Daiva Rastenytė

Specificity of transcranial sonography in parkinson spectrum disorders in comparison to degenerative cognitive syndromes

BackgroundHyperechogenicity of the substantia nigra (SN+), detected by transcranial sonography (TCS), was reported as a characteristic finding in Parkinsons disease (PD), with high diagnostic accuracy values, when compared mainly to healthy controls or essential tremor (ET) group. However, some data is accumulating that the SN + could be detected in other neurodegenerative and even in non-neurodegenerative disorders too. Our aim was to estimate the diagnostic accuracy of TCS, mainly focusing on the specificity point, when applied to a range of the parkinsonian disorders, and comparing to the degenerative cognitive syndromes.MethodsA prospective study was carried out at the Hospital of Lithuanian University of Health Sciences from January until September 2011. Initially, a TCS and clinical examination were performed on 258 patients and 76 controls. The General Electric Voluson 730 Expert ultrasound system was used. There were 12.8% of cases excluded with insufficient temporal bones, and 4.3% excluded with an unclear diagnosis. The studied sample consisted of the groups: PD (n = 71, 33.2%), ET (n = 58, 27.1%), PD and ET (n = 10, 4.7%), atypical parkinsonian syndromes (APS) (n = 3, 1.4%), hereditary neurodegenerative parkinsonism (HDP) (n = 3, 1.4%), secondary parkinsonism (SP) (n = 23, 10.8%), mild cognitive impairment (MCI) (n = 33, 15.4%), dementia (n = 13, 6.1%), and control (n = 71).ResultsThere were 80.3% of PD patients at stages 1 & 2 according to Hoehn and Yahr. At the cut-off value of 0.20 cm2 of the SN+, the sensitivity for PD was 94.3% and the specificity - 63.3% (ROC analysis, AUC 0.891), in comparison to the rest of the cohort. At the cut-off value of 0.26 cm2, the sensitivity was 90% and the specificity 82.4%.The estimations for the lowest specificity for PD, in comparison to the latter subgroups (at the cut-off values of 0.20 cm2 and 0.26 cm2, respectively) were: 0% and 33.3% to APS, 33.3% and 66.7% to HDP, 34.8% and 69.6% to SP, 55.2% and 82.8% to ET, 75% and 91.7% to dementia.ConclusionsThe high sensitivity of the test could be employed as a valuable screening tool. But TCS is more useful as a supplementary diagnostic method, due to the specificity values not being comprehensive.

Association of language dysfunction and age of onset of benign epilepsy with centrotemporal spikes in children

BACKGROUND Language dysfunction in children with benign epilepsy with centrotemporal spikes (BECTS) has been well recognized but data regarding its risk factors are heterogenous. AIMS To assess language function in children with BECTS and its association with the age of epilepsy onset. METHODS We assessed language function in 61 children with BECTS and 35 age and sex-matched controls. Children with BECTS performed significantly worse on all language tasks as compared to controls and overall better language function was positively correlated with older age of the child. Early age at seizure onset demonstrated significant negative correlation with language dysfunction, age below 6 years being related to the lowest performance scores. There was no relationship between the language function and the laterality of epileptic focus, seizure treatment status, or the duration of epilepsy. CONCLUSION Children with BECTS have language difficulties that are more pronounced in younger age group. Despite better language functioning in older children with BECTS, their verbal abilities remain inferior to those of children without epilepsy. Early age at seizure onset is a significant factor predicting worse language functioning in children with BECTS.

Development of the Lithuanian Version of Sniffin’ Sticks 12 Odor Identification Test

Background: Evaluation of smell function is essential especially in cases of gradual deterioration, e.g., in neurodegenerative diseases, where rates of unawareness of the disorder are high and the importance of screening for olfactory dysfunction is increasing. To date, none of the tests for evaluation of olfactory dysfunction has been validated in Lithuania. The aim of the study was to develop a Lithuanian version of Sniffin’ Sticks 12 (SS12) odor identification test. Materials and Methods: The study was performed in 4 stages. The first stage included translation and back-translation from German, pilot group testing and language adaptation of the original SS12 test. In the second stage a survey group of 99 subjects was questioned for familiarity with the descriptors, used in the original version of the test. In the third stage after replacement of the least familiar distracters, a modified version of SS12 was created. Original and modified versions of SS12 were tested on 112 and 119 healthy subjects accordingly. The fourth stage of the study proved necessary as neither of the two SS12 versions turned out to be valid. After another round of replacement of the misleading distracters the second modified version of SS12 was created and it was tested on 115 healthy subjects. Results: Unsatisfactory correct identification rates of less than 75 percent in the same one item (lemon) were observed using both original and modified SS12 versions. With the second modification of distracters of SS12, identification of lemon increased significantly and overcame 75 percent. The decrease of SS12 scores in relation to age was ascertained in the study sample. Gender and smoking status did not prove to be independent predictors of SS12 scores in multiple linear regression analysis. Conclusion: The study presents an olfactory testing tool, which is adapted and modified culturally for use in the Lithuanian population.

