Predictive factors of severity and persistence of oropharyngeal dysphagia in sub-acute stroke.

PURPOSE: This study aims to understand the factors contributing to the severity of oropharyngeal dysphagia and its persistence in the sub-acute phase of stroke. METHODS: We retrospectively collected the data of all the patients suffering from a stroke in the last year. The severity of stroke was reported according to the NIHSS score. All the patients were evaluated with the Dysphagia Risk Score and with a FEES. We classified the Dysphagia Risk Score and FEES results using the PAS score and ASHA-NOMS levels. The data were analysed statistically with ANOVA test, Student's t test and Pearson's correlation coefficient. RESULTS: A series of 54 patients were evaluated. The ANOVA test did not find any difference in the mean score of Dysphagia Risk Score, PAS and ASHA-NOMS when compared with the brain area of stroke. An NIHSS at hospital admission (stroke unit) of more than 12 was predictive of ASHA-NOMS score 1-4 after 60 days (p < 0.05). A PAS score between 6 and 8 at first FEES evaluation was predictive of poor (1-4) ASHA-NOMS score after 60 days (p < 0.01). A moderate positive linear correlation was found between NIHSS score and both PAS (r 0.65) and Dysphagia Risk Score (r 0.50); a moderate negative linear correlation was recorded between NIHSS and ASHA-NOMS (r - 0.66) scores. CONCLUSION: In the sub-acute phase of stroke, the predictive factors of persistent dysphagia are not linked to the damaged neuroanatomical region and others factors such as NIHSS value and high PAS score seem more useful.

Right fronto-parietal white matter disruption contributes to speech impairments in amyotrophic lateral sclerosis.

INTRODUCTION: Non-linguistic properties of speech are widely heterogeneous and require complex neurological integration. The association between white matter integrity and the severity of dysarthria was investigated in a group of patients diagnosed with amyotrophic lateral sclerosis (ALS). METHODS: Thirty-six patients diagnosed with amyotrophic lateral sclerosis completed a magnetic resonance imaging protocol inclusive of diffusion-weighted images. A clinical assessment of pneumo-phono-articulatory abilities was conducted for each patient, and a composite score of residual speech capacity was calculated. Tract-Based Spatial Statistics was carried out to model the potential association between residual speech capacity and microstructural properties of white matter (fractional anisotropy, mean and radial diffusivity). RESULTS: A significant negative association was found between residual speech capacity and mean diffusivity in a large white matter cluster located in frontal, parietal and right temporal regions. These subcortical areas were characterised by pathological microstructural disruption, as revealed by post hoc analyses. CONCLUSIONS: Non-linguistic aspects of speech are associated with microstructural integrity of frontal, parietal and right temporal white matter in amyotrophic lateral sclerosis. Such mapping is consistent with the centres responsible of volitional control of speech and sensory feedback during non-linguistic speech production.

MyomiRNAs Dysregulation in ALS Rehabilitation.

Amyotrophic lateral sclerosis (ALS) is a rare, progressive, neurodegenerative disorder caused by degeneration of upper and lower motor neurons. The disease process leads, because of lower motor neuron involvement, to progressive muscle atrophy, weakness, and fasciculations and for the upper motor neuron involvement leads to spasticity. Muscle atrophy in ALS is caused by a neural dysregulation in the molecular network controlling fast and slow muscle fibers. Denervation and reinnervation processes in skeletal muscle occur in the course of ALS and are modulated by rehabilitation. MicroRNAs (miRNAs) are small, non-coding RNAs that are involved in different biological functions under various pathophysiological conditions. MiRNAs can be secreted by various cell types and they are markedly stable in body fluids. MiR-1, miR-133 a miR-133b, and miR-206 are called "myomiRs" and are considered markers of myogenesis during muscle regeneration and contribute to neuromuscular junction stabilization or sprouting. We observed a positive effect of a standard aerobic exercise rehabilitative protocol conducted for six weeks in 18 ALS patients during hospitalization in our center. This is a preliminary study, in which we correlated clinical scales with molecular data on myomiRs. After six weeks of moderate aerobic exercise, we found lower levels in serum of myomiRNAs. Our data suggest that circulating miRNAs changed during skeletal muscle recovery in response to physical rehabilitation in ALS. However, no firm conclusions can be made on the ALS-specific effect of exercise on miRNA levels.

