Bijen Nazliel

A Brief Prehospital Stroke Severity Scale Identifies Ischemic Stroke Patients Harboring Persisting Large Arterial Occlusions

Background and Purpose— The Los Angeles Motor Scale (LAMS) is a brief 3-item stroke severity assessment measure designed for prehospital and Emergency Department use. Methods— The LAMS and NIHSS were scored in under-12-hour acute anterior circulation ischemic stroke patients. Stroke severity ratings were correlated with cervicocerebral vascular occlusion on CTA, MRA, and catheter angiography. Receiver operating curves, c statistics, and likelihood ratios were used to evaluate the predictive value for vascular occlusion of stroke severity ratings. Results— Among 119 patients, mean age was 67 (±18), 45% were male. Time from onset to ED arrival was mean 190 minutes (range 10 to 660). Persisting large vessel occlusions (PLVOs) were present in 62% of patients. LAMS stroke severity scores were higher in patients harboring a vascular occlusion, median 5 (IQR 4 to 5) versus 2 (IQR 1 to 3). Similarly, NIHSS stroke severity scores were higher in PLVO patients, 19 (14 to 24) versus 5 (3 to 7). ROC curves demonstrated that the LAMS was highly effective in identifying patients with PLVOs, c statistic 0.854. At the optimal threshold of 4 or higher, LAMS scores showed sensitivity 0.81, specificity 0.89, and overall accuracy 0.85. LAMS performance was comparable to NIHSS performance (c statistic 0.933). The positive likelihood ratio associated with a LAMS score ≥4 was 7.36 and the negative likelihood ratio 0.21. Conclusions— Stroke severity assessed by the LAMS predicts presence of large artery anterior circulation occlusion with high sensitivity and specificity. The LAMS is a promising instrument for use by prehospital personnel to identify select stroke patients for direct transport to Comprehensive Stroke Centers capable of endovascular interventions.

Relationship between foot sensation and standing balance in patients with multiple sclerosis

The aims of the present study were to investigate the relationship between the foot sensations and standing balance in patients with Multiple Sclerosis (MS) and find out the sensation, which best predicts balance. Twenty-seven patients with MS (Expanded Disability Status Scale 1-3.5) and 10 healthy volunteers were included. Threshold of light touch-pressure, duration of vibration, and distance of two-point discrimination of the foot sole were assessed. Duration of static one-leg standing balance was measured. Light touch-pressure, vibration, two-point discrimination sensations of the foot sole, and duration of one-leg standing balance were decreased in patients with MS compared with controls (p<0.05). Sensation of the foot sole was related with duration of one-leg standing balance in patients with MS. In the multiple regression analysis conducted in the 27 MS patients, 47.6% of the variance in the duration of one-leg standing balance was explained by two-point discrimination sensation of the heel (R(2)=0.359, p=0.001) and vibration sensation of the first metatarsal head (R(2)=0.118, p=0.029). As the cutaneous receptors sensitivity decreases in the foot sole the standing balance impairs in patients with MS. Two-point discrimination sensation of the heel and vibration sensation of the first metatarsal head region are the best predictors of the static standing balance in patients with MS. Other factors which could be possible to predict balance and effects of sensorial training of foot on balance should be investigated.

Comparison of functional exercise capacity, pulmonary function and respiratory muscle strength in patients with multiple sclerosis with different disability levels and healthy controls.

OBJECTIVE To compare functional exercise capacity, pulmonary function and respiratory muscle strength in fully ambulatory patients with multiple sclerosis with different disability levels and healthy controls, and to elucidate the determinant factors of functional exercise capacity. METHODS Forty-three fully ambulatory patients with multiple sclerosis and 30 healthy controls were included in the study. Patients were grouped according to Expanded Disability Status Scale (EDSS); Group I (EDSS 0-2), Group II (EDSS 2.5-4.5). Functional exercise capacity was evaluated using a six-minute walk test, and measurement of pulmonary function, and maximal inspiratory and expiratory pressures (MIP, MEP). The Pulmonary Index was used as a clinical predictor of respiratory dysfunction. RESULTS Respiratory muscle strength was lower in multiple sclerosis groups compared with controls, but the difference in MIP and %MIP did not reach statistical significance in Group I. The six-minute walk test distance was significantly shorter and peak expiratory flow was lower in multiple sclerosis groups (p < 0.05). Of the variance in the six-minute walk test distance, 75% was explained by EDSS (R2 = 0.55, p < 0.001), difference in heart rate (R2 = 0.06, p = 0.007), age (R2 = 0.05, p = 0.009) and gender (R2 = 0.09, p = 0.003). CONCLUSION Respiratory muscles are weakened, functional exercise capacity is reduced and pulmonary function is affected even in the early phase of multiple sclerosis. Ambulatory patients with multiple sclerosis who have a higher level of disability have lower pulmonary function, respiratory muscle strength and functional capacity than less disabled ones and controls. Neurological disability level, age, gender and heart rate difference on exertion are the determinants of functional exercise capacity.

