood Transfusion Service, Budapest, Hungary.,Molecular Diagnostics, Hungarian National Blood Transfusion Service, Budapest, Hungary
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Molnar T, Peterfalvi A, Szereday L, Pusch G, Szapary L, Komoly S, Bogar L, Illes Z. Deficient leucocyte antisedimentation is related to post-stroke infections and outcome. J Clin Pathol 2015; 61:1209-13. [PMID: 18955576 DOI: 10.1136/jcp.2008.059840] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Patients with stroke are more susceptible to infections, suggesting possible deficiencies of early immune responses, particularly of leucocytes. AIMS To serially examine leucocyte antisedimentation rate (LAR), a simple test to detect activation of leucocytes, and correlate it with S100beta, procalcitonin and outcome in patients with acute ischaemic events. METHODS Venous blood samples were taken from 61 healthy volunteers and 49 patients with acute ischaemic events (acute ischaemic stroke (AIS), n = 38; transient ischaemic attack (TIA), n = 11) within 6 hours, at 24 and 72 hours after onset of symptoms. RESULTS LAR was significantly higher in acute ischaemic events compared to controls within 6 hours after onset of stroke regardless of post-stroke infections. In addition, the increase of LAR was delayed and attenuated in TIA in contrast to AIS. A deficiency in early increase of LAR was associated with post-stroke infections and a poor outcome, measured by the Glasgow Outcome Scale in AIS. There was a positive correlation between LAR and S100beta at 72 hours after the onset of ischaemic stroke. Increased levels of S100beta at 24 and 72 hours after stroke were associated with poor outcome. CONCLUSIONS An early activation of leucocytes indicated by an increase of LAR is characteristic of acute ischaemic cerebrovascular events. A delayed and ameliorated leucocyte activation represented by LAR is characteristic of TIA in contrast to stroke. Deficient early activation predisposes to post-stroke infections related to poor outcome. In addition, the extent of tissue injury correlates with the magnitude of innate immune responses.
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Affiliation(s)
- T Molnar
- Department of Anaesthesiology and Intensive Therapy, University of Pecs, Pecs, Hungary
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Massilamany C, Jamerson M, Madayiputhiya N, Nandakumar R, Marciano-Cabral F, Sejbaek T, Illes Z, Reddy J. An evidence for a potential linkage between Acanthamoeba infections and multiple sclerosis (P4551). The Journal of Immunology 2013. [DOI: 10.4049/jimmunol.190.supp.197.13] [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] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
We recently observed that Acanthamoeba castellanii (ACA), a free-living amoeba, has the potential to trigger central nervous system autoimmunity by generating cross-reactive T cells for multiple myelin antigens, namely, proteolipid protein (PLP) 139-151 and myelin basic protein (MBP) 89-101. Additionally, the homology model derived for human leukocyte antigen-DR2, complexed with MBP 85-99 and its mimicry epitope, predicts the possibility of generating cross-reactive T cells for human MBP 85-99 in Acanthamoeba-exposed individuals. These observations raise a question whether prior exposure to ACA infection can trigger multiple sclerosis (MS). To address this hypothesis, we extracted DNA from cerebrospinal fluid obtained from MS patients and individuals with other neurological disorders, and subjected them to PCR that amplified a 500 bp fragment of the small subunit 18S rDNA using ACA-specific primer set. We confirmed the identity of PCR products by sequencing. To provide additional evidence for a linkage of ACA to MS pathogenesis, we asked whether anti-human PLP antibody can detect amoebic rhodanese-related sulfurtransferase (RST), since this protein contains the mimicry epitope ACA 83-95 for PLP 139-151. Through western blotting and LC/MS analyses, we noted that PLP antibody binds RST, suggesting that anti-Acanthamoeba immune responses have the potential to target myelin antigens. Collectively, the data suggest a linkage of ACA infection to MS pathogenesis.
