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Sapienza Global Bedside Evaluation of Swallowing after Stroke: theGLOBE‐3S study
Background and purposeDysphagia occurs in up to 50% of all patients with acute stroke. There is debate regarding which is the most effective screening tool in identifying aspiration in patients with acute stroke. We assessed the accuracy of the Sapienza Global Bedside Evaluation of Swallowing after Stroke (GLOBE‐3S), which combines the Toronto Bedside Swallowing Screening Test (TOR‐BSST©) with oxygen desaturation and laryngeal elevation measurement during swallowing.MethodsWe prospectively enrolled consecutive patients with stroke within 72 h of symptom onset. All patients with stroke firstly underwent a standard neurological examination, then theGLOBE‐3S evaluation and finally the fiberoptic endoscopic evaluation of swallowing (FEES). Two different assessors, a neurologist and a speech pathologist, blind to both the clinical data and each other's evaluation, administered theGLOBE‐3S andFEESexamination. We assessed the accuracy of theGLOBE‐3S in detecting post‐stroke swallow impairment with aspiration using theFEESas the standard.ResultsWe enrolled 50 patients with acute stroke, 28 of whom (56%) had swallowing impairment with aspiration atFEESevaluation. A total of 33 patients (66%) failed theGLOBE‐3S evaluation. TheGLOBE‐3S reached a sensitivity of 100% and a specificity of 77.3% (negative predictive value, 100%; positive likelihood ratio, 4.34). The median time required for theGLOBE‐3S to be performed was 297 s.ConclusionsGLOBE‐3S is quick to perform at the bedside and can accurately identify aspiration in patients with acute stroke. By including the measurement of laryngeal elevation and monitoring of oxygen desaturation, it could represent a highly sensitive instrument to avoid the misdiagnosis of silent aspirators.
Migrainous Infarction in a Patient With Sporadic Hemiplegic Migraine and Cystic Fibrosis: A 99mTc‐HMPAO Brain SPECT Study
Genetic mutations of sporadic hemiplegic migraine (SHM) are mostly unknown. SHM pathophysiology relies on cortical spreading depression (CSD), which might be responsible for ischemic brain infarction. Cystic fibrosis (CF) is caused by a monogenic mutation of the chlorine transmembrane conductance regulator (CFTR), possibly altering brain excitability. We describe the case of a patient with CF, who had a migrainous stroke during an SHM attack. A 32‐year‐old Caucasian male was diagnosed with CF, with heterozygotic delta F508/unknown CFTR mutation. The patient experiences bouts of coughing sometimes triggering SHM attacks with visual phosphenes, aphasia, right‐sided paresthesia, and hemiparesis. He had a 48‐hour hemiparesis triggered by a bout of coughing with hemoptysis, loss of consciousness, and severe hypoxia‐hypercapnia. MRI demonstrated transient diffusion hyperintensity in the left frontal‐parietal‐occipital regions resulting in a permanent infarction in the primary motor area. Later, a brain perfusion SPECT showed persistent diffuse hypoperfusion in the territories involved in diffusion‐weighted imaging alteration. Migrainous infarction, depending on the co‐occurrence of 2 strictly related phenomena, CSD and hypoxia, appears to be the most plausible explanation. Brain SPECT hypoperfusion suggests a more extensive permanent neuronal loss in territories affected by aura. CF may be then a risk factor for hemiplegic migraine and stroke since bouts of coughing can facilitate brain hypoxia, triggering auras.
Alice in Wonderland Syndrome: A Clinical and Pathophysiological Review
Alice in Wonderland Syndrome (AIWS) is a perceptual disorder, principally involving visual and somesthetic integration, firstly reported by Todd, on the literary suggestion of the strange experiences described by Lewis Carroll in Alice in Wonderland books. Symptoms may comprise among others aschematia and dysmetropsia. This syndrome has many different etiologies; however EBV infection is the most common cause in children, while migraine affects more commonly adults. Many data support a strict relationship between migraine and AIWS, which could be considered in many patients as an aura or a migraine equivalent, particularly in children. Nevertheless, AIWS seems to have anatomical correlates. According to neuroimaging, temporoparietal-occipital carrefour (TPO-C) is a key region for developing many of AIWS symptoms. The final part of this review aims to find the relationship between AIWS symptoms, presenting a pathophysiological model. In brief, AIWS symptoms depend on an alteration of TPO-C where visual-spatial and somatosensory information are integrated. Alterations in these brain regions may cause the cooccurrence of dysmetropsia and disorders of body schema. In our opinion, the association of other symptoms reported in literature could vary depending on different etiologies and the lack of clear diagnostic criteria.
