Clinical features of MOGAD with brainstem involvement in the initial attack versus NMOSD and MS

OBJECTIVE

To assess the characteristics of Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disorder (MOGAD) with brainstem involvement in the first event (BSIFE) and make comparisons with aquaporin-4-IgG seropositive neuromyelitis optica spectrum disorder (AQP4-IgG-NMOSD) and multiple sclerosis (MS).

METHODS

From 2017 to 2022, this study identified MOG-IgG-positive patients with brainstem or both brainstem and cerebellum lesions in the first episode. As a comparison group, AQP4-IgG-NMOSD (n = 30) and MS (n = 30) patients with BSIFE were enroled.

RESULTS

Thirty-five patients (35/146, 24.0%) were the BSIFE of MOGAD. Isolated brainstem episodes occurred in 9 of the 35 (25.7%) MOGAD patients, which was similar to MS (7/30, 23.3%) but was lower than AQP4-IgG-NMOSD (17/30, 56.7%, P = 0.011). Pons (21/35, 60.0%), medulla oblongata (20/35, 57.1%) and middle cerebellar peduncle (MCP, 19/35, 54.3%) were the most frequently affected areas. Intractable nausea (n = 7), vomiting (n = 8) and hiccups (n = 2) happened in MOGAD patients, but EDSS of MOGAD was lower than AQP4-IgG-NMOSD (P = 0.001) at the last follow-up. MOGAD patients with or without BSIFE did not significantly differ in terms of the ARR (P = 0.102), mRS (P = 0.823), or EDSS (P = 0.598) at the most recent follow-up. Specific oligoclonal bands appeared in MOGAD (13/33, 39.4%) and AQP4-IgG-NMOSD (7/24, 29.2%) in addition to MS (20/30, 66.7%). Fourteen MOGAD patients (40.0%) experienced relapse in this study. When the brainstem was involved in the first attack, there was an increased likelihood of a second attack occurring at the same location (OR=12.22, 95%CI 2.79 to 53.59, P = 0.001). If the first and second events were both in the brainstem, the third event was likely to occur at the same location (OR=66.00, 95%CI 3.47 to 1254.57, P = 0.005). Four patients experienced relapses after the MOG-IgG turned negative.

CONCLUSION

BSIFE occurred in 24.0% of MOGAD. Pons, medulla oblongata and MCP were the most frequently involved regions. Intractable nausea, vomiting and hiccups occurred in MOGAD and AQP4-IgG-NMOSD, but not MS. The prognosis of MOGAD was better than AQP4-IgG-NMOSD. In contrast to MS, BSIFE may not indicate a worse prognosis for MOGAD. When patients with BSIFE, MOGAD tent to reoccur in the brainstem. Four of the 14 recurring MOGAD patients relapsed after the MOG-IgG test turned negative.

Forced inspiratory suction and swallow tool (FISST): an automation of Valsalva maneuver variants for therapeutic interventions

INTRODUCTION

The Valsalva maneuver and its modifications have been utilized across several conditions in medicine; however, there have been difficulties in its application. Thus, at the University of Texas Health Science Center in San Antonio, we designed and patented an affordable and accessible device that mimics Valsalva called "Forced Inspiratory Suction and Swallow Tool (FISST).

AREAS COVERED

In this review, we discuss the premise for the design of FISST, based on applications of the law of conservation energy, the continuity equation, and Bernoulli's principle. We then detail the mechanism by which FISST stimulates hiccup cessation by increasing negative inspiratory pressure when drinking through the apparatus, causing diaphragmatic contraction and disruption of the hiccup reflex. We then detail the efficacy and future applications of FISST in addressing other pathologies.

EXPERT OPINION

FISST has been used to address hiccups by utilizing its reverse-Valsalva effect to increase parasympathetic stimulation by increasing vagal tone. In a prospective study that we conducted on a cohort of 249 hiccup subjects worldwide, this tool achieved 92% effectiveness. Additionally, several cases, including a published case report, have found FISST successful in terminating supraventricular tachycardias (SVT). FISST may be further utilized in diagnosing or addressing various upper airway pathologies and should be explored further.

