Characterization of Neurosarcoid Myelitis and Assessment of Treatment Response: A Multicenter Retrospective Study

Objective

To determine if initial treatment with corticosteroids plus steroid-sparing immunosuppressive therapy (IST) results in faster gadolinium contrast-enhancement resolution in neurosarcoid myelitis (NSM) than corticosteroid monotherapy (CSM).

Background

Neurosarcoidosis is a rare cause of myelitis, treated initially with corticosteroids. Whether combination therapy of corticosteroids plus IST is more effective than CSM at disease onset is unknown.

Design/Methods

We retrospectively reviewed cases of definite or probable NSM, defined by Neurosarcoidosis Consortium Consensus Group, in adults treated at six United States centers. We characterized clinicoradiographic features and treatment outcomes after NSM diagnosis. Treatment groups were defined as CSM, corticosteroids plus intermediate oral IST (methotrexate or mycophenolate mofetil), corticosteroids plus highly effective IST (cyclophosphamide/TNF-alpha inhibitors), or corticosteroids plus other. We hypothesized that initial treatment with corticosteroids and IST would result in faster gadolinium contrast-enhancement resolution (primary end point).

Results

63 patients with NSM (32 female, 30 definite, median age 48) were identified. 86% had spinal cord enhancement on post-gadolinium T1 sequences (8% without enhancement, 6% without data). Time from symptom onset to treatment initiation varied from 11 days to 10 years (median 4 months). All but one patient received corticosteroids initially. 16/63 received corticosteroids alone. 29/63 received corticosteroids and subsequently IST (10 TNF-alpha inhibitor/cyclophosphamide, 10 mycophenolate/methotrexate, 9 other). Median time to IST initiation was 9.1 months (range 1–132). 16/63 were treated with initial IST (4 TNF-alpha/cyclophosphamide, 8 mycophenolate/methotrexate, 4 other). There was no significant difference in time to contrast-enhancement resolution between corticosteroids with/without subsequent IST versus corticosteroids + initial IST (Wilcoxon-rank sum test 0.93) or CSM versus corticosteroids + initial IST (Wilcoxon-rank sum test 0.97). Limitations are small sample size, variations in initiation of treatment and doses used, and intervals of clinical/radiographic follow-up.

Conclusions

Standardization of reporting and monitoring of treatment and outcomes is needed for patients with NSM to better assess optimal initial therapy plans.

Ischemic Stroke in Neurosarcoidosis: A Retrospective Cohort Analysis

Objective

To provide a detailed analysis of the clinical features and course of ischemic stroke secondary to sarcoidosis of the CNS and to observe the effects of immunosuppression in the prevention of recurrent cerebrovascular disease.

Background

Cerebrovascular disease is rarely reported in neurosarcoidosis and constitutes one of its least well-described forms, though recognition for it has grown in the last decade with recent studies estimating a higher frequency of occurrence than previously known.

Design/Methods

Patients with ischemic stroke were included if the mechanism was directly attributable to sarcoidosis of the CNS. Patients were excluded if an alternative stroke etiology was of equal or higher likelihood than CNS sarcoidosis.

Results

Neurologic disease was the initial presenting manifestation of sarcoidosis in 8/11 (72.7%), and ischemic stroke was an inaugural manifestation of sarcoidosis in 4/11 (36.4%). Small vessel disease was the predominant ischemia subtype (10/11, 90.9%) with pontine perforating vessels (6/11, 54.5%) and lenticulostriate arteries (3/11, 27.3%) being the vessels most often affected. Vessels with a more rostral supratentorial distribution were uncommonly affected. Common neuroinflammatory accompaniments included leptomeningitis (10/11, 90.9%) and cranial nerve disease (4/11, 36.4%). Recurrent strokes occurred in 8/11 (72.7%), and recurrent neuroinflammation occurred in 7/11 (63.6%). Antiplatelet drugs were used in 6/11 (54.5%). Most patients (10/11, 90.9%) required at least two lines of immunosuppression to achieve inflammatory disease remission in this context; infliximab was the most successfully employed immunosuppressant (7/8 treatment courses, 87.5%). The presenting median modified Rankin Scale score of 4.0 improved to 2.0 over a median period of follow-up of 52.0 months.

Conclusions

Ischemic strokes in neurosarcoidosis occur in a caudal-to-rostral distribution, tend to affect small caliber blood vessels that lack collateral blood flow, and typically associate with inflammatory leptomeningeal disease.

A multi-center case series of sarcoid optic neuropathy

OBJECTIVE

The diagnosis of sarcoid optic neuropathy is time-sensitive, as delayed treatment risks irreversible vision loss. We sought to analyze its characteristics and outcomes.

METHODS

We performed a multi-center retrospective study of sarcoid optic neuropathy among 5 USA medical centers. Inclusion criteria were: 1) clinical optic neuropathy; 2) optic nerve/sheath enhancement on neuroimaging; 3) pathological confirmation of systemic or nervous system sarcoidosis.

RESULTS

Fifty-one patients were included. The median onset age of sarcoid optic neuropathy was 50 years (range, 17-70 years) and 71% were female. The median visual acuity at nadir in the most affected eye was 20/80 (range, 20/20 to no-light-perception). Thirty-four of 50 (68%) patients had radiologic evidence of other nervous system involvement and 20 (39%) patients had symptoms/signs of other cranial nerve dysfunction. Cerebrospinal fluid analysis revealed an elevated white blood cell count in 22 of 31 (71%) patients (median: 14/μL; range: 1-643/μL). Pathologic confirmation of sarcoidosis was by biopsy of systemic/pulmonary site, 34 (67%); optic nerve/sheath, 9 (18%); or other nervous system region, 8 (16%). Forty patients improved with treatment (78%), 98% receiving corticosteroids and 65% receiving steroid-sparing immunosuppressants, yet 11/46 patients (24%) had a visual acuity of 20/200 or worse at last follow-up.

