PROGNOSTIC VALUE OF MOTOR EVOKED POTENTIALS IN MOTOR FUNCTION RECOVERY OF UPPER LIMB AFTER STROKE

Objective: To determine the prognostic value of clinical assessment and motor evoked potentials for upper limb strength and functional recovery after acute stroke, and to establish the possible use of motor evoked potentials in rehabilitation. Design: A prospective study. Subjects: Fifty-two patients with hemiparesis were enrolled one month post-stroke; 38 patients concluded the study at 12 months. Methods: Motor evoked potentials were recorded at baseline and after one month. Upper limb muscular strength (Medical Research Council Scale, MRC) and functional tests (Frenchay Arm Test, Barthel Index) were used as dependent outcome variables 12 months later. Motor evoked potentials were classified as present or absent. Predictive values of motor evoked potentials and MRC were evaluated. Results: At 12 months, patients with baseline recordable motor evoked potentials showed a good functional recovery (positive predictive value 94%). The absence of motor evoked potentials did not exclude muscular strength recovery (negative predictive value 95%). Motor evoked potentials had a higher positive predictive value than MRC only in patients with MRC < 2. Conclusion: Motor evoked potentials could be a supportive tool to increase the prognostic accuracy of upper limb motor and functional outcome in hemiparetic patients, especially those with severe initial paresis (MRC < 2) and/or with motor evoked potentials absent in the post-stroke acute phase

Does a combination of ≥2 abnormal tests vs. the ERC-ESICM stepwise algorithm improve prediction of poor neurological outcome after cardiac arrest? A post-hoc analysis of the ProNeCA multicentre study.

BACKGROUND Bilaterally absent pupillary light reflexes (PLR) or N20 waves of short-latency evoked potentials (SSEPs) are recommended by the 2015 ERC-ESICM guidelines as robust, first-line predictors of poor neurological outcome after cardiac arrest. However, recent evidence shows that the false positive rates (FPRs) of these tests may be higher than previously reported. We investigated if testing accuracy is improved when combining PLR/SSEPs with malignant electroencephalogram (EEG), oedema on brain computed tomography (CT), or early status myoclonus (SM). METHODS Post-hoc analysis of ProNeCA multicentre prognostication study. We compared the prognostic accuracy of the ERC-ESICM prognostication strategy vs. that of a new strategy combining ≥2 abnormal results from any of PLR, SSEPs, EEG, CT and SM. We also investigated if using alternative classifications for abnormal SSEPs (absent-pathological vs. bilaterally-absent N20) or malignant EEG (ACNS-defined suppression or burst-suppression vs. unreactive burst-suppression or status epilepticus) improved test sensitivity. RESULTS We assessed 210 adult comatose resuscitated patients of whom 164 (78%) had poor neurological outcome (CPC 3-5) at six months. FPRs and sensitivities of the ≥2 abnormal test strategy vs. the ERC-ESICM algorithm were 0[0-8]% vs. 7 [1-18]% and 49[41-57]% vs. 63[56-71]%, respectively (p < .0001). Using alternative SSEP/EEG definitions increased the number of patients with ≥2 concordant test results and the sensitivity of both strategies (67[59-74]% and 54[46-61]% respectively), with no loss of specificity. CONCLUSIONS In comatose resuscitated patients, a prognostication strategy combining ≥2 among PLR, SSEPs, EEG, CT and SM was more specific than the 2015 ERC-ESICM prognostication algorithm for predicting 6-month poor neurological outcome

Course and Lethality of SARS-CoV2 Epidemic in Nursing Homes after Vaccination in Florence, Italy

Evidence on the effectiveness of SARS-CoV-2 vaccines in nursing home (NHs) residents is limited. We examined the impact of the BNT162b2 mRNA SARS-CoV-2 vaccine on the course of the epidemic in NHs in the Florence Health District, Italy, before and after vaccination. Moreover, we assessed survival and hospitalization by vaccination status in SARS-CoV-2-positive cases occurring during the post-vaccination period. We calculated the weekly infection rates during the pre-vaccination (1 October–26 December 2020) and post-vaccination period (27 December 2020–31 March 2021). Cox analysis was used to analyze survival by vaccination status. The study involved 3730 residents (mean age 84, 69% female). Weekly infection rates fluctuated during the pre-vaccination period (1.8%–6.5%) and dropped to zero during the post-vaccination period. Nine unvaccinated (UN), 56 partially vaccinated (PV) and 35 fully vaccinated (FV) residents tested SARS-CoV-2+ during the post-vaccination period. FV showed significantly lower hospitalization and mortality rates than PV and UV (hospitalization: FV 3%, PV 14%, UV 33%; mortality: FV 6%, PV 18%, UV 56%). The death risk was 84% and 96% lower in PV (HR 0.157, 95%CI 0.049–0.491) and FV (HR 0.037, 95%CI 0.006–0.223) versus UV. SARS-CoV-2 vaccination was followed by a marked decline in infection rates and was associated with lower morbidity and mortality among infected NH residents

Direct-acting antivirals and hepatocellular carcinoma in chronic hepatitis C: A few lights and many shadows

With the introduction of direct-acting antiviral agents (DAA), the rate of sustained virological response (SVR) in the treatment of hepatitis C virus (HCV) has radically improved to over 95%. Robust scientific evidence supports a beneficial role of SVR after interferon therapy in the progression of cirrhosis, resulting in a decreased incidence of hepatocellular carcinoma (HCC). However, a debate on the impact of DAAs on the development of HCC is ongoing. This review aimed to analyse the scientific literature regarding the risk of HCC in terms of its recurrence and occurrence after the use of DAAs to eradicate HCV infection. Among 11 studies examining HCC occurrence, the de novo incidence rate ranged from 0 to 7.4% (maximum follow-up: 18 mo). Among 18 studies regarding HCC recurrence, the rate ranged from 0 to 54.4% (maximum "not well-defined" followup: 32 mo). This review highlights the major difficulties in interpreting data and reconciling the results of the included studies. These difficulties include heterogeneous cohorts, potential misclassifications of HCC prior to DAA therapy, the absence of an adequate control group, short follow-up times and different kinds of follow-up. Moreover, no clinical feature-based scoring system accounts for the molecular characteristics and pathobiology of the tumours. Nonetheless, this review does not suggest that there is a higher rate of de novo HCC occurrence or recurrence after DAA therapy in patients with previous HCV infection. \ua9 2018 The Author(s). Published by Baishideng Publishing Group Inc. All rights reserved

The role of early electroclinical assessment in improving the evaluation of patients with disorders of consciousness

We all share the need to optimise the evaluation of patients with disorders of consciousness (DOC), given the high rate of misdiagnosis of vegetative state based on clinical examination. We believe that one way to do this is to optimise assessment from the early stages, in order to reduce discontinuity between the hospital and rehabilitation phases. While clinical observation remains the "gold standard" for the diagnostic assessment of patients with DOC, neurophysiological investigations (electroencephalography, short latency evoked potentials and event-related potentials) could help to further understanding of the pathophysiology underlying the state of unresponsiveness, differentiate coma from other apparently similar conditions (i.e., locked-in and locked-in-like syndromes), and potentially integrate prognostic evaluation with monitoring of the evolution of the clinical state. Moreover, these techniques have the considerable advantage of being available at the bedside. Discontinuity between the hospital and rehabilitation phases is rightly considered to be one of the critical points in the assessment of patients with DOC. In our view, a continuum of expert neurological assessment that begins with monitoring of the acute phase (focusing on evolution of primary brain damage and secondary complications) and follows through to the patient’s discharge from the intensive care unit (focusing on the pathophysiology of brain damage and prognostication based on clinical, neuroimaging and neurophysiological tests) could help to: i) optimise the rehabilitation programme according to the expectations of recovery; ii) provide a basis for comparison with subsequent periodic re-evaluations; iii) ensure uniformity of assessment regardless of the heterogeneity of care facilities; and iv) characterise a subset of patients who, showing discrepancies between neurophysiological tests and clinical status, are more likely to undergo unexpected recovery