Health record hiccups-5,526 real-world time series with change points labelled by crowdsourced visual inspection

BACKGROUND

Large routinely collected data such as electronic health records (EHRs) are increasingly used in research, but the statistical methods and processes used to check such data for temporal data quality issues have not moved beyond manual, ad hoc production and visual inspection of graphs. With the prospect of EHR data being used for disease surveillance via automated pipelines and public-facing dashboards, automation of data quality checks will become increasingly valuable.

FINDINGS

We generated 5,526 time series from 8 different EHR datasets and engaged >2,000 citizen-science volunteers to label the locations of all suspicious-looking change points in the resulting graphs. Consensus labels were produced using density-based clustering with noise, with validation conducted using 956 images containing labels produced by an experienced data scientist. Parameter tuning was done against 670 images and performance calculated against 286 images, resulting in a final sensitivity of 80.4% (95% CI, 77.1%-83.3%), specificity of 99.8% (99.7%-99.8%), positive predictive value of 84.5% (81.4%-87.2%), and negative predictive value of 99.7% (99.6%-99.7%). In total, 12,745 change points were found within 3,687 of the time series.

CONCLUSIONS

This large collection of labelled EHR time series can be used to validate automated methods for change point detection in real-world settings, encouraging the development of methods that can successfully be applied in practice. It is particularly valuable since change point detection methods are typically validated using synthetic data, so their performance in real-world settings cannot be assumed to be comparable. While the dataset focusses on EHRs and data quality, it should also be applicable in other fields.

Emphysematous Pyelonephritis and Hiccups, a Case Report

The initial manifestation of emphysematous pyelonephritis (EPN) with hiccups is extremely rare. We report a 47-year-old diabetic man with complaint of persistent hiccups as the first manifestation. Class 3B EPN was confirmed based on findings of Contrast-enhanced abdominal multi-slice CT scan. There were no neurologic deficits, Medications that lead to hiccups and gastrointestinal dysfunction. Our patient was treated with antimicrobial therapy and double J stenting. His hiccups completely resolved in one week and had no relapse.

[Investigation into the Effect of Shitei Extract, a Traditional Chinese Medicine Formulation, on Hiccups]

Hiccups are occasionally experienced by most individuals, and although not life-threatening, they may leadto a decline in quality of life. Shitei extract(shitei, persimmon calyx)may be usedfor the treatment of hiccups. The effects of shitei extract were investigatedin patients admittedto the Japanese RedCross Musashino Hospital between October 2011 andM ay 2016. Numerous prescriptions for shitei extract were reportedin the Department of Respiratory Organs andNeurosurgery. The primary causes of hiccups were chemotherapy andbrain disease. Of 149 patients, 107(71.8%)sufferedfrom hiccups. None of the patients reported adverse events related to the administration of shitei extract. The incidence of hiccups was significantly higher in patients with brain disease(p=0.0075), treatedwith chemotherapy for cancer(p=0.0402), or requiring the insertion of a gastric tube(p=0.0065). Among those treatedwith chemotherapy for cancer, shitei extract was effective against hiccups in 82.0% patients(45 of 55). Furthermore, four patients receivedprophylaxis with shitei extract for the prevention of hiccups after chemotherapy. In conclusion, these results indicate that shitei extract is an effective and safe therapeutic drug for the treatment of hiccups. In particular, shitei extract was effective in the prevention of hiccups after chemotherapy.

Alterations in maternally perceived fetal movement and their association with late stillbirth: findings from the Midland and North of England stillbirth case-control study

OBJECTIVE

To report perception of fetal movements in women who experienced a stillbirth compared with controls at a similar gestation with a live birth.

DESIGN

Case-control study.

SETTING

41 maternity units in the UK.

PARTICIPANTS

Cases were women who had a late stillbirth ≥28 weeks gestation (n=291) and controls were women with an ongoing pregnancy at the time of the interview (n=733). Controls were frequency matched to cases by obstetric unit and gestational age.

METHODS

Data were collected using an interviewer-administered questionnaire which included questions on maternal perception of fetal movement (frequency, strength, increased and decreased movements and hiccups) in the 2 weeks before the interview/stillbirth. Five fetal movement patterns were identified incorporating the changes in strength and frequency in the last 2 weeks by combining groups of similar pattern and risk. Multivariable analysis adjusted for known confounders.

