Adherence issues related to sublingual immunotherapy as perceived by allergists

Objectives: Sublingual immunotherapy (SLIT) is a viable alternative to subcutaneous immunotherapy to treat allergic rhinitis and asthma, and is widely used in clinical practice in many European countries. The clinical efficacy of SLIT has been established in a number of clinical trials and meta-analyses. However, because SLIT is self-administered by patients without medical supervision, the degree of patient adherence with treatment is still a concern. The objective of this study was to evaluate the perception by allergists of issues related to SLIT adherence. Methods: We performed a questionnaire-based survey of 296 Italian allergists, based on the adherence issues known from previous studies. The perception of importance of each item was assessed by a VAS scale ranging from 0 to 10. Results: Patient perception of clinical efficacy was considered the most important factor (ranked 1 by 54% of allergists), followed by the possibility of reimbursement (ranked 1 by 34%), and by the absence of side effects (ranked 1 by 21%). Patient education, regular follow-up, and ease of use of SLIT were ranked first by less than 20% of allergists. Conclusion: These findings indicate that clinical efficacy, cost, and side effects are perceived as the major issues influencing patient adherence to SLIT, and that further improvement of adherence is likely to be achieved by improving the patient information provided by prescribers. © 2010 Scurati et al, publisher and licensee Dove Medical Press Ltd

Action observation improves sit-to-walk in patients with Parkinson's disease and freezing of gait. Biomechanical analysis of performance

Introduction: Freezing of gait (FoG) is one of the most disabling gait disorders in Parkinson's disease (PD), reflecting motor and cognitive impairments, mainly related to dopamine deficiency. Recent studies investigating kinematic and kinetic factors affecting gait in these patients showed a postural instability characterized by disturbed weight-shifting, inappropriate anticipatory postural adjustment, worse reactive postural control, and a difficulty executing complex motor tasks (i.e. sit-to-walk). These symptoms are difficult to alleviate and not very responsive to Levodopa. For this reason, additional therapeutic actions based on specific therapeutic protocols may help patients with their daily lives. We conducted a randomized control trial aimed to test if two clinical protocols for PD patients with FoG were effective to improve postural control. Methods: Rehabilitation protocols, conceived to improve gait, were based on learning motor exercises with the Action Observation plus Sonification (AOS) technique, or by the use of external sensory cues. We collected biomechanical data (Center of Mass COM, Center of Pressure COP, and moving timings), using the sit-to-walk task as a measure of motor and gait performance. Results: Kinetic and kinematic data showed that when treatment effects consolidate, patients treated with AOS protocol are more efficient in merging subsequent motor tasks (sit-to-stand and gait initiation), and diminished the total moving time and the area of the COP positions. Conclusion: We demonstrated for the first time that PD patients with FoG treated with an AOS protocol aimed at relearning appropriate gait patterns increased balance control and re-acquired more efficient postural control

Acute myelitis as presenting symptom of HIV-HTLV-1 co-infection

9noA 21-year-old woman presented with acute-onset spastic paraparesis. The MRI spinal scan revealed a contrast-enhanced T2 hyperintensity between C5-T2. The most common neurotropic pathogens were excluded by first level tests. Under suspicion of an acute immune-mediated myelitis, a corticosteroid therapy was administered. However, a seropositivity for both human immunodeficiency virus (HIV) type 1 and human T-lymphotropic virus (HTLV) subsequently emerged. An antiretroviral therapy was started while steroids discontinued. Patient's clinical conditions remained unchanged. HIV-HTLV-1 co-infection should be included in the differential diagnosis of any acute myelitis, even in patients with a preserved immune status and no risk factors.reservedmixedCucca, A; Stragapede, L.; Antonutti, L.; Catalan, M.; Caracciolo, I.; Valentinotti, R.; Granato, A.; D’Agaro, P.; Manganotti, P.Cucca, Alberto; Stragapede, Lara; Antonutti, L.; Catalan, Mauro; Caracciolo, Ilaria; Valentinotti, R.; Granato, Antonio; D'Agaro, Pierlanfranco; Manganotti, Paol

Ischemic Volume and Neurological Deficit: Correlation of Computed Tomography Perfusion with the National Institutes of Health Stroke Scale Score in Acute Ischemic Stroke

