Mayo Clinic Cases in Neuroimmunology

2021 ◽  
Author(s):  
Andrew McKeon ◽  
B. Mark Keegan ◽  
W. Oliver Tobin
Keyword(s):  
Randomized Clinical Trials ◽  
Demyelinating Disease ◽  
Imaging Techniques ◽  
Clinical History ◽  
Test Results ◽  
Neurologic Disorders ◽  
Immune Molecule ◽  
Board Review ◽  
Video Material ◽  
Diagnostic Pitfalls

In the past 2 decades, diagnostics and therapeutics in neuroimmunology have rapidly evolved and increased in complexity. Diagnosis is assisted by various laboratory and advanced imaging techniques. Randomized clinical trials in multiple sclerosis and neuromyelitis optica, and smaller studies for rarer autoimmune diseases, have led to distinct immune molecule–targeted and mechanism-specific therapies. The fields of cerebrovascular medicine, neurooncology, and neuroinfectious diseases have not remained static either. All of these gains present a challenge, however, in that early and accurate neurologic diagnosis is more important than ever. In our experience, some diagnostic pitfalls lie in the interpretation of test results and images without reference to the nuances of the clinical history and examination. Although some things change (eg, technology), other things never change (eg, clinical common sense). The 83 case-based chapters focus on key components of the history, examination and test findings, and differential diagnosis, although we also reference treatment approaches extensively throughout. To bring some form to this extensive repertoire of cases, the book is divided into 3 sections covering central nervous system demyelinating disease, autoimmune neurologic disorders, and others. Illustrations include imaging and, where relevant, pathologic images and video material. Board review–style questions are also provided.

scholarly journals Cardiotoxic effects and myocardial injury: the search for a more precise definition of drug cardiotoxicity

2021 ◽  
Vol 59 (1) ◽  
pp. 51-57
Author(s):  
Daniela Maria Cardinale ◽  
Martina Zaninotto ◽  
Carlo Maria Cipolla ◽  
Claudio Passino ◽  
Mario Plebani ◽  
...  
Keyword(s):  
Early Detection ◽  
Myocardial Injury ◽  
Randomized Clinical Trials ◽  
Imaging Techniques ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Cardiac Imaging Techniques ◽  
Ventricular Ejection Fraction ◽  
Early Evaluation ◽  
Definition Of

AbstractDrug-induced cardiotoxicity is a major clinical problem; cardiotoxic drugs may induce both cardiac dysfunction and myocardial injury. Several recent studies reported that cardiac troponins measured with high-sensitivity methods (hs-cTn) can enable the early detection of myocardial injury related to chemotherapy or abuse of drugs that are potentially cardiotoxic. Several authors have some concerns about the standard definition of cardiotoxicity, in particular, regarding the early evaluation of chemotherapy cardiotoxicity in cancer patients. Several recent studies using the hs-cTn assay indicate that myocardial injury may precede by some months or years the diagnosis of heart failure (HF) based on the evaluation of left ventricular ejection fraction (LVEF). Accordingly, hs-cTn assay should considered to be a reliable laboratory test for the early detection of asymptomatic or subclinical cardiotoxic damage in patients undergoing cancer chemotherapy. In accordance with the Fourth Universal Definition of Myocardial Infarction and also taking into account the recent experimental and clinical evidences, the definition of drug-cardiotoxicity should be updated considering the early evaluation of myocardial injury by means of hs-cTn assay. It is conceivable that the combined use of hs-cTn assay and cardiac imaging techniques for the evaluation of cardiotoxicity will significantly increase both diagnostic sensitivity and specificity, and also better prevent chemotherapy-related left ventricular (LV) dysfunction and other adverse cardiac events. However, large randomized clinical trials are needed to evaluate the cost/benefit ratio of standardized protocols for the early detection of cardiotoxicity using hs-cTn assay in patients receiving chemotherapy for malignant diseases.

Abstract P391: Marine N-3 Fatty Acids Reduce Atherosclerosis Cardiovascular Disease: A Systemic Review and Meta-analysis of Clinical Trials

Circulation ◽  
2013 ◽  
Vol 127 (suppl_12) ◽  
Author(s):  
Akira Sekikawa ◽  
Nobutake Hirooka ◽  
Abhishek Vishnu ◽  
Vashudha Ahuja ◽  
Emmanuel Sampene ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Fatty Acids ◽  
Clinical Trials ◽  
Randomized Clinical Trials ◽  
Imaging Techniques ◽  
Meta Analysis ◽  
Quantitative Information ◽  
Systemic Review ◽  
Cochrane Library ◽  
Cardiac Imaging Techniques