PRIMARY OUTCOME MEASURE

Association of maternally perceived fetal movements in relation to late stillbirth.

RESULTS

In multivariable analyses, women who reported increased strength of movements in the last 2 weeks had decreased risk of late stillbirth compared with those whose movements were unchanged (adjusted OR (aOR) 0.18, 95% CI 0.13 to 0.26). Women with decreased frequency (without increase in strength) of fetal movements were at increased risk (aOR 4.51, 95% CI 2.38 to 8.55). Daily perception of fetal hiccups was protective (aOR 0.31, 95% CI 0.17 to 0.56).

CONCLUSIONS

Increased strength of fetal movements and fetal hiccups is associated with decreased risk of stillbirth. Alterations in frequency of fetal movements are important in identifying pregnancies at increased risk of stillbirth, with the greatest risk in women noting a reduction in fetal activity. Clinical guidance should be updated to reflect that increase in strength and frequency of fetal movements is associated with the lowest risk of stillbirth, and that decreased fetal movements are associated with stillbirth.

TRIAL REGISTRATION NUMBER

NCT02025530.

[Clinical observation on yintang (Ex-HN 3) point-injection for treatment of obstinate hiccup]

OBJECTIVE

To search for an effective method for treatment of obstinate hiccup.

METHODS

Ninety cases of obstinate hiccup secondary to cerebral diseases were randomly divided into 3 groups, 30 cases in each group. Group A were treated by injection of compound chlorpromazine into Yintang (Ex-HN 3), group B by intramuscular injection of compound chlorpromazine and group C by acupuncture at Yintang (Ex-HN 3). Their therapeutic effects were compared.

RESULTS

The effective rate was 93.3% in the group A, 10.0% in the group B and 30.0% in the group C, the group A being better than the group B and the group C (P < 0.01).

CONCLUSION

Injection of compound chlorpromazine into Yintang (Ex-HN 3) has a significant therapeutic effect on obstinate hiccup.

[A case of medial medullary infarction with prominent deep sensory impairment]

We report a patient with medial medullary infarction who showed deep sensory impairment as his prominent neurological manifestation. A 54-year-old man with a history of hypertension was admitted to our hospital with numbness of the bilateral upper and lower extremities, followed by dysarthria and right hemiparesis. Physical examination revealed no abnormalities except for high blood pressure. He hiccuped continuously. On neurological examination, he exhibited dysarthria, mild dysphagia and right hemiparesis without facial or lingual paresis. Sensitivity to light touch and pinprick was normal, but sensitivity to vibration and joint position was severely decreased in the bilateral upper and lower extremities, predominantly in the lower extremities and on the right side in the upper extremities. He had been treated with antiedema agents and thromboxane synthetase inhibitor. His hiccups stopped within two weeks, and his right hemiparesis gradually improved within one month. However, his deep sensory impairments remained prominent. Blood examinations disclosed positive lupus anticoagulant. MRI showed bilateral infarction at the medial portion of the upper medulla oblongata, extending to both pyramids, especially on the left. Somatosensory evoked potentials (SEP) after median nerve stimulation showed P14 and the later components with prolonged latency. No SEP were recorded after posterior tibial nerve stimulation. The latency of P14 was well correlated with the severity of deep sensory impairments in the upper extremities. Neurological manifestations of our patient are not typical of medial medullary infarction, and are informative about the functional anatomy of the deep sensory tract in the medulla oblongata. We discuss the relation of the intractable hiccups to the bilateral medial medullary lesions, and emphasize the importance of lupus anticoagulant as one of the risk factors in brainstem infarction.