Effects of combined endurance and resistance training in Amyotrophic Lateral Sclerosis: A pilot, randomized, controlled study.

Based on available evidence, muscle strengthening and cardiovascular exercises can help maintain function and not adversely affect the progression of disease in patients with ALS. However, this evidence is not sufficiently detailed to recommend a specific exercise prescription. The purpose of this project was to assess clinical outcomes of a combined exercise programme to increase knowledge of rehabilitation in ALS patients. 38 ALS patients were assigned randomly to two groups: one group underwent a specific exercise programme (ALS-EP) based on a moderate aerobic workout and isometric contractions, and the second group followed a standard neuromotor rehabilitation treatment. Objective evaluation consisted of cardiovascular measures, muscle strength and fatigue. Some positive effects of physical activity on ALS patients were found. Among the benefits, an overall improvement of functional independence in all patients, independently of the type of exercise conducted was seen. In addition, improvements in muscle power, oxygen consumption and fatigue were specifically observed in the ALS-EP group, all hallmarks of a training effect for the specific exercises. In conclusion, moderate intensity exercise is beneficial in ALS, helping in avoiding deconditioning and muscle atrophy resulting from progressive inactivity.

Micro-RNAs in ALS muscle: Differences in gender, age at onset and disease duration.

Few studies have explored the role of microRNAs (or miRNAs) in Amyotrophic Lateral Sclerosis (ALS) muscle, possibly because of the difficulty in obtaining samples and because this is a rare disease. We measured the expression levels of muscle-specific miRNAs (miRNA-1, miRNA-206, miRNA-133a, miRNA-133b, miRNA-27a) and inflammatory/angiogenic miRNAs (miRNA-155, miRNA-146a, miRNA-221, miRNA-149*) in the muscles of 13 ALS patients and controls. To highlight differences, patients were subdivided according to their gender, age at onset of symptoms, and disease duration. A significant over-expression of all miRNAs was observed in ALS patients versus controls, in male patients versus females, in patients with early onset versus patients with late onset, and in patients with long disease duration versus patients with short duration. A differential expression of miRNAs according to gender could be explained by the hormonal regulation which determines the body muscle mass. The course of the disease might reflect differential degree of muscle atrophy and signaling at miRNA levels. An evident role is also played by inflammatory/angiogenetic factors as shown by the observed miRNA changes.

Efficacy of botulinum toxin type-A and swallowing treatment for oropharyngeal dysphagia recovery in a patient with lateral medullary syndrome.

BACKGROUND: Wallenberg's syndrome (WS) is known as posterior inferior cerebellar artery syndrome. Dysphagia has been reported from 51% to 94% of the patients, ranging from mild to severe. CASE REPORT: We reported a case of a patient (male; 52 years) with WS. MRI showed an intense hypodense area in the dorsolateral part of the ponto-medullary junction. The clinical signs were severe dysphagia, fed by PEG (FOIS 1; PAS 7), sialorrhea, trismus and ataxia. CLINICAL REHABILITATION IMPACT: Dysphagia was treated by botulinum toxin type-A (BoNT-A), which was injected into the parotid and submandibular salivary glands, temporalis and masseter muscles, cricopharyngeal muscle associated with specific swallowing exercise and food trails. The 3-months follow-up showed significant saliva reduction and improvement of swallowing to from PEG feeding to consistent oral intake of food (FOIS 3, PAS 5). The treatment with BoNT-A combined with swallowing rehabilitation was fundamental in order to restore the swallowing functions.