The effects of pilates on balance, mobility and strength in patients with multiple sclerosis.

BACKGROUND Although there are evidences as to Pilates developing dynamic balance, muscle strength and flexibility in healthy people, evidences related to its effects on Multiple Sclerosis patients are insufficient. OBJECTIVES The aims of this study were to investigate the effects of Pilates on balance, mobility, and strength in ambulatory patients with Multiple Sclerosis. METHODS Twenty six patients were divided into two groups as experimental (n = 18) and control (n = 8) groups for an 8-week treatment program. The experimental group underwent Pilates and the control group did abdominal breathing and active extremity exercises at home. Balance and mobility were measured with Berg Balance Scale and Timed up and go test, upper and lower muscle strength with hand-held dynamometer. Confidence in balance skills while performing daily activities was evaluated with Activities Specific Balance Confidence Scale. RESULTS Improvements were observed in balance, mobility, and upper and lower extremity muscle strength in the Pilates group (p < 0.05). No significant differences in any outcome measures were observed in the control group (p > 0.05). CONCLUSION Due to its structure which is made up of balance and strengthening exercises, Pilates training may develop balance, mobility and muscle strength of MS patients. For this reason, we think that, Pilates exercises which are appropriate for the disability level of the patient may be suggested.

Upper extremity function and its relation with hand sensation and upper extremity strength in patients with multiple sclerosis.

The purpose of this study was to investigate the relationships between the upper extremity functions, upper extremity strength and hand sensation in patients with Multiple Sclerosis (MS). Twenty-two patients with MS (mean age: 38.5 ± 8.31 years, median Expanded Disability Status Scale (EDSS): 2) and 10 healthy subjects were included. Upper extremity function was measured with the Nine-hole peg test, upper extremity strength (shoulder flexion-abduction, elbow flexion, pinch and grip) with hand-held dynamometer, hand grip dynamometer and manual pinch meter, threshold of light touch-pressure with Semmes-Weinstein monofilament, duration of vibration with 128-Hz frequency tuning fork, and distance of two-point discrimination with an aesthesiometer. Strength and functional level of the upper extremity, light touch-pressure, two-point discrimination, vibration sensations of the hand were lower in patients with MS compared with healthy controls (p < 0.05). Light touch-pressure sensation of thumb and index fingers, two-point discrimination of index finger and elbow flexion strength were found to be related with upper extremity function in patients with MS (p< 0.05). These results indicate that the hand sensation, upper extremity strength and function were affected in MS patients. Additionally upper extremity functions seem to be related with light touch-pressure and two-point discrimination sensations of the hand and elbow flexion strength. Upper extremity strengthening and sensorial training of the hand may contribute to the upper extremity function in patients with MS.

Serum nitric oxide metabolites in patients with multiple sclerosis.

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system characterized by myelin breakdown. The free radical nitric oxide (NO), which is considered to be a major metabolite in immune function and in autoimmune disorders, is among the possible mediators causing the inflammatory reactions in MS. Consequently, NO has been implicated in the pathogenesis of MS and its animal model experimental allergic encephalomyelitis (EAE). In this study, stable metabolites of NO (NO(2-)+NO(3-)) levels were determined in sera of MS patients (n=23) and control subjects (n=16). NO(2-)+NO(3-) levels were higher in MS patients when compared to control subjects. However, there was not any correlation with serum NO(2-)+NO(3-) values and clinical features of the disease such as duration of sickness, the time elapsed from the last attack and EDSS values. Our results imply that nitric oxide may be involved in the pathogenesis of MS although further studies are required to elucidate underlying mechanisms.

Effects of Ai-Chi on balance, functional mobility, strength and fatigue in patients with multiple sclerosis: A pilot study

BACKGROUND Multiple Sclerosis (MS) patients are often referred to aquatic physical therapy, but unfortunately, researches on the effects of aquatic therapy in MS patients are limited. OBJECTIVE The purpose of this study was to investigate the effects of Ai-Chi on balance, functional mobility, strength and fatigue in ambulatory patients with MS. METHODS Twenty-three ambulatory female patients were divided into two groups as experimental (n = 15) or control (n = 8) for an 8-week treatment program. The experimental group underwent Ai-Chi exercises in a swimming pool and the control group performed active arm and leg exercises combined with abdominal breathing exercises at home. Static standing balance was measured with duration of one-leg stance, functional mobility was evaluated with Timed-up and Go test and 6 minute walk test, upper and lower muscle strength was assessed with hand-held dynamometer and fatigue was evaluated with Fatigue Severity Scale. RESULTS Improvements were observed in static standing balance, functional mobility, upper and lower extremity muscle strength and fatigue in the Ai-Chi group (p < 0.05), but no significant differences in any outcome measures were observed in the control group (p > 0.05) after the intervention. CONCLUSIONS According to these findings Ai-Chi may improve balance, functional mobility, upper and lower extremity muscle strength and fatigue in patients with MS.

Vitiligo and multiple sclerosis in a patient treated with interferon beta-1a: a case report.

Dear Sir, Interferon (IFN) beta-1a is an approved immunomodulating treatment for relapsing-remitting multiple sclerosis. Subcutaneous injections were given three times weekly. The most frequent side effects of IFN beta-1a are inflammatory reactions at the injections sites (72%) and flu-like symptoms (69%) [1]. It has been reported that IFN-alfa therapy induce vitiligo or make it worse [2,3]. However, the development of vitiligo in response to IFN-beta treatment has not been reported. Although the mechanism for interferoninduced vitiligo is not known, it is believed that IFN-alfa causes vitiligo via induction of antimelanocyte autoantibodies or activation of cytotoxic T cells [2]. It has been stated that vitiligo lesions completely resolved after discontinuation of IFN-alfa treatment [4]; however, Seckin et al. stated that the lesions did not resolve after the cessation of treatment and new lesions continued to evolve despite of withdrawal of treatment [2]. We present the case of a 33-year-old female patient who developed vitiligo lesions after receiving 22 mcg of subcutaneous recombinant IFN beta-1a therapy three times weekly for relapsing-remitting multiple sclerosis. Her baseline value of the complete blood count, biochemical test, ferritin, vitamin B12, folate, homocysteine levels and thyroid function tests were with in normal limits. Her blood vasculitis marker, brucella agglutination, VDRL, angiotensin converting enzyme and Borrelia Burgdorferi, hepatitis markers, anti-human immunodeficiency virus antibody were negative. She tolerated the therapy well, and no concurrent steroid treatment was given. After 2 years of therapy, she developed depigmented patches on the dorsal aspects of her hands (Fig. 1). The patient gave permission for the publication of the photographs. The therapy was continued despite these skin lesions. Twenty-two months after the appearance of first skin lesions, new depigmented patches occurred on periorificial areas and on chin (Fig. 2). After the appearance of vitiligo lesions on the perioral region and the chin, the laboratory evaluation of the patient was repeated. The free T3 and free T4 levels were normal, whereas the TSH values were above the normal limits (12.97 IU/ml; normal range, 0.35–4.94 IU/ml). She was treated with 0.05% Clobetasone butyrate for the lesions on the periorofacial and chin region, and with 0.05% Clobetasol 17-propionate for the lesions on the both dorsum of the hands. No improvement was observed after the treatment of topical corticosteroid for 1.5 months; there was no any progression in that period also. She was planning to become pregnant; so her IFN beta-1a treatment was terminated and there was a mild decrease in the dimensions of the lesions at the 45th day follow-up. She was treated with levothyroxine 50 mcg/day for hypothyroidism. The free T3 and free T4 levels were normal, while the TSH level was still high (8.27 IU/ml) at 3rd month. The TSH level became in normal limit at the fourth months. The vitiligo lesions significantly improved 3 months post-cessation of IFN beta-1a and were stable in follow-up 6 months. Figure 1 Depigmented patches on the dorsal aspects of both hands.

Blink reflex abnormalities in diabetes mellitus.

Damage of the peripheral nervous system is particularly frequent in diabetes mellitus (DM), but somatic cranial neuropathies usually presenting as mononeuropathies are rare. Oculomotor and facial nerves are among the most commonly affected, whereas the Vth, IXth and Xth cranial nerves are less often affected. While existing neurophysiological tests in the subclinical diagnosis of damage to the peripheral nerve in diabetic patients have advanced, the same does not hold true for the subclinical diagnosis of the central nervous system (CNS). Electrophysiological studies such as the blink reflex was shown to be an effective method for revealing subclinical involvement of cranial nerves in generalised neuropathies.

Evaluating sub-clinical cognitive dysfunction and event-related potentials (P300) in clinically isolated syndrome

ObjectiveThis study investigated the presence of sub-clinical cognitive dysfunction in patients with clinically isolated syndrome (CIS) and the abnormalities of cognitive event-related potentials (ERPs).MethodsSubclinical cognitive dysfunction was assessed in 20 patients with CIS and in 20 healthy controls.ResultsPatients had impairments in verbal learning and long-term memory, evaluating attention, executive function and visuospatial skills, in decreasing order of frequency. SDLT and SIT were the most, and COWAT and BNT were the least affected tests. The N200 and P200 latencies were prolonged, and N100, N200 and P200 amplitudes were reduced in the patients relative to the controls, from the Fz, Cz and Pz electrode positions (p<0.05).ConclusionDetailed cognitive testing is valuable in determining subclinical cognitive dysfunction in CIS patients. ERP abnormalities as well as abnormalities in detailed cognitivetesting in patients with CIS are helpful in the diagnosis of sub-clinical cognitive dysfunction.