Waist circumference, a body shape index, and molecular subtypes of colorectal cancer: A pooled analysis of four cohort studies
Abstract Background Waist circumference (WC) and its allometric counterpart, “a body shape index” (ABSI), are risk factors for colorectal cancer (CRC); however, it is uncertain whether associations with these body measurements are limited to specific molecular subtypes of the disease. Methods Data from 2,772 CRC cases and 3,521 controls were pooled from four cohort studies within the Genetics and Epidemiology of Colorectal Cancer Consortium. Four molecular markers (BRAF mutation, KRAS mutation, CpG island methylator phenotype, and microsatellite instability) were analysed individually and in combination (Jass-types). Multivariable logistic and multinomial logistic models were used to assess the associations of WC and ABSI with overall CRC risk and in case-only analyses evaluating heterogeneity by molecular subtype, respectively. Results Higher WC (ORper 5cm=1.06, 95%CI:1.04-1.09) and ABSI (ORper 1-SD=1.07, 95%CI:1.00-1.14) were associated with elevated CRC risk. There was no evidence of heterogeneity between the molecular subtypes. No difference was observed regarding the influence of WC and ABSI on the four major molecular markers in proximal colon, distal colon, and rectal cancer, as well as in early and later onset CRC. Associations did not differ in the Jass-type analysis. Conclusions Higher WC and ABSI were associated with elevated CRC risk; however, they do not differentially influence all four major molecular mutations involved in colorectal carcinogenesis but underscore the importance of maintaining a healthy body weight in CRC prevention. Impact The proposed results have potential utility in colorectal cancer prevention.
Predicting Preeclampsia in Gestational Diabetes Mellitus using the sFlt-1/PlGF Ratio.
CONTEXT: The sFlt-1/PlGF ratio blood test can aid the prediction of preeclampsia (PE) in advance of a clinical diagnosis. Gestational diabetes mellitus (GDM) predisposes to PE, but may influence levels of these biomarkers independently of PE. OBJECTIVE: To determine whether the sFlt-1/PlGF ratio retains its clinical utility to predict PE in patients with GDM. DESIGN: Retrospective analysis of sFlt-1/PlGF ratio and associated clinical outcome data acquired between September 2016 and September 2022. SETTING: The Royal Women's Hospital, Melbourne, Australia. PATIENTS: 1,416 sFlt-1/PlGF ratio results from pregnant women with and without GDM, and with and without PE, referred for sFlt-1/PlGF testing. INTERVENTION: N/A. MAIN OUTCOME MEASURE: sFlt-1, PlGF and sFlt-1/PlGF ratio test results in relation to PE and GDM. RESULTS: There were no significant differences in the AUC, specificity, sensitivity, PPV or NPV between the PE + No GDM and PE + GDM groups in both the 0-7 and 8-14 day before delivery categories. In the 0-7 day category the PE + No GDM group had a AUC of 0.82 (95% CI: 0.79-0.87), sensitivity of 85.3% (95% CI: 80.8% - 89.1%), NPV of 92.7% (95% CI: 90.5% - 94.5%), and the PE + GDM group had an AUC of 0.87 (95% CI: 0.82-0.93), sensitivity of 89.4% (95% CI: 76.9% - 96.5%) and NPV of 94.8% (95% CI: 88.7% - 97.7%). CONCLUSIONS: The results of this investigation indicate that whilst GDM may lead to changes in the sFlt-1/PlGF ratio, the sFlt-1/PlGF ratio test retains its clinical utility in predicting PE onset.
A digital dashboard for reporting mental, neurological and substance use disorders in Nairobi, Kenya: Implementing an open source data technology for improving data capture.
The availability of quality and timely data for routine monitoring of mental, neurological and substance use (MNS) disorders is a challenge, particularly in Africa. We assessed the feasibility of using an open-source data science technology (R Shiny) to improve health data reporting in Nairobi City County, Kenya. Based on a previously used manual tool, in June 2022, we developed a digital online data capture and reporting tool using the open-source Kobo toolbox. Primary mental health care providers (nurses and physicians) working in primary healthcare facilities in Nairobi were trained to use the tool to report cases of MNS disorders diagnosed in their facilities in real-time. The digital tool covered MNS disorders listed in the World Health Organization's (WHO) Mental Health Gap Action Program Intervention Guide (mhGAP-IG). In the digital system, data were disaggregated as new or repeat visits. We linked the data to a live dynamic reproducible dashboard created using R Shiny, summarising the data in tables and figures. Between January and August 2023, 9064 cases of MNS disorders (4454 newly diagnosed, 4591 revisits and 19 referrals) were reported using the digital system compared to 5321 using the manual system in a similar period in 2022. Reporting in the digital system was real-time compared to the manual system, where reports were aggregated and submitted monthly. The system improved data quality by providing timely and complete reports. Open-source applications to report health data is feasible and acceptable to primary health care providers. The technology improved real-time data capture, reporting, and monitoring, providing invaluable information on the burden of MNS disorders and which services can be planned and used for advocacy. The fast and efficient system can be scaled up and integrated with national and sub-national health information systems to reduce manual data reporting and decrease the likelihood of errors and inconsistencies.
Attitudes and perceptions towards epilepsy in an onchocerciasis-endemic region of Tanzania: a mixed approach to determine the magnitude and driving factors.