Selective attention impairment in amyotrophic lateral sclerosis.

Objective of this study was to evaluate attentional control mechanisms in amyotrophic lateral sclerosis (ALS) using an auditory event-related potentials (ERPs) paradigm. Fifteen mild to moderate ALS patients and 15 healthy controls were administered a brief neuropsychological test battery and an ERPs paradigm assessing selective attention. Four types of auditory stimuli were presented in random order: short standard (200 Hz, 200 ms), long standard (200 Hz, 500 ms), short deviant (1000 Hz, 200 ms) and long deviant (1000 Hz, 500 ms). Participants had to respond to the long deviant stimuli only. During the task the electroencephalogram (EEG) was recorded. The N200, P300 and re-orienting negativity (RON) ERP components were analysed. Compared to controls ALS patients showed reduced amplitudes and delayed latencies of N200, P300 and RON. These results could be attributable to both an alteration in change detection resulting in a reduction of the allocation and re-orientation of attentional resources or a general slowing or reduction of neural processing efficiency in the same system. The ERPs results support the hypothesis that ALS involves extramotor cognitive functions including auditory attentional processing at all processing stages, early (200 ms) and late (300-600 ms). These data prove the usefulness and sensitivity of the auditory ERPs in detection of cognitive functions in ALS patients.

Circulating microRNAs as biomarkers of muscle differentiation and atrophy in ALS.

AIMS: The identification of circulating biomarkers is needed to facilitate diagnosis and prognosis of amyotrophic lateral sclerosis (ALS) and to offer indicators of therapeutic response in clinical trials. We aimed to investigate the levels of muscle-specific microRNAs in serum of ALS patients subdivided according to bulbar or spinal onset. METHODS: In 14 ALS patients (10 spinal, 4 bulbar) we measured the serum levels of muscle-specific miR-206, miR-1, miR-133a/b, miR-27a, and the expression of myostatin and follistatin, which are negative regulators of muscle growth. Morphometric analysis of muscle fiber size was used to correlate muscle atrophy with biochemical-molecular parameters. RESULTS: In ALS patients the expression of miR-206 and miR-133 was significantly increased and that of miR-27a was significantly reduced as compared to controls, and also between spinal vs. bulbar ALS. Myostatin/follistatin ratio was significantly higher in ALS than in controls and in bulbar versus spinal ALS. Bulbar ALS patients present higher degree of muscle atrophy than spinal ALS, as documented by our muscle fiber morphometric analysis. CONCLUSIONS: Muscle mass regulators are particularly down-expressed in bulbar ALS, suggesting a more rapid and diffuse atrophic process. These biomarkers may be considered as useful biochemical and molecular indicators involved both in neuromuscular junction maintenance and reinnervation process.

Morphometric correlates of dysarthric deficit in amyotrophic lateral sclerosis.

Our objective was to investigate the volumetric correlates of speech in amyotrophic lateral sclerosis (ALS). Twenty-three ALS patients had a structural 3D MRI scan, neuropsychological, linguistic and speech assessments. Twenty-three healthy adults of comparable age, education, white-matter hyperintensity load and intracranial volumes were also recruited. Between-group differences in grey matter and white matter (WM) were examined to characterize ALS patients accurately. The association between residual speech and volumetric maps was studied in these patients. Results demonstrated that ALS patients showed a pattern of WM reduction, which was located in peri-cortical motor/premotor fibres bilaterally, and in a large volume extending from the pons/midbrain to the cerebellum. A speech composite score was computed, and this was positively associated with premotor/supplementary-motor WM bilaterally, and right cerebellar WM. Since premotor associations were found in volumes where ALS patients showed WM reduction, this region is believed to be directly involved in speech execution in this group. Since cerebellar associations were instead found in volumes free from shrinkage, this region is interpreted as playing a modulatory role, compensating for the impact of ALS pathology.

Autonomic dysfunction in the early stage of ALS with bulbar involvement.