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Affiliation(s)
| | - Melissa Jamerson
- 2Department of Microbiology and Immunology, Virginia Commonwealth University School of Medicine, Richmond, VA
| | | | - Renu Nandakumar
- 3Redox Biology Center, Department of Biochemistry, University of Nebraska-Lincoln, Lincoln, NE
| | - Francine Marciano-Cabral
- 2Department of Microbiology and Immunology, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Tobias Sejbaek
- 4Department of Neurology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Zslot Illes
- 4Department of Neurology, Odense University Hospital and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- 5Department of Clinical and Experimental Neuroimmunology, University of Pecs, Pecs, Hungary
| | - Jay Reddy
- 1School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE
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Banati M, Csecsei P, Koszegi E, Nielsen HH, Suto G, Bors L, Trauninger A, Csepany T, Rozsa C, Jakab G, Molnar T, Berthele A, Kalluri SR, Berki T, Illes Z. Antibody response against gastrointestinal antigens in demyelinating diseases of the central nervous system. Eur J Neurol 2013; 20:1492-5. [PMID: 23293933 DOI: 10.1111/ene.12072] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [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: 07/09/2012] [Accepted: 11/07/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Antibodies against gastrointestinal antigens may indicate altered microbiota and immune responses in the gut. Recent experimental data suggest a connection between gastrointestinal immune responses and CNS autoimmunity. METHODS Antibodies against gliadin, tissue transglutaminase (tTG), intrinsic factor (IF), parietal cells (PC) and Saccharomyces cerevisiae (ASCA) were screened in the sera of 45 patients with AQP4-seropositive neuromyelitis optica (NMO) and NMO spectrum diseases (NMO/NMO-SD), 17 patients with AQP4-seronegative NMO, 85 patients with clinically definite multiple sclerosis (MS), and 48 healthy controls (HC). RESULTS Thirty-seven percentages of patients with AQP4-seropositive NMO/NMO-SD and 28% of patients with MS had at least one particular antibody in contrast to 8% of HC (P < 0.01, respectively). Antibodies were most common (46%) in AQP4-seropositive myelitis (P = 0.01 versus HS, P = 0.05 versus MS). Anti-gliadin and ASCA were more frequent in the AQP4-seropositive NMO-spectrum compared to controls (P = 0.01 and P < 0.05, respectively). CONCLUSION Antibody responses against gastrointestinal antigens are common in MS and AQP4-seropositive NMO/NMO-SD, especially in longitudinally extensive myelitis.
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Affiliation(s)
- M Banati
- Department of Neurology, University of Pecs, Pecs, Hungary
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14
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Meggyes M, Miko E, Barakonyi A, Bogar B, Szerekes-Bartho J, Varnagy A, Farkas B, Bodis J, Illes Z, Szereday L. The possible role of Galectin-9/TIM-3 pathway in the pathogenesis of pre-eclampsia. J Reprod Immunol 2012. [DOI: 10.1016/j.jri.2012.03.314] [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: 11/26/2022]
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15
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Meggyes M, Bogar B, Palkovics T, Miko E, Barakonyi A, Szekeres-Bartho J, Illes Z, Szereday L. The significance of Tim-3 and Galectin-9 expression during pregnancy in a mouse model. J Reprod Immunol 2012. [DOI: 10.1016/j.jri.2012.03.316] [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: 10/28/2022]
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Sellner J, Boggild M, Clanet M, Hintzen RQ, Illes Z, Montalban X, Du Pasquier RA, Polman CH, Sorensen PS, Hemmer B. EFNS guidelines on diagnosis and management of neuromyelitis optica. Eur J Neurol 2010; 17:1019-32. [PMID: 20528913 DOI: 10.1111/j.1468-1331.2010.03066.x] [Citation(s) in RCA: 293] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND PURPOSE Neuromyelitis optica (NMO) or Devic's disease is a rare inflammatory and demyelinating autoimmune disorder of the central nervous system (CNS) characterized by recurrent attacks of optic neuritis (ON) and longitudinally extensive transverse myelitis (LETM), which is distinct from multiple sclerosis (MS). The guidelines are designed to provide guidance for best clinical practice based on the current state of clinical and scientific knowledge. SEARCH STRATEGY Evidence for this guideline was collected by searches for original articles, case reports and meta-analyses in the MEDLINE and Cochrane databases. In addition, clinical practice guidelines of professional neurological and rheumatological organizations were studied. RESULTS Different diagnostic criteria for NMO diagnosis [Wingerchuk et al. Revised NMO criteria, 2006 and Miller et al. National Multiple Sclerosis Society (NMSS) task force criteria, 2008] and features potentially indicative of NMO facilitate the diagnosis. In addition, guidance for the work-up and diagnosis of spatially limited NMO spectrum disorders is provided by the task force. Due to lack of studies fulfilling requirement for the highest levels of evidence, the task force suggests concepts for treatment of acute exacerbations and attack prevention based on expert opinion. CONCLUSIONS Studies on diagnosis and management of NMO fulfilling requirements for the highest levels of evidence (class I-III rating) are limited, and diagnostic and therapeutic concepts based on expert opinion and consensus of the task force members were assembled for this guideline.