Behaviors associated with onset of gastroesophageal reflux episodes in infants. Prospective study using split-screen video and pH probe

To identify behaviors associated with the onset of gastroesophageal reflux episodes in infants both systematically and prospectively, each of 10 patients (aged 2 to 32 weeks) was studied during 2 hours of intraluminal esophageal pH probe monitoring, using a split-screen audiovisual recording technique. Videotape analysis of eight infants who had scoreable reflux events revealed six discrete behaviors closely associated temporally (P < .001 to < .05) with the onset of reflux events: "discomfort" (crying or frowning), "emission" (of liquid or gas, i.e., regurgitation, drooling, or burping), yawning, stridor, stretching, and mouthing. Three behaviors (hiccuping, sneezing, and thumb-sucking) were infrequent but were significantly associated with onset of reflux events in one or two patients each. A tenth behavior, coughing or gagging, was significantly associated with onset of reflux events in two patients, but not in the rest, despite relatively frequent occurrence. Exploration of temporal relations between reflux and each behavior suggested that discomfort, emission, mouthing, and cough-gag may have caused reflux episodes, and that all 10 of the behaviors may have been caused by reflux episodes. These findings and a "quiet period" immediately preceding episodes in six of the infants suggest interesting pathophysiologic mechanisms in infants which require further evaluation.

Objective and quantitative evaluation of fetal movement with ultrasonic Doppler actocardiogram

Actocardiogram is the simultaneous recording of fetal movement (FM) and fetal heart rate (FHR) with the use of a single transducer by weak ultrasound. Fetal behavioral states, fetal hiccups, nonpathologic sinusoidal FHR pattern induced by cyclic FM were reported in the use of this technique. Computer processing of FM signals enabled automatic recognition of fetal behavior. Fetal hypoxic state preceding fetal distress was diagnosed by the actocardiogram. Cross-correlation coefficient of FHR and delayed FM was high, showing a new possibility of detailed grading of mild fetal hypoxia.

Classification and quantitative aspects of fetal movements during the second half of normal pregnancy

Qualitative and quantitative aspects of fetal behaviour were studied in nine healthy nulliparae during the second half of pregnancy. Continuous real-time ultrasound observations of 60 min duration were carried-out at four-weekly intervals from 20 to 36 weeks of gestation, using two dynamically focussed linear array transducers positioned lengthwise allowing viewing of sagittal sections through the entire fetus. Various movement patterns were classified according to de Vries et al. (de Vries, J.I.P., Visser, G.H.A. and Prechtl, H.F.R (1982): The emergence of fetal behaviour I. Qualitative aspects. Early Hum. Dev., 7, 301-22). The reproducibility as expressed by the mean standard deviation in the analysis of the percentage incidence of the different movement patterns was good (1.6-2.2%). Both the incidence and percentage of observation time in which general movements were present decreased with advancing gestational age. Breathing movements frequently occurred as an isolated phenomenon; occasionally they were associated with jaw movements, swallowing, hiccups or general movements. The incidence of breathing movements as well as the percentage of observation time in which breathing movements were present, demonstrated an increase up to 32 weeks with a drop at 36 weeks of gestation. Hiccups occurred episodically, following each other in regular succession. Both the incidence and the percentage of observation time in which hiccups were present fluctuated widely. Stretches and startles displayed a decrease in incidence with advancing gestational age, whilst eye movements showed an increase. Rhythmical jaw movements were often followed by swallowing. Occasionally, yawns or tongue movements were seen. They may be combined with breathing and general movements. The incidence of jaw movements increased up to 28 weeks with a decline after. Both brief and longer periods of hand-face contacts were documented with wide variation in incidence. Head rotations frequently occurred as a single event; the incidence showed a decrease up to 28 weeks followed by an increase at 36 weeks of gestation. The incidence of head retroflexion varied widely with gestational age.

If the fetus can vocalize, how can we detect it?

In this paper, a method to detect the vocal activities of the fetus is reported. An estimation of the intensity and frequency of the voice was made on the assumption that the fetus can vocalize. Based upon these results, experiments to detect the voice were made. From the analysis of the results, it was made clear that the voice seemed to be buried in the noise and difficult to detect.

Fetal behaviour in early pregnancy

The emergence of embryonic and fetal movements in the first half of gestation is described. From their emergence onwards movements are specific and easily recognizable and during the course of gestation their appearance hardly changes; they closely resemble movement patterns observed in preterm and full-term newborn infants. Most of the movements described during the course of gestation have already emerged before 16 wk. The quantity of the distinct motor patterns undergoes several changes before 20 wk of gestation. This holds for their incidence and for their temporal sequence. The fact that fetal movements are specific and easily recognizable from their onset onwards makes them useful for assessing the development of the nervous system in normal and abnormal conditions.