BACKGROUND: Epilepsy remains a significant public health concern in Tanzania, with affected individuals enduring stigma, whether through actions or perceptions. Myths, misunderstandings, and misconceptions about epilepsy have persisted due to a multitude of factors. Here, we assessed attitudes and perceptions toward epilepsy in Mahenge. METHODS: A cross-sectional study utilising a mixed-methods approach was undertaken in eight villages in the Ulanga district of Mahenge, integrating a semi-structured questionnaire and focus group discussions (FGDs). The questionnaire involved 778 community members, and 15 FGDs were conducted (seven groups with people with epilepsy and eight without). Descriptive statistics, chi-square, and logistic regression were used for quantitative analysis, while we used NVivo version 14 for thematic analysis of qualitative data. RESULTS: Of 778 participants, over half were women (425, 54.6%) with a median age of 41 years (IQR: 30-55) and most had completed primary education (79.9%). The majority of participants were aware of epilepsy (96.8%), yet they displayed low knowledge (51%), negative attitudes (45.5%), and perceptions (42.1%) towards the disorder. A low level of understanding was significantly associated with negative attitudes (Adjusted Odds Ratio [AOR] = 1.89, 95%CI: 1.41-2.53) and perceptions (AOR = 3.22, 95%CI: 2.05-5.04) towards epilepsy. In the qualitative analysis, often hereditary factors and infections were named as causes of epilepsy, along with misconceptions involving witchcraft and divine punishment. There was also a misconception about the contagiousness of epilepsy. Traditional healers were often the initial point of treatment. Epilepsy-related stigma was evident, with individuals with epilepsy facing derogatory labels, social isolation, and barriers to education. Lastly, there was a lack of understanding regarding a possible association between epilepsy and onchocerciasis. CONCLUSIONS: Despite high awareness of epilepsy, there is insufficient understanding, negative attitudes, and perceptions, including misconceptions and stigma about this neurologic condition. Community-based education programmes are essential for promoting proper healthcare-seeking behaviour and dispelling myths.
"epilepSee" Glasses: A Wearable Seizure Prevention Device for Photosensitive Epilepsy
Temporarily reducing retinal stimulation when exposed to a hazardous photic stimulus by activating a rapidly responding electrochromic material could provide a novel seizure prevention method, referred to as the "EpilepSee Glasses", for people with photosensitive epilepsy.Analysis of an electroencephalogram (EEG) recording has shown reduced photoparoxysmal responses when exposed to flashing light whilst wearing a pair of glasses with one lens covered by an electrochromic material. By characterising the variation of the light seen in a user's field of vision in real time, and exploiting the fact that a stimulus must, on average, be present for at least 1 second to cause a seizure, the glasses' lens only needs to activate upon detection of a potentially harmful stimulus. This means that when the optical environment is deemed safe by the device, the user will experience minimal change to their quality of life.Further development could result in this proof-of-concept device evolving into a simple, affordable solution for noninvasive seizure prevention, filling an otherwise unexplored gap in treatment methods.
Challenges and opportunities of acquiring cortical recordings for chronic adaptive deep brain stimulation
Deep brain stimulation (DBS), a proven treatment for movement disorders, also holds promise for the treatment of psychiatric and cognitive conditions. However, for DBS to be clinically effective, it may require DBS technology that can alter or trigger stimulation in response to changes in biomarkers sensed from the patient’s brain. A growing body of evidence suggests that such adaptive DBS is feasible, it might achieve clinical effects that are not possible with standard continuous DBS and that some of the best biomarkers are signals from the cerebral cortex. Yet capturing those markers requires the placement of cortex-optimized electrodes in addition to standard electrodes for DBS. In this Perspective we argue that the need for cortical biomarkers in adaptive DBS and the unfortunate convergence of regulatory and financial factors underpinning the unavailability of cortical electrodes for chronic uses threatens to slow down or stall research on adaptive DBS and propose public–private partnerships as a potential solution to such a critical technological gap.
Oxford brain health clinic: protocol and research database
IntroductionDespite major advances in the field of neuroscience over the last three decades, the quality of assessments available to patients with memory problems in later life has barely changed. At the same time, a large proportion of dementia biomarker research is conducted in selected research samples that often poorly reflect the demographics of the population of patients who present to memory clinics. The Oxford Brain Health Clinic (BHC) is a newly developed clinical assessment service with embedded research in which all patients are offered high-quality clinical and research assessments, including MRI, as standard.Methods and analysisHere we describe the BHC protocol, including aligning our MRI scans with those collected in the UK Biobank. We evaluate rates of research consent for the first 108 patients (data collection ongoing) and the ability of typical psychiatry-led NHS memory-clinic patients to tolerate both clinical and research assessments.Ethics and disseminationOur ethics and consenting process enables patients to choose the level of research participation that suits them. This generates high rates of consent, enabling us to populate a research database with high-quality data that will be disseminated through a national platform (the Dementias Platform UK data portal).