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Affiliation(s)
- J Sellner
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Germany.
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Abstract
The authors report long-lasting airplane headache in a patient with non-allergic, chronic rhinosinusitis. Association of mucosal inflammation with compromised sinonasal ventilation and sinus barotrauma created a base for not only the pain but also for the prolongation of symptoms. Effective therapy with antihistamine and nasal decongestant supports the theory that sinonasal barotrauma plays a triggering role in the pathophysiology of airplane headache.
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Affiliation(s)
- Z Pfund
- Department of Neurology, University of Pécs, Pécs, Hungary.
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Banati M, Sandor J, Mike A, Illes E, Bors L, Feldmann A, Herold R, Illes Z. Social cognition and Theory of Mind in patients with relapsing-remitting multiple sclerosis. Eur J Neurol 2009; 17:426-33. [DOI: 10.1111/j.1468-1331.2009.02836.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Veto S, Acs P, Bauer J, Lassmann H, Berente Z, Sumegi B, Komoly S, Gallyas F, Illes Z. FP30-WE-05 Poly(ADP-ribose) polymerase (PARP) is activated in multiple sclerosis pattern III lesions and its inhibition prevents experimental demyelination and oligodendrocyte death. J Neurol Sci 2009. [DOI: 10.1016/s0022-510x(09)70428-9] [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: 10/20/2022]
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Aradi M, Trauninger A, Pal E, Derczy K, Molnar M, Illes Z, Vardi V. PO26-TH-14 Magnetic resonance imaging and proton MR spectroscopy of muscles and brain in late-onset Pompe's disease. J Neurol Sci 2009. [DOI: 10.1016/s0022-510x(09)71157-8] [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: 11/30/2022]
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Pusch G, Feher G, Szomor A, Kover F, Gomori E, Illes Z. Intravascular lymphoma presenting with neurological signs but diagnosed by prostate biopsy: suspicion as a key to early diagnosis. Eur J Neurol 2009; 16:e39-41. [DOI: 10.1111/j.1468-1331.2008.02382.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Molnar T, Peterfalvi A, Bogar L, Illes Z. Role of the leukocyte antisedimentation rate in prediction of early recognition of post-stroke infection. Crit Care 2008. [PMCID: PMC4088546 DOI: 10.1186/cc6396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Illes Z, Kondo T, Yokoyama K, Ohashi T, Tabira T, Yamamura T. Identification of autoimmune T-cells among in vivo expanded CD25+ T-cells in multiple sclerosis. J Neuroimmunol 1998. [DOI: 10.1016/s0165-5728(98)91617-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Illes Z, Yamamaura T, Kondo T, Tabira T, Newcombe J. Selective loss of invariant Va24-JaQ+ T-cells in multiple sclerosis. J Neuroimmunol 1998. [DOI: 10.1016/s0165-5728(98)91618-6] [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: 10/26/2022]
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