Introduction: Although marine n-3 fatty acids are believed to be cardioprotective through their anti-arrhythmic, anti-thrombotic, anti-atherogenic and other effects, results from recent meta-analyses of marine n-3 fatty acids on cardiovascular disease (CVD) are controversial. We performed a meta-analysis of marine n-3 fatty acids on CVD outcomes in randomized clinical trials (RCTs) to test the hypothesis that marine n-3 fatty acids are anti-atherogenic. We also tested the hypothesis that such benefit is dose-dependent. Methods: A systematic review of English language articles using PubMed, EMBASE and Cochrane Library through Aug 2012 was performed selecting RCTs evaluating the effect of marine n-3 fatty acids intake for 2 years or more on cardiovascular diseases, coronary disease, arteriosclerosis, cardiac imaging techniques, and carotid artery ultrasound. Descriptive and quantitative information was extracted. Odds ratios were calculated for cardiac event outcome. Correlation coefficients were obtained from studies of which outcome is intima-media thickness (IMT) and coronary lumen diameter (CD). We converted the estimates into a single effect size; the log odds ratio and its corresponding standard error. Results: Of 14,236 citations retrieved, 13 studies were selected, including studies reporting IMT (n=3) and CD (n=2) and major CVD events (n=8). Overall, marine n-3 fatty acids significantly reduced atherosclerotic CVD (RR 0.94: 95%CI 0.90 to 0.99, p<0.05). There was no evidence of heterogeneity (p=0.65) or publication bias (p=0.37, Begg’s test). A sub-analysis among 8 studies of major CVD events showed the similar results (RR 0.94: 95% CI 0.89 to 0.99, p<0.05). Another sub-analysis among 4 studies excluding sudden cardiac death as an outcome showed RR of 0.91 (95% CI 0.82 to 1.02, p=0.097). A meta-regression analysis shows that dose of marine n-3 fatty acids was inversely associated with CVD outcome, although the association was not statistically significant (p=0.06). Conclusions: The result of our meta-analysis supports a modest anti-atherogenic effect of marine n-3 fatty acids. This benefit may be proportional to the amount of marine n-3 fatty acids consumed.

scholarly journals Cobalamin (vitamin B12) deficiency detection by urinary methylmalonic acid quantitation

Blood ◽  
1982 ◽  
Vol 59 (6) ◽  
pp. 1128-1131 ◽  
Author(s):  
EJ Norman ◽  
OJ Martelo ◽  
MD Denton
Keyword(s):  
Methylmalonic Acid ◽  
Megaloblastic Anemia ◽  
Vitamin B12 Deficiency ◽  
Cobalamin Deficiency ◽  
Clinical Test ◽  
Test Results ◽  
Neurologic Disorders ◽  
Schilling Test ◽  
B12 Deficiency ◽  
And Function

Abstract A study was made to assess the value of cobalamin deficiency detection through quantitation of urinary methylmalonic acid (MMA). Urinary MMA was measured in 1118 patients suffering from megaloblastic anemia, other anemias, elevated red cell mean corpuscular volume, or unexplained neurologic disorders. Patients without proven cobalamin deficiency had urinary MMA levels less than 20 micrograms/ml. All patients (n = 27) confirmed to have cobalamin deficiency showed MMA levels greater than 20 micrograms/ml. Data are presented showing the Schilling test results, the comparison of serum cobalamin to urinary MMA levels, and other basic hematologic data. MMA levels are a good indication of cobalamin distribution and function since they are directly related to a cobalamin-dependent metabolic pathway. With rapid, reliable quantitation by mass spectrometry, urinary MMA can now be a useful clinical test.

The Utility of an Occupational Contact Dermatitis Patch Test Database in the Analysis of Workplace Prevention Activities in Toronto, Canada

2020 ◽  
Author(s):  
D Linn Holness ◽  
Irena Kudla ◽  
Joel G DeKoven ◽  
Sandra Skotnicki
Keyword(s):  
Contact Dermatitis ◽  
Patch Test ◽  
Skin Diseases ◽  
Health And Safety ◽  
Clinical Information ◽  
Clinical History ◽  
Surveillance Systems ◽  
Test Results ◽  
Occupational Contact Dermatitis ◽  
Occupational Contact

Abstract Background Occupational skin diseases are common suggesting that there are still gaps in workplace prevention. Patch test surveillance systems provide an opportunity to collect work related information in addition to clinical information and patch test results. Objectives To examine 5 years of data related to workplace prevention by industry sector in a patch test surveillance database for workers with a diagnosis of occupational contact dermatitis. Methods The study was approved by the Research Ethics Board of St Michael’s Hospital. Information including demographics, clinical history, healthcare utilization, and workplace characteristics and prevention practices in addition to patch test results was collected from consenting patients. Results Workers in the healthcare and manufacturing sectors were more likely to report workplace training including skin protection training, whereas those in services and construction were less likely to report training. Conclusions Collecting basic workplace information with patch test surveillance databases can inform the occupational health and safety system about prevention practices in the workplace and identify areas for focussed intervention.