Spatial and Temporal Gait Characteristics in Patients Admitted to a Neuro-Rehabilitation Department with Age-Related White Matter Changes: A Gait Analysis and Clinical Study

Background: Patients with age-related white matter changes (ARWMC) frequently present a gait disorder, depression and cognitive impairment. Our aims are to define which alterations in the gait parameters are associated with motor or neuro-psychological impairment and to assess the role of motor, mood or cognitive dysfunction in explaining the variance of the gait parameters. Methods: Patients with gait disorders admitted to a Neuro-rehabilitation Department, affected by vascular leukoencephalopathy who had ARWMC confirmed by a brain MRI, were consecutively enrolled, classified by a neuroradiological scale (Fazekas 1987) and compared to healthy controls. We excluded subjects unable to walk independently, subjects with hydrocephalus or severe aphasia, with orthopaedic and other neurological pathologies conditioning the walking pattern. Patients and controls were assessed by clinical and functional scales (Mini Mental State Examination, Geriatric Depression Scale, Nevitt Motor Performance Scale, Berg Balance Scale, Functional Independence Measure), and computerised gait analysis was performed to assess the spatial and temporal gait parameters in a cross-sectional study. Results: We recruited 76 patients (48 males, aged 78.3 ± 6.2 years) and 14 controls (6 males, aged 75.8 ± 5 years). In the multiple regression analysis, the gait parameter with overall best model summary values, associated with the ARWMC severity, was the stride length even after correction for age, sex, weight and height (R2 = 0.327). The motor performances justified at least in part of the gait disorder (R2 change = 0.220), but the mood state accounted independently for gait alterations (R2 change = 0.039). The increase in ARWMC severity, the reduction of motor performance and a depressed mood state were associated with a reduction of stride length (R = 0.766, R2 = 0.587), reduction of gait speed (R2 = 0.573) and an increase in double support time (R2 = 0.421). Conclusion: The gait disorders in patients with ARWMC are related to motor impairment, but the presence of depression is an independent factor for determining gait alterations and functional status. These data pave the way for longitudinal studies, including gait parameters, to quantitatively assess gait changes after treatment or to monitor the natural progression of the gait disorders

Data on multimodal approach for early poor outcome (Cerebral Performance Categories 3-5) prediction after cardiac arrest

The data presented in this article are related to our research article entitled ‘Neurophysiological and neuroradiological multimodal approach for early poor outcome prediction after cardiac arrest’ (Scarpino et al., 2018) [1]. We reported two additional analyses, including results gathered from somatosensory evoked potentials(SEPs), brain computed tomography(CT) and electroencephalography(EEG) performed on 183 subjects within the first 24 h after cardiac arrest(CA). In the first analysis, we considered the Cerebral Performance Categories(CPC) 3, 4 and 5a,b (severe disability, unresponsive wakefulness state, neurological death and non-neurological death, respectively) as poor outcomes. In the second analysis, patients that died from non-neurological causes (CPC 5b) were excluded from the analysis. Concerning the first analysis, bilateral absent/absent-pathologic(AA/AP) cortical SEPs predicted poor outcome with a sensitivity of 49.3%. A Grey Matter/White Matter(GM/WM) ratio <1.21 predicted poor outcome with a sensitivity of 41.7%. Isoelectric/burst-suppression EEG patterns predicted poor outcome with a sensitivity of 33.5%. If at least one of these poor prognostic patterns was present, the sensitivity for an ominous outcome increased to 60.9%. Concerning the second analysis, AA/AP cortical SEPs predicted poor outcome with a sensitivity of 52.5%. GM/WM ratio <1.21 predicted poor outcome with a sensitivity of 50.4%. Isoelectric/burst-suppression EEG patterns predicted poor outcome with a sensitivity of 39.8%