Our objective was to assess the autonomic function of ALS patients with and without bulbar signs to characterize dysautonomia in ALS disease. Standard autonomic tests and spectral analysis of heart rate variability (HRV), reflecting changes in the sympathovagal balance, were examined in 33 ALS patients (14 with bulbar signs) and 30 controls. Results showed that in the supine position, ALS patients had significantly lower total power and absolute values of high-frequency power indicating a depressed sinus arrhythmia. Patients with bulbar signs showed more marked autonomic alterations at rest. Tilting did not induce the expected increase in low-frequency and decrease in high-frequency power of HRV in all patients. No correlation was found between autonomic tests and clinical parameters. Our findings suggest an early subclinical involvement of the autonomic system in ALS, particularly affecting parasympathetic cardiac control. Patients with prominent bulbar signs show a more severe autonomic dysfunction under resting conditions.

Chronic treatment with fluoxetine decreases cerebral metabolic responses to the 5-HT1A agonist 8-hydroxy-2(di-N-propylamino)tetralin and increases those to the 5-HT2A/2C agonist 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane and to the dopaminergic agonist apomorphine.

Fluoxetine is a selective serotonin (5-HT) reuptake inhibitor that, when given chronically, alters different neurotransmitter systems. To assess functional changes occurring in the 5-HT and dopaminergic systems, we investigated the effects of 5-HT(1A) agonist 8-hydroxy-2(di-N-propylamino)tetralin (8-OH-DPAT), of the 5-HT(2A/2C) agonist 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI) and of the dopamine D(1/2) agonist apomorphine (APO) on behavior and on regional cerebral metabolic rates for glucose (rCMRglc) in rats pretreated for 3weeks with saline or fluoxetine (8mg/kg/day). Behavioral effects were assessed for 8-OH-DPAT by scoring the 5-HT syndrome, for DOI by counting head shakes and for APO with an activity monitor. rCMRglc were measured with quantitative autoradiographic [(14)C]2-deoxyglucose technique in 60 brain regions at 10min after acute administration of 8-OH-DPAT 1mg/kg, at 30min after DOI 5mg/kg or at 10min after APO 1mg/kg. Chronic fluoxetine did not alter the 5-HT syndrome by 8-OH-DPAT, decreased head shakes by DOI and enhanced hyperlocomotion by APO. 8-OH-DPAT produced rCMRglc increases in sensorimotor regions that were unaffected by fluoxetine pretreatment and diffuse metabolic decrements that were attenuated by fluoxetine in limbic and raphe areas (17% and 4% mean decreases, respectively, in saline control and fluoxetine-pretreated rats). DOI produced widespread rCMRglc declines that were intensified by fluoxetine (14% and 20% decreases, in control and fluoxetine rats). APO caused rCMRglc increases in 22 brain regions that were potentiated by fluoxetine in dopaminergic motor areas (10% and 25% increases, in control and fluoxetine rats). In conclusion, fluoxetine enhances 5-HT neurotransmission by blunting responsivity of 5-HT(1A) autoreceptors and increasing that of 5-HT(2A/2C) postsynaptic receptors and enhances dopaminergic D(1/2) receptor neurotransmission.

Post-acute P300 predicts recovery of consciousness from traumatic vegetative state.

BACKGROUND: Evoked potentials allow one to assess functional integrity of sensory pathways projecting to primary sensory cortices and event-related potentials assess higher order cortical functions associated with stimulus detection and decision-making. Evoked and event-related potentials have been used to predict emergence from coma. This study aimed to determine whether they can help prediction of consciousness recovery in post-traumatic vegetative state (VS). METHODS: Thirty-four patients in post-traumatic VS were assessed clinically and neurophysiologically at 2-3 months after injury and followed up to 1 year. Patients were assessed with the Disability Rating Scale (DRS) and with electroencephalogram (EEG), brainstem auditory (BAEP) and somatosensory evoked potentials (SEP) and P300. Demographic, clinical and neurophysiