Treatments and Outcomes Among Patients with Sydenham Chorea: A Meta-Analysis

Importance

Sydenham chorea is the most common acquired chorea of childhood worldwide; however, treatment is limited by a lack of high-quality evidence.

Objectives

To evaluate historical changes in the clinical characteristics of Sydenham chorea and identify clinical and treatment factors at disease onset associated with chorea duration, relapsing disease course, and functional outcome.

Data Sources

The systematic search for this meta-analysis was conducted in PubMed, Embase, CINAHL, Cochrane Library, and LILACS databases and registers of clinical trials from inception to November 1, 2022 (search terms: [Sydenham OR Sydenham's OR rheumatic OR minor] AND chorea).

Study Selection

Published articles that included patients with a final diagnosis of Sydenham chorea (in selected languages).

Data Extraction and Synthesis

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Individual patient data on clinical characteristics, treatments, chorea duration, relapse, and final outcome were extracted. Data from patients in the modern era (1945 through 2022) were entered into multivariable models and stratified by corticosteroid duration for survival analysis of chorea duration.

Main Outcomes and Measures

The planned study outcomes were chorea duration at onset, monophasic course (absence of relapse after ≥24 months), and functional outcome (poor: modified Rankin Scale score 2-6 or persisting chorea, psychiatric, or behavioral symptoms at final follow-up after ≥6 months; good: modified Rankin Scale score 0-1 and no chorea, psychiatric, or behavioral symptoms at final follow-up).

Results

In total, 1479 patients were included (from 307 articles), 1325 since 1945 (median [IQR] age at onset, 10 [8-13] years; 875 of 1272 female [68.8%]). Immunotherapy was associated with shorter chorea duration (hazard ratio for chorea resolution, 1.51 [95% CI, 1.05-2.19]; P = .03). The median chorea duration in patients receiving 1 or more months of corticosteroids was 1.2 months (95% CI, 1.2-2.0) vs 2.8 months (95% CI, 2.0-3.0) for patients receiving none (P = .004). Treatment factors associated with monophasic disease course were antibiotics (odds ratio [OR] for relapse, 0.28 [95% CI, 0.09-0.85]; P = .02), corticosteroids (OR, 0.32 [95% CI, 0.15-0.67]; P = .003), and sodium valproate (OR, 0.33 [95% CI, 0.15-0.71]; P = .004). Patients receiving at least 1 month of corticosteroids had significantly lower odds of relapsing course (OR, 0.10 [95% CI, 0.04-0.25]; P < .001). No treatment factor was associated with good functional outcome.

Conclusions and Relevance

In this meta-analysis of treatments and outcomes in patients with Sydenham chorea, immunotherapy, in particular corticosteroid treatment, was associated with faster resolution of chorea. Antibiotics, corticosteroids and sodium valproate were associated with a monophasic disease course. This synthesis of retrospective data should support the development of evidence-based treatment guidelines for patients with Sydenham chorea.

Clinical Reasoning: A Teenage Girl With Progressive Hyperkinetic Movements, Seizures, and Encephalopathy

The "epilepsy-dyskinesia" spectrum is increasingly recognized in neurogenetic and neurometabolic conditions. It can be challenging to diagnose because of clinical and genetic heterogeneity, atypical or nonspecific presentations, and the rarity of each diagnostic entity. This is further complicated by the lack of sensitive or specific biomarkers for most nonenzymatic neurometabolic conditions. Nevertheless, clinical awareness and timely diagnosis are paramount to facilitate appropriate prognostication, counseling, and management.This report describes a case of a teenage girl who had presented at 14 months with a protracted illness manifesting as gastrointestinal upset and associated motor and cognitive regression. A choreoathetoid movement disorder, truncal ataxia, and microcephaly evolved after the acute phase. Neurometabolic and inflammatory investigations, EEG, brain MRI, muscle biopsy (including respiratory chain enzyme studies), and targeted genetic testing were unremarkable. A second distinct regression phase ensued at 14 years consisting of encephalopathy, multifocal motor seizures, absent deep tendon reflexes and worsening movements, gut dysmotility, and dysphagia. Video EEGs showed an evolving developmental and epileptic encephalopathy with multifocal seizures and nonepileptic movements. MRI of the brain revealed evolving and fluctuating patchy bihemispheric cortical changes, cerebellar atrophy with signal change, mild generalized brain volume loss, and abnormal lactate on MR spectroscopy. The article discusses the differential diagnostic approach and management options for patients presenting with neurologic regression, encephalopathy, seizures, and hyperkinetic movements. It also emphasizes the utility of next-generation sequencing in providing a rapid, efficient, cost-effective way of determining the underlying etiology of complex neurologic presentations.