Distinguishing primary central nervous system lymphoma from other central nervous system diseases: a neurosurgical perspective on diagnostic dilemmas and approaches

2006 ◽  
Vol 21 (5) ◽  
pp. 1-7 ◽  
Author(s):  
Matthew A. Hunt ◽  
Kristoph Jahnke ◽  
Tulio P. Murillo ◽  
Edward A. Neuwelt
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Demyelinating Disease ◽  
Imaging Techniques ◽  
Tumor Resection ◽  
Delayed Diagnosis ◽  
Central Nervous System Lymphoma ◽  
Final Diagnosis ◽  
Diagnosis And Treatment ◽  
Initial Symptoms

Object White matter diseases, including demyelinating or inflammatory disorders, may be indistinguishable clinically and radiologically from some central nervous system (CNS) tumors. In such situations, determination of the final diagnosis is difficult. An example is the differential diagnosis of non-acquired immunodeficiency syndrome–related primary central nervous system lymphoma (PCNSL) and multiple sclerosis (MS), a demyelinating disease. Unfortunately, delayed diagnosis and treatment of PCNSL can negatively affect prognosis. Methods The authors reviewed the cases of eight patients with PCNSL or MS. In each case, the initial diagnosis (PCNSL or MS) was equivocal. In these cases, conventional diagnostic approaches were not definitive, thus further delaying diagnosis. The initial symptoms, the selected diagnostic tests, and the presumptive as well as final diagnosis for each case are discussed. The final diagnosis was PCNSL in six cases and MS in two. The uncertainty about the clinical or initial pathological presentation required further diagnostic evaluation in all cases. Two important neurosurgical guidelines are the avoidance of corticosteroid agents and performance of biopsy sampling rather than volumetric tumor resection. High-volume lumbar puncture, slit-lamp examination/vitrectomy, new CNS imaging techniques, and repeated biopsy procedures also proved helpful. Conclusions In PCNSL, early definitive diagnosis and treatment are the keys to successful outcomes. Knowledge of strategies essential to early diagnosis lessens the need for brain biopsy sampling, but this procedure is still usually necessary. In such selected cases, biopsy sampling is appropriate even when pathological investigation shows MS rather than PCNSL. Complete resection is not indicated in PCNSL and can lead to additional sequelae.

scholarly journals Assessing and disclosing test results for ‘mild cognitive impairment’: the perspective of old age psychiatrists in Scotland

2022 ◽  
Vol 22 (1) ◽  
Author(s):  
Stina Saunders ◽  
Craig W. Ritchie ◽  
Tom C. Russ ◽  
Graciela Muniz-Terrera ◽  
Richard Milne
Keyword(s):  
Cognitive Impairment ◽  
Mild Cognitive Impairment ◽  
Old Age ◽  
Assessment Tool ◽  
Clinical History ◽  
Diagnostic Process ◽  
Test Results ◽  
Risk Disclosure ◽  
Therapy Assessment ◽  
The Individual

Abstract Background Mild cognitive impairment (MCI) is a condition that exists between normal healthy ageing and dementia with an uncertain aetiology and prognosis. This uncertainty creates a complex dynamic between the clinicians’ conception of MCI, what is communicated to the individual about their condition, and how the individual responds to the information conveyed to them. The aim of this study was to explore clinicians’ views around the assessment and communication of MCI in memory clinics. Method As part of a larger longitudinal study looking at patients’ adjustment to MCI disclosure, we interviewed Old Age Psychiatrists at the five participating sites across Scotland. The study obtained ethics approvals and the interviews (carried out between Nov 2020–Jan 2021) followed a semi-structured schedule focusing on [1] how likely clinicians are to use the term MCI with patients; [2] what tests clinicians rely on and how much utility they see in them; and [3] how clinicians communicate risk of progression to dementia. The interviews were voice recorded and were analysed using reflective thematic analysis. Results Initial results show that most clinicians interviewed (Total N = 19) considered MCI to have significant limitations as a diagnostic term. Nevertheless, most clinicians reported using the term MCI (n = 15/19). Clinical history was commonly described as the primary aid in the diagnostic process and also to rule out functional impairment (which was sometimes corroborated by Occupational Therapy assessment). All clinicians reported using the Addenbrooke’s Cognitive Examination-III as a primary assessment tool. Neuroimaging was frequently found to have minimal usefulness due to the neuroradiological reports being non-specific. Conclusion Our study revealed a mixture of approaches to assessing and disclosing test results for MCI. Some clinicians consider the condition as a separate entity among neurodegenerative disorders whereas others find the term unhelpful due to its uncertain prognosis. Clinicians report a lack of specific and sensitive assessment methods for identifying the aetiology of MCI in clinical practice. Our study demonstrates a broad range of views and therefore variability in MCI risk disclosure in memory assessment services which may impact the management of individuals with MCI.