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is the most adopted stroke patients' evaluation tool in emergency settings to assess the severity of stroke and to determine the patients' eligibility for specific treatments. Computed tomography perfusion (CTP) is crucial to identify salvageable tissue that can benefit from the reperfusion treatment. The aim of this study is to identify the relation between the NIHSS scores and the hypoperfused volumes evaluated by CTP in patients with hyperacute ischemic stroke. METHODS: This retrospective study was conducted on 105 patients with ischemic stroke who underwent NIHSS assessment and CTP in the hyperacute phase. Hypoperfused volume was evaluated by CTP maps processed with semi-automatic algorithm. An analysis was conducted to determine the degree of correlation between the NIHSS scores and the ischemic lesion volumes and to investigate the relation between the anterior and the posterior circulation strokes, as well as between the right and the left hemispheric strokes. RESULTS: A significant correlation was found between ischemic volume and NIHSS score at baseline (r\u2009=\u2009.82; P\u2009<\u2009.0001) in the entire cohort. A high NIHSS-volume correlation was identified in the anterior circulation stroke (r\u2009=\u2009.76; P\u2009<\u2009.0001); whereas, it was nonsignificant in the posterior circulation stroke. NIHSS score and volume correlated for the left and the right hemispheric strokes (r\u2009=\u2009.83 and .81; P\u2009<\u2009.0001), showing a slightly higher slope in the left. CONCLUSION: This study showed a strong correlation between the baseline NIHSS score and the ischemic volume estimated by CTP. We confirmed that NIHSS is a reliable predictor of perfusion deficits in acute ischemic stroke. CTP allows fast imaging assessment in the hyperacute phase. The results highlight the importance of these diagnostic tools in the assessment of stroke severity and in acute decision-making

Brain oscillatory activity and CT perfusion in hyper-acute ischemic stroke

OBJECTIVES: The combined use of perfusion neuroimaging and brain oscillatory activity may provide a better clinical picture of neurovascular coupling of the injured area in ischemic stroke. The aim is to assess stroke-related topographic electroencephalography (EEG) changes during the earliest phase of ischemic stroke and to compare them with hypoperfusion identified by computer tomography perfusion (CTP). PATIENTS AND METHODS: The study included 15 patients with ischemic stroke, who underwent both CTP and EEG recording within 4.5\u202fh. Topographic representation of power for each band was calculated and compared with hypoperfusion areas estimated by CTP maps. RESULTS: Predominance of slow delta frequencies was found in all patients. The main finding is the agreement between slow rhythms hemispheric prevalence on EEG maps and cerebral hypoperfusion area identified using CTP. CONCLUSION: The results of this preliminary study show that the combined use of EEG and CTP, as highly available techniques, in acute ischemic stroke may be helpful in clinical practice and provide information about functional and metabolic aspects of brain involvement. The joint use of these methodologies may give a better clinical insight of the functionality of injured area in the hyperacute phase

Wake-up stroke and CT perfusion: effectiveness and safety of reperfusion therapy

OBJECTIVE: Ischemic stroke is a neuroemergency condition highly treatable with thrombolysis and thrombectomy. Recently, observational studies have brought insights into clinical and imaging characteristics of wake-up stroke, which interested up to 25% of ischemic stroke patients. In clinical practice, wake-up strokes are usually not considered for reperfusion therapy. The aim of this study was to investigate the use CT perfusion imaging in patients with wake-up stroke and to assess the effect of neuroimaging information provided by CT perfusion maps on the efficacy and safety of thrombolysis and thrombectomy. PATIENTS AND METHOD: We studied 22 wake-up stroke (WUS) patients (13F/9M mean age) who underwent reperfusion therapy after the eligibility assessed by the CT perfusion imaging (<\u200950% core-to-penumbra ratio and negative CT perfusion). RESULTS: Mean National Institutes of Health Stroke Scale (NIHSS) was 8.1\u2009\ub1\u20094.9 at admission while 3.3\u2009\ub1\u20095.1 at discharge, significantly different from admission (p\u2009<\u20090.001). As many as ten patients had mRS lower than 3 at discharge. Intracranial hemorrhage occurred in five patients and caused symptoms worsening only in two patients (decrease of NIHSS score of 4 points) of which one patient died. CONCLUSION: The main finding of this study is that wake-up stroke with adequate selection by CT perfusion may benefit reperfusion treatment

Novel quantitative approach for crossed cerebellar diaschisis detection in acute ischemic stroke using CT perfusion