Chemical constituents and acetylcholinesterase inhibitory activity of Beilschmiedia insignis Gamble

ABSTRACT. Secondary metabolites from natural products are potential sources of acetylcholinesterase inhibitors, which are key enzymes in the treatment of many neurodegenerative diseases. Inspired by the reported activities of alkaloids herein we report the chemical investigation on the chemical constituents from Beilschmiedia insignis and their acetylcholinesterase inhibitory activity. Isolation of the stem bark of B. insignis led to the isolation and identification of five aporphine alkaloids, namely isocorydine (1), norisocorydine (2), (+)-laurotetanine (3), (+)-N-methyllaurotetanine (4), and (+)-boldine (5), together with β-sitosterol (6), β-sitostenone (7), lupeol (8), and lupenone (9). The chemical structures of these compounds were obtained by analysis of their spectroscopic data, as well as the comparison with that of reported data. Acetylcholinesterase inhibitory activity revealed that all isolated alkaloids were found to inhibit AChE with percentage inhibition values ranged from 44.9 to 74.5%. This is the first report on phytochemicals from B. insignis.                     KEY WORDS: Lauraceae, Beilschmiedia insignis, Alkaloid, Acetylcholinesterase, Alzheimer   Bull. Chem. Soc. Ethiop. 2021, 35(3), 685-691. DOI: https://dx.doi.org/10.4314/bcse.v35i3.19

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Improved ankle and knee control with a dual-channel functional electrical stimulation system in chronic hemiplegia. A case report

The aim of tis report is to describe the effects of a dual-channel functional electrical stimulation (FES) system applied daily as an orthotic device to the dorsiflexors and hamstrings muscles in a subject with chronic hemiparesis. Prior to the application of FES, the patient's gait was characterized by a footdrop and knee hyperextension during stance. measurements of gait performance were collected before FES application, after a conditioning period of six weeks, and following ten months of daily use. Outcomes included lower limb kinematics and temporal gait measures. The kinematic assessments indicated significant benefits for gait with the dorsiflexors and hamstrings FES, as compared to no stimulation and peroneal FES alone. In addition ot improved ankle control, knee hyperextension was reduced during stance, and the self-selected comfortable gait velocity increased following ten months of daily use. The results of this report suggest that dual-channel FES for the dorsiflexors and hamstrings muscles may affect ankle and knee control beyond that witch can be attributed to peroneal stimulation alone. The positive effects observed in this case study point to the potential of dual-channel FES as a viable treatment options in the rehabilitation of patients with similar impairments.

Evaluation of antioxidant and nitric oxide inhibitory activities of selected Malaysian medicinal plants

Methanol extracts of seven Malaysian medicinal plants were screened for antioxidant and nitric oxide inhibitory activities. Antioxidant activity was measured by using FTC, TBA and DPPH free radical scavenging methods and Griess assay was used for the measurement of nitric oxide inhibition in lipopolysaccharide (LPS) and interferon-gamma (IFN-gamma)-treated RAW 264.7 cells. All the extracts showed strong antioxidant activity comparable to or higher than that of alpha-tocopherol, BHT and quercetin in FTC and TBA methods. The extracts from Leea indica and Spermacoce articularis showed strong DPPH free radical scavenging activity comparable with quercetin, BHT and Vit C. Spermacoce exilis showed only moderate activity but other species were weak as compared to the standards. In the Griess assay Lasianthus oblongus, Chasalia chartacea, Hedyotis verticillata, Spermacoce articularis and Leea indica showed strong inhibitory activity on nitric oxide production in LPS and IFN-gamma-induced RAW 264.7 cells. Extracts from Psychotria rostrata and Spermacoce exilis also inhibited NO production but this was due to their cytotoxic effects upon cells during culture.