scholarly journals Using Machine-Learning Techniques to Identify Responders vs. Non-responders in Randomized Clinical Trials.

2020 ◽  
Author(s):  
Vasiliki Nikolodimou ◽  
Paul Agapow
Keyword(s):  
Machine Learning ◽  
Randomized Clinical Trials ◽  
Clustering Algorithms ◽  
Human Monoclonal Antibody ◽  
Clinical History ◽  
Differential Response ◽  
Unsupervised Clustering ◽  
Machine Learning Techniques ◽  
Genetic Characteristics ◽  
Learning Techniques

Despite the expectation of heterogeneity in therapy outcomes, especially for complex diseases like cancer, analyzing differential response to experimental therapies in a randomized clinical trial (RCT) setting is typically done by dividing patients into responders and non-responders, usually based on a single endpoint. Given the existence of biological and patho-physiological differences among metastatic colorectal cancer (mCRC) patients, we hypothesized that a data-driven analysis of an RCT population outcomes can identify sub-types of patients founded on differential response to Panitumumab - a fully human monoclonal antibody directed against the epidermal growth factor receptor. Outcome and response data of the RCT population were mined with heuristic, distance-based and model-based unsupervised clustering algorithms. The population sub-groups obtained by the best performing clustering approach were then examined in terms of molecular and clinical characteristics. The utility of this characterization was compared against that of the sub-groups obtained by the conventional responders' analysis and then contrasted with aetiological evidence around mCRC heterogeneity and biological functioning. The Partition around Medoids clustering method results into the identification of seven sub-types of patients, statistically distinct from each other in survival outcomes, prognostic biomarkers and genetic characteristics. Conventional responders analysis was proven inferior in uncovering relationships between physical, clinical history, genetic attributes and differential treatment resistance mechanisms. Combined with improved characterization of the molecular subtypes of CRC, applying Machine Learning techniques, like unsupervised clustering, onto the wealth of data already collected by previous RCTs can support the design of further targeted, more efficient RCTs and better identification of patient groups who will respond to a given intervention.

scholarly journals Cobalamin (vitamin B12) deficiency detection by urinary methylmalonic acid quantitation

Blood ◽  
1982 ◽  
Vol 59 (6) ◽  
pp. 1128-1131
Author(s):  
EJ Norman ◽  
OJ Martelo ◽  
MD Denton
Keyword(s):  
Methylmalonic Acid ◽  
Megaloblastic Anemia ◽  
Vitamin B12 Deficiency ◽  
Cobalamin Deficiency ◽  
Clinical Test ◽  
Test Results ◽  
Neurologic Disorders ◽  
Schilling Test ◽  
B12 Deficiency ◽  
And Function

A study was made to assess the value of cobalamin deficiency detection through quantitation of urinary methylmalonic acid (MMA). Urinary MMA was measured in 1118 patients suffering from megaloblastic anemia, other anemias, elevated red cell mean corpuscular volume, or unexplained neurologic disorders. Patients without proven cobalamin deficiency had urinary MMA levels less than 20 micrograms/ml. All patients (n = 27) confirmed to have cobalamin deficiency showed MMA levels greater than 20 micrograms/ml. Data are presented showing the Schilling test results, the comparison of serum cobalamin to urinary MMA levels, and other basic hematologic data. MMA levels are a good indication of cobalamin distribution and function since they are directly related to a cobalamin-dependent metabolic pathway. With rapid, reliable quantitation by mass spectrometry, urinary MMA can now be a useful clinical test.

scholarly journals COVID-19 Pneumonia: A Review of Typical Ct Findings and Differential Diagnosis

2020 ◽  
Vol 1 (3) ◽  
pp. 01-22
Author(s):  
Anthony Venyo
Keyword(s):  
Ct Scan ◽  
Imaging Techniques ◽  
Systemic Disease ◽  
Variable Number ◽  
Emergency Setting ◽  
Test Results ◽  
Imaging Characteristics ◽  
Novel Coronavirus ◽  
High Index Of Suspicion ◽  
Acid Test