Trends and regional inequalities in mortality from stroke in the context of health care reform in Lithuania

BACKGROUND AND OBJECTIVE The objective of the study was to analyze mortality from stroke in Lithuania the context of health care reform with particular interest in urban/rural and regional inequalities. Based on the analysis of trends in mortality, and to detection of break-points over two decades of socioeconomic transition, it focused on the challenges in stroke care provision. MATERIALS AND METHODS The analysis covered the entire country. Information on deaths from 1991 to 2012 was gathered from death certificates held by the Lithuanian Department of Statistics. The joinpoint analysis was used to identify the best-fitting points, wherever a statistically significant change in mortality occurred. Age-standardized mortality rates were calculated for 60 municipalities of Lithuania. RESULTS The positive break-points in mortality from stroke were registered in 2007 for females and 2008 for males, when the increasing trends reversed to the declining. More positive changes occurred in urban areas, where stroke mortality is lower compare to rural since 1996. Considerable inequalities were disclosed among administrative regions of Lithuania: ratio between the highest and the lowest rates in different municipalities reached 4.88 for males and 3.35 for females. CONCLUSIONS There are good reasons to expect the favorable stroke mortality trends observed will follow the same direction in the future. Stroke centers are growing up in their competence while networking is also under the development. The new strategies in stroke care should result not only in the declining mortality rates and numbers of severely handicapped stroke patients, but also in diminishing regional and urban/rural inequalities.

Validation of the EFFECT questionnaire for competence-based clinical teaching in residency training in Lithuania

BACKGROUND AND AIM In 2013, all residency programs at the Lithuanian University of Health Sciences were renewed into a competency-based medical education curriculum. To assess the quality of clinical teaching in residency training, we chose the EFFECT (evaluation and feedback for effective clinical teaching) questionnaire designed and validated at the Radboud University Medical Centre in the Netherlands. The aim of this study was to validate the EFFECT questionnaire for quality assessment of clinical teaching in residency training. MATERIALS AND METHODS The research was conducted as an online survey using the questionnaire containing 58 items in 7 domains. The questionnaire was double-translated into Lithuanian. It was sent to 182 residents of 7 residency programs (anesthesiology reanimathology, cardiology, dermatovenerology, emergency medicine, neurology, obstetrics and gynecology, physical medicine and rehabilitation). Overall, 333 questionnaires about 146 clinical teachers were filled in. To determine the item characteristics and internal consistency (Cronbachs α), the item and reliability analyses were performed. Furthermore, confirmatory factor analysis (CFI) was performed using a model for maximum-likelihood estimation. RESULTS Cronbachs α within different domains ranged between 0.91 and 0.97 and was comparable with the original version of the questionnaire. Confirmatory factor analysis demonstrated satisfactory model-fit with CFI of 0.841 and absolute model-fit RMSEA of 0.098. CONCLUSIONS The results suggest that the Lithuanian version of the EFFECT maintains its original validity and may serve as a valid instrument for quality assessment of clinical teaching in competency-based residency training in Lithuania.

Associations of HLA DRB1 alleles with IgG oligoclonal bands and their influence on multiple sclerosis course and disability status

BACKGROUND AND AIM Oligoclonal bands (OCB) may be associated with the genes of HLA complex, which allows to consider the possible interaction of genetic and immunological factors and its importance in the development and progression of multiple sclerosis (MS). The aim of this study was to evaluate the associations between HLA DRB1 alleles and oligoclonal bands (OCBs) in the disease course and disability of multiple sclerosis (MS) patients. MATERIALS AND METHODS This was a prospective study of 120 patients with MS. HLA DRB1 alleles were genotyped using the polymerase chain reaction. Matched cerebrospinal fluid (CSF) and plasma samples were analyzed using isoelectric focusing and IgG specific immunofixation to test for the presence of intrathecal specific OCB. RESULTS HLA DRB1*08 allele was related to a lower degree of disability. Oligoclonal bands were an independent and significant factor that influenced disability status irrespective of HLA DRB1* 04, *07, *08, *13, *15 and *16 alleles. Age at the onset and duration of the disease were independent and significant factors for MS progression in all logistic regression models with each newly added HLA DRB1 allele. HLA DRB1*08 allele was related to 75% lower odds that relapsing remitting (RR) MS will change to a progressive course MS irrespective of the other factors investigated. Detection of OCBs in the CSF was associated with the higher possibility of RR MS progression in all cases, except when the *08 allele was present. CONCLUSIONS OCBs had an influence on disability status, while HLA DRB1*08 allele was significantly associated with lower possibility that RR MS will change to progressive course MS.