Purpose: Crossed cerebellar diaschisis (CCD) is a common finding in hyper-acute ischemic stroke, related to supratentorial dysfunction of the contralateral hemisphere. Several studies investigated a possible relationship between CCD and clinical outcomes but still no evidence emerged. We proposed a novel quantitative whole cerebellum analysis using CT perfusion (CTP) imaging to investigate the relationship between CCD and stroke severity, hypoperfused volume and outcome measures. Methods: 55 patients with supratentorial ischemic stroke who underwent CTP evaluation within 4.5 h since symptom onset were enrolled. CCD was evaluated by CTP image-processing and by calculating the mean transit time (MTT)-map asymmetry index in the whole cerebellum. MTT asymmetry correlation with ischemic volume and clinical outcomes was investigated. Results: MTT asymmetry was found in most of the included patients and significantly correlated with NIH Stroke Scale (NIHSS) score at baseline and CTP ischemic volume. MTT asymmetry was significantly correlated with hemorrhagic transformation, NIHSS and modified Rankin Scale (mRS) score on discharge in treated patients. Conclusions: CCD was detectable by CTP in acute supratentorial ischemic stroke by processing the whole cerebellum volume. CCD perfusion asymmetry was significantly correlated with neurological and perfusion deficit on admission as well as with clinical outcomes in treated patients

Spontaneous Coronary Artery Dissection Across the Health Care Pathway: A National, Multicenter, Patient‐Informed Investigation

Background Clinical practice guidelines for the management and convalescence of patients with spontaneous coronary artery dissection (SCAD) have yet to be developed. The targeted content, delivery, and outcomes of interventions that benefit this population remain unclear. Patient‐informed data are required to substantiate observational research and provide evidence to inform and standardize clinical activities. Methods and Results Patients diagnosed with SCAD (N=89; 86.5% women; mean age, 53.2 years) were purposively selected from 5 large tertiary care hospitals. Patients completed sociodemographic and medical questionnaires and participated in an interview using a patient‐piloted semistructured interview guide. Interviews were transcribed and subjected to framework analysis using inductive and then deductive coding techniques. Approximately 1500 standard transcribed pages of interview data were collected. Emotional distress was the most commonly cited precipitating factor (56%), with an emphasis on anxiety symptoms. The awareness and detection of SCAD as a cardiac event was low among patients (35%) and perceived to be moderate among health care providers (55%). Health care providers' communication of the prognosis and self‐management of SCAD were perceived to be poor (79%). Postevent psychological disorders among patients were evident (30%), and 73% feared recurrence. Short‐ and longer‐term follow‐up that was tailored to patients' needs was desired (72%). Secondary prevention programming was recommended, but there were low completion rates of conventional cardiac rehabilitation (48%), and current programming was deemed inadequate. Conclusions This early‐stage, pretrial research has important implications for the acute and long‐term management of patients with SCAD. Additional work is required to validate the hypotheses generated from this patient‐oriented research

A Big-Data Variational Bayesian Framework for Supporting the Prediction of Functional Outcomes in Wake-Up Stroke Patients

Prognosis in Wake-up ischemic stroke (WUS) is important for guiding treatment and rehabilitation strategies, in order to improve recovery and minimize disability. For this reason, there is growing interest on models to predict functional recovery after acute ischemic events in order to personalize the therapeutic intervention and improve the final functional outcome. The aim of this preliminary study is to evaluate the possibility to predict a good functional outcome, in terms of modified Rankin Scale (mRS 64 2), in thrombolysis treated WUS patients by Bayesian analysis of clinical, demographic and neuroimaging data at admission. The study was conducted on 54 thrombolysis treated WUS patients. The Variational Bayesian logistic regression with Automatic Relevance Determination (VB-ARD) was used to produce model and select informative features to predict a good functional outcome (mRS 64 2) at discharge. The produced model showed moderately high 10\ua0 7\ua05-fold cross validation accuracy of 71% to predict outcome. The sparse model highlighted the relevance of NIHSS at admission, age, TACI stroke syndrome, ASPECTs, ischemic core CT Perfusion volume, hypertension and diabetes mellitus. In conclusion, in this preliminary study we assess the possibility to model the prognosis in thrombolysis treated WUS patients by using VB ARD. The identified features related to initial neurological deficit, history of diabetes and hypertension, together with necrotic tissue relate ASPECT and CTP core volume neuroimaging features, were able to predict outcome with moderately high accuracy