CONCLUSIONS

Sarcoid optic neuropathy frequently occurs with other clinical and radiologic abnormalities caused by neurosarcoidosis and diagnostic confirmation occasionally requires optic nerve/sheath biopsy. Improvement with treatment is common but most patients have some residual visual disability. Improved recognition and a more expeditious diagnosis and treatment may spare patients from permanent vision loss.

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center

BACKGROUND

Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

RESULTS

Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

CONCLUSIONS

Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

[Preliminary data on post-pancreatectomy diabetes mellitus treated by islet-cell autotransplantation]

The present study describes the first islet autotransplant program in Romania, and the first 3 cases of subtotal pancreatectomy for chronic pancreatitis combined with islet autotransplant. The primary objective was to pain relief by pancreatic resection, but also to preserve the endocrine function by islet autotransplant. Extensive distal pancreatectomy is effective in relieving pain, but should be limited to patients with small duct disease, in whom more conservative methods have failed, because of severe metabolic consequences. Islets were prepared by Liberase digestion of the excised pancreas, and infused unpurified into the portal vein in one case and in the omental pouch and peritoneum in two cases. All patients were relieved of pain, have achieved insulin independence, and positive C peptide levels, but one patient died of a acute bronchopneumonia 60 days post-transplantation. The mean islet yields were 2100 islet equivalents/Kg body weight. Islet autotransplantation can be considered a useful therapeutic option serving to prevent the occurrence of surgically-induced diabetes. The results have indicate that the omental pouch is a viable site for islet autotransplantation, that can accommodate a large tissue volume, is easy to access to implant, and the IBMIR (instant blood mediated inflammatory reaction) may be less severe.

Predicting splice variant from DNA chip expression data

Alternative splicing of premessenger RNA is an important layer of regulation in eukaryotic gene expression. Splice variation of a large number of genes has been implicated in various cell growth and differentiation processes. To measure tissue-specific splicing of genes on a large scale, we collected gene expression data from 11 rat tissues using a high-density oligonucleotide array representing 1600 rat genes. Expression of each gene on the chip is measured by 20 pairs of independent oligonucleotide probes. Two algorithms have been developed to normalize and compare the chip hybridization signals among different tissues at individual oligonucleotide probe level. Oligonucleotide probes (the perfect match [PM] probe of each probe pair), detecting potential tissue-specific splice variants, were identified by the algorithms. The identified candidate splice variants have been compared to the alternatively spliced transcripts predicted by an EST clustering program. In addition, 50% of the top candidates predicted by the algorithms were confirmed by RT-PCR experiment. The study indicates that oligonucleotide probe-based DNA chip assays provide a powerful approach to detect splice variants at genome scale.

Analysis of drug pharmacology towards predicting drug behavior by expression profiling using high-density oligonucleotide arrays

An important aspect of the drug development process is prediction of efficacious and toxic side effects. Profiling of mRNA expression is a powerful approach to analyze the molecular phenotype of cells under various conditions, for example, in response to stimulation by compounds. We attempt to explore the approach of using expression profiling to identify patterns or fingerprints that are correlated with specific drug properties or behaviors. Identification of such expression patterns may also lead to revelation of the potential action mechanism of drugs and fingerprints indicative of certain drug efficacy or side effects. We describe here a strategy that was used to identify a set of genes whose differential expression pattern correlates with activation mode and target specificity of a specific group of drug compounds.

Network computing

Pioneering health care organizations are saving money and gaining greater control of their networks by trading their PCs in for thin clients. But the devices are far from pervasive in health care.

Strategies for clinics. How integrated delivery systems are applying automation at their group practices

Integrated delivery systems that have created or acquired physician group practices are attempting to determine the best way to apply information technology at these sites. This involves standardizing on one practice management system for all sites, determining the feasibility of installing electronic patient records systems and expanding computer networks to accommodate the exchange of data among outpatient as well as inpatient sites.

Data entry on the run

An ambulance service in Louisiana equips medics with pen-tablet computers to speed collection of accurate and complete information.

Pioneers assess the role Java can play in health care

Since Sun Microsystems Inc. introduced Java in 1995, the new object-oriented programming language has attracted a great deal of attention. While many CIOs continue to sort the hype from the substance, a handful of health care organizations are deploying Java-based applications.

Repeated fetal losses associated with antiphospholipid antibodies: a collaborative randomized trial comparing prednisone with low-dose heparin treatment

OBJECTIVE

We attempted to compare the use of low-dose heparin with a standard dose of 40 mg prednisone daily (both plus low-dose aspirin) for treatment of pregnant women with antiphospholipid antibody-associated recurrent fetal loss with respect to maternal and perinatal morbidity and efficacy in prevention of fetal death.

STUDY DESIGN

A multicenter randomized trial included 20 patients. Generalizability of results from randomized patients was evaluated by means of additional data from 13 women refusing and 12 women ineligible for randomization. Data from study groups were compared with Fisher's exact test, and generalizability was evaluated with a chi 2 test for trend.

RESULTS

Live birth rates were the same (75%) with either treatment, but "serious" maternal morbidity and the frequency of preterm delivery were significantly higher among women randomly assigned to prednisone (p = 0.02 vs p = 0.006). Preterm delivery among prednisone-treated women was usually associated with premature rupture of the membranes or preeclampsia. These results could be generalized to the other groups of women ascertained during the course of the study.

CONCLUSIONS

Low-dose heparin should be preferred to prednisone when treatment is indicated for high-risk pregnant women with antiphospholipid antibodies.