Crucial role of carotid ultrasound for the rapid diagnosis of hyperacute aortic dissection complicated by cerebral infarction: A case report and literature review

Aortic dissection is a life-threatening rare condition that may virtually present by any organ system dysfunction, the nervous system included. Acute cerebral infarction among multiple other neurological and non-neurological presentations is part of this acute aortic syndrome. Rapid and correct diagnosis is of extreme importance keeping in mind the possibility of thrombolytic treatment if a patient with a suspected ischemic stroke arrives to the Emergency Department within a 4.5-h window after symptom onset. Systemic intravenous thrombolysis in the case of an acute brain infarction due to aortic dissection may lead to fatal outcomes. In this neurological emergency it is important to rule out underlying aortic dissection by choosing appropriately quick and accurate diagnostic tool. We aimed to present a prospective follow-up case, where carotid ultrasound examination was the primary key method that led to a correct diagnosis in hyperacute (<24h) Stanford type A aortic dissection presenting as an acute ischemic stroke, and thereafter with a repeated contrast-enhanced computed tomography and transthoracic echocardiography, helped to monitor topography of intravascular processes and hemodynamic properties during the clinical course of a disease, which influenced treatment decisions. Thus, we reviewed the literature mainly focusing on the various neurological aspects associated with aortic dissection.

Associations between peripheral vertigo and gastroesophageal reflux disease

We hypothesize that peripheral vertigo is associated with gastroesophageal reflux disease (GERD). Two mechanisms could be considered – gastric acids may directly irritate the respiratory mucosa and cause inflammation, or Helicobacter pylori (H. pylori) could be present and cause local infection. Reflux material (Hydrochloric acid (HCl) and pepsin) could get into the middle ear via Eustachian tube and affect osseous structures directly. Disturbance of ossicles could cause tinnitus, which is more common for peripheral vertigo. H. pylori could also get in the esophagus and in the upper respiratory tract via gastroesophageal reflux, and could cause tympanosclerosis and fixation of ossicles. In our study group, 120 of 153 (78.4%) patients had gastroesophageal reflux disease (GERD). Diagnostic tests of H. pylori (rapid urease test or blood antibody test) were performed for 96 of 120 (80%) patients with GERD and were found positive for 32 of 96 (33.3%) patients. Peripheral vertigo was present in 93 of 120 (77.6%) patients with GERD compared to 33 of 126 (26%) patients without GERD (χ(2)=9.016, p=0.003). H. pylori and peripheral vertigo coexisted in 26 of 126 patients (20.6%) (OR 1.36; 95% CI 0.49-3.74, p=0.55). Our study demonstrated statistically significant association between peripheral vertigo and GERD but not between peripheral vertigo and H. pylori. Further more extensive investigations are needed in order to explore our hypothesis.

Transcranial Ultrasonographic Image Analysis System for Decision Support in Parkinson Disease: Transcranial US Image Analysis System for Parkinson Disease

Transcranial ultrasonography (US) is a relatively new neuroimaging modality proposed for early diagnostics of Parkinson disease (PD). The main limitation of transcranial US image‐based diagnostics is a high degree of subjectivity caused by low quality of the transcranial images. The article presents a developed image analysis system and evaluates the potential of automated image analysis on transcranial US.

Detection of aquaporin-4 antibodies for patients with CNS inflammatory demyelinating diseases other than typical MS in Lithuania

Abstract Objectives Neuromyelitis optica (NMO) is frequently associated with aquaporin‐4 autoantibodies (AQP4‐Ab); however, studies of NMO in Lithuania are lacking. Therefore, the main objective of our study is to assess positivity for AQP4‐Ab in patients presenting with inflammatory demyelinating central nervous system (CNS) diseases other than typical multiple sclerosis (MS) in Lithuania. Materials and methods Data were collected from the two largest University hospitals in Lithuania. During the study period, there were 121 newly diagnosed typical MS cases, which were included in the MS registry database. After excluding these typical MS cases, we analyzed the remaining 29 cases of other CNS inflammatory demyelinating diseases, including atypical MS (n = 14), acute transverse myelitis, TM (n = 8), acute disseminated encephalomyelitis, ADEM (n = 3), clinically isolated syndrome, CIS (n = 2), atypical optic neuritis, ON (n = 1), and NMO (n = 1). We assessed positivity for AQP4‐Ab for the 29 patients and evaluated clinical, laboratory, and instrumental differences between AQP4‐Ab seropositive and AQP4‐Ab seronegative patient groups. Results AQP4‐Ab test was positive for three (10.3%) patients in our study, with initial diagnoses of atypical MS (n = 2) and ADEM (n = 1). One study patient was AQP4‐Ab negative despite being previously clinically diagnosed with NMO. There were no significant clinical, laboratory, or instrumental differences between the groups of AQP4‐Ab positive (3 [10.3%]) and negative (26 [89.7%]) patients. Conclusions AQP4‐Ab test was positive for one‐tenth of patients with CNS inflammatory demyelinating diseases other than typical MS in our study. AQP4‐Ab testing is highly recommended for patients presenting with not only TM and ON but also an atypical course of MS and ADEM.