Pneumonia that is caused by the 2019 novel coronavirus (SARS-CoV-2, which is also referred to as 2019-nCoV recently did break out in Wuhan China has been coined the terminology of COVID-19. With the spread of the disease, similar cases of COVID-19 had been confirmed in various regions of the world. Because COVID-19 is a relatively new global disease, clinicians, and patients across the globe would initially not be conversant with the clinical features and radiology imaging characteristics of SARS-CoV-2 pneumonia. The causes of pneumonia are protein, many secondary to an underlying cardiorespiratory abnormality while some are related systemic disease. Various imaging techniques generally diagnose cases of Pneumonia. In the current climate, COVID-19 Pneumonia has taken center stage; confirmation relies upon microbiological studies such as real-time polymerase chain reaction or sequencing. These investigations are not usually available in an emergency setting. Computed Tomography (CT) can be used as an essential complement for the diagnosis of COVID-19 Pneumonia in the current epidemic context. But the later may be misleading as other cases of Pneumonia, and interstitial lung disease can easily be confused with COVID-19 Pneumonia. Also, Covid19 Pneumonia may be missed if not considered. The attention of clinicians should be alerted to the possibility of COVID-19 to conduct the appropriate tests to confirm or negate the diagnosis of COVID-19. In asymptomatic as well as in symptomatic patients that have COVID1-9 pneumonia, the initial COVID-19 nuclei acid test results could be normal, which upon subsequent repeat testing would become normal. Still, radiology imaging using a CT scan of thorax would tend to demonstrate various non-specific features that affect a variable number of lobes of the lungs, and these features quickly increase in size when a repeat CT scan of the thorax is undertaken. These findings tend to predate positive COVID-19 test results in some cases of COVID-19. The non-specific changes tend to resolve when the patient resolves from COVID-19 pneumonia. A catalog of radiology images that demonstrate various types of cardio-pulmonary lesions which when encountered by clinicians should alert them to exclude the possibility of COVID-19 Pneumonia has been included in the paper as an aid to alerting clinicians to have a high index of suspicion of radiology images of the thorax which should help them to quickly undertake appropriate tests to confirm or negate the diagnosis of COVID-19 pulmonary infection.

Skin Tests in the Diagnosis of Allergic Conditions

1981 ◽  
Vol 2 (10) ◽  
pp. 327-332
Author(s):  
Lillian P. Kravis
Keyword(s):  
Skin Test ◽  
Skin Testing ◽  
Clinical History ◽  
Skin Tests ◽  
Food Allergies ◽  
Type I ◽  
Test Results ◽  
Type Iv ◽  
Transfer Testing ◽  
Allergic Disorders

Allergic disorders may be classified into four main categories of immunologic hypersensitivity reactions: type I, immediate or anaphylactic; type II, cytotoxic; type III, involving immune complexes; and type IV, delayed or cell mediated. Type I reactions are those most commonly encountered in clinical allergy. They may be well defined by skin testing, provided the patients to be tested are carefully selected and the tests are applied properly and interpreted critically. Major indications for direct skin testing are: (1) to separate atopic from nonatopic patients; (2) to help in identifying specific allergens in atopic persons; and (3) to reassess the allergic profile in patients receiving immunotherapy. Other indications for skin-testing, of more limited applicability, include: (1) screening for hypersensitivity to vaccines; (2) testing for reactivity to drugs (and particularly penicillin); (3) testing for immediate and delayed reactions in such conditions as bronchopulmonary aspergillosis; and (4) in evaluation of patients with reactions to insect stings. Skin-testing has limited usefulness in early infancy, in chronic urticaria, in the investigation of food allergies, in atopic dermatitis not accompanied by other manifestations of atopy, or in allergic reactions to drugs other than penicillin. A checklist to be consulted prior to performing or interpreting skin tests should include: (1) assurance of the potency of the extract used in testing; (2) knowledge of the nonspecific irritant properties of any extracts used for testing; (3) history of administration of antihistamine drugs or epinephrine prior to testing; and (4) the correlation of skin test results with clinical history. The help of a qualified allergist should be sought if: (1) skin test results are at variance with the historical data; or (2) systemic reactions are induced by skin testing; or (3) the patient fails to respond to the therapy dictated by the skin test results. Alternatives or supplements to skin-testing include RAST testing and measurement of histamine release from sensitized leukocytes. These have rendered passive transfer testing (PK or Prausnitz-Küstner) substantially obsolete. Direct allergy skin testing remains the most sensitive, most specific, and most reliable method presently available to the physician for investigation of IgE-mediated allergic disorders.

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