Urinary schistosomiasis in schoolchildren on Zanzibar Island (Unguja), Tanzania: a parasitological survey supplemented with questionnaires

The distribution of urinary schistosomiasis in schoolchildren on Zanzibar Island (Unguja) was surveyed in May 2001 to test a potential correlation with the distribution of snail species of the Bulinus africanus group and to record contemporary baseline epidemiological data. Quasi-random samples of 40 schoolchildren of mixed sexes were selected from each of 10 schools. Schistosoma haematobium infections were detected upon the basis of micro-haematuria with subsequent confirmation by microscopy examination for schistosome eggs. At the time of urine collection, each child was interviewed with a suite of 12 questions prepared as a standardized questionnaire. Total prevalence of urinary schistosomiasis (known locally as kichocho) was 12% although schistosome infections were absent in 5 schools. Schools located west of 39 degrees 19'E and north of 6 degrees 10'S harboured nearly all of the infections; the highest prevalence (55%) was found at Kinyasini where many B. globosus habitats occur nearby. The general level of understanding of kichocho was low (24%) and individual self-diagnosis was poor (sensitivity, 8.5%; specificity, 85%). Grouped freshwater-contact patterns of schoolchildren differed significantly between schools and correlated well with prevalence of infections within schools. Across the island the area of active transmission of S. haematobium to humans appears confined within the distribution of B. globosus. There was no epidemiological evidence to suggest any involvement of B. nasutus in local transmission, confirming previous laboratory findings. In areas where B. globosus occurs, targeted snail control should be considered, to reduce schistosome transmission.

New insights into the transmission biology of urinary schistosomiasis in Zanzibar

A better understanding of the transmission biology of urinary schistosomiasis in Zanzibar, Tanzania was only possible after the development of molecular DNA markers for identification of Bulinus africanus group snails, the potential intermediate hosts of Schistosoma haematobium. Hitherto, identification of natural populations of B. globosus and B. nasutus was problematic and the intermediate host status and distribution of either species remained speculative. By recourse to molecular markers, snail distribution maps could be drawn, revealing an allopatric distribution and, more importantly, leading to the discovery that B. nasutus played no role in transmission. Indeed, in Unguja the area of active transmission of S. haematobium to humans is confined within the distribution of B. globosus. This strong relationship may prove useful for predicting the distribution of urinary schistosomiasis within Zanzibar and, if snail schistosome compatibilities persist, in other areas nearby, e.g. coastal Tanzania and Kenya. The transmission biology of urinary schistosomiasis in Zanzibar is reviewed, the paper reports on ongoing malacological studies in Zanzibar and Kenya and finally closes by posing the question whether medical malacology forms an essential component associated with mass-scale chemotherapy control programmes.

Adaptation of the Photosynthetic Apparatus in Maize Leaves as a Result of Nitrogen Limitation : Relationships between Electron Transport and Carbon Assimilation

In maize (Zea mays L., cv Contessa), nitrogen (NO(3) (-)) limitation resulted in a reduction in shoot growth and photosynthetic capacity and in an increase in the leaf zeaxanthin contents. Nitrogen deficiency had only a small effect on the quantum yield of CO(2) assimilation but a large effect on the light-saturated rate of photosynthesis. Linear relationships persisted between the quantum yield of CO(2) assimilation and that of photosystem II photochemistry in all circumstances. At high irradiances, large differences in photochemical quenching and nonphotochemical quenching of Chl a fluorescence as well as the ratio of variable to maximal fluorescence (Fv/Fm) were apparent between nitrogen-deficient plants and nitrogen-replete controls, whereas at low irradiances these parameters were comparable in all plants. Light intensity-dependent increases in nonphotochemical quenching were greatest in nitrogen-deficient plants as were the decreases in Fv/Fm ratio. In nitrogen-deficient plants, photochemical quenching decreased with increasing irradiance but remained higher than in controls at high irradiances. Thermal dissipative processes were enhanced as a result of nitrogen deficiency (nonphotochemical quenching was elevated and Fv/Fm was lowered) allowing PSII to remain relatively oxidised even when carbon metabolism was limited via nitrogen limitation.