Ultrasonic assessment of fetal activity

Modern ultrasound techniques enable dynamic studies of fetal activity in utero to be studied and quantified. Real-time B-mode scanning has become the method of choice for this purpose because of its ease of use and precision. Fetal movements can be visualized as early as in the seventh week of pregnancy and the development of the movement patterns can be followed throughout the pregnancy. Up to 16 types of movements have been described by several research groups. In early pregnancy, the finding of normal fetal movements is a good prognostic sign in cases of threatened abortion. A decrease in the movement incidence or a qualitative change of the movements are associated with poor outcome. In late pregnancy, the mean incidence of general fetal movements has been found on average to be 9 to 18 per cent of observation time. Fetal breathing movements, mainly with typical "see-saw' configurative changes of the fetal trunk, occur episodically: both long-term and short-term periodicity have been revealed. For recognition of the time incidence pattern of fetal movements or breathing, a sufficiently long observation time (80 to 100 minutes) is necessary. The incidence of fetal breathing movements increases with gestational age and breathing movements become more regular in mature fetuses. Fetal motor activity is subject to several external influences: glucose given to the mother causes an increase in the fetal breathing movement incidence; maternal hypercarbia stimulates the fetal breathing movements; alcohol administered to the mother abolishes fetal breathing; maternal smoking changes the time spacing of breathing and increases the fetal breathing rate; and exposure of the fetus to sound causes an increase in the number of movements. Real-time ultrasonography enables detection and recording of several other fetal activities: hiccups, swallowing and changes in the stomach volume, micturition, and fetal eye movements. The latter fetal activity is used together with fetal movements, fetal mouth movements and fetal heart rate for the identification of the fetal behavioural states. Quantification of fetal activity as a clinical test of fetal well-being was expected to give an alarm signal in cases of fetal hypoxia and imminent asphyxia. In general, the predictive value of a negative result (i.e., a finding of normal fetal activity) was high; the predictive value of decreased or abnormal fetal activity was found to be much less predictive of fetal compromise.(ABSTRACT TRUNCATED AT 400 WORDS)

Fetal hiccups: an associated fetal heart rate pattern

Fetal hiccups are commonly diagnosed during the antepartum period, and they have a tendency to recur. The reflex of hiccuping is similar to that of gasping, except hiccuping efforts are made against a closed airway. An episode of intrapartum hiccups was confirmed via real-time ultrasound scanning during monitoring with a direct fetal scalp electrode. A neonatal heart rate pattern during hiccuping is also included. Distinctive fetal and neonatal heart rate patterns were observed during the hiccuping episode. It is speculated that the fetal heart rate pattern seen with hiccups may resemble that of fetal gasping.

Patterns of human fetal breathing during the last 10 weeks of pregnancy

Continuous measurements of human fetal breathing movements and gross fetal body movements were made with an ultrasonic real-time scanner for periods of 24 houro 31 weeks' gestation, a significant increase in fetal breathing movements occurred during the second and third hours after meals; this pattern apparently followed an increase in maternal plasma glucose concentrations. At 38 to 39 weeks' gestation, fetal breathing movements increased during the second and third hours after breakfast, but the troughs seen before lunch and supper at 30 to 31 weeks' gestation were not present. Fetal breathing movements diminished over the day and reached a minimum between 1900 and 2400 hours. Fetal breathing activity increased in both groups between 0400 and 0700 hours while mothers were asleep; this was not related to an increase in maternal glucose concentrations. Absence of fetal breathing movements was observed for up to 122 minutes in this analysis of 480 hours in 20 patients. These data show that much more information must be obtained on factors that normally influence fetal breathing activity. Only then can research strategies be suggested for clinical evaluation of the usefulness of fetal breathing movements in the assessment of fetal health.

Fetal breathing: a review

The history, physiology, pharmacology, and clinical application of fetal breathing are reviewed. Early optimism that measurements of fetal breathing would aid in perinatal management decisions has remained unfulfilled. Problems to be overcome include standardization of technique and measurement parameters and allowance for physiologic variations. Recent research developments indicate that the likely role of fetal breathing in perinatal medicine will be in conjunction with other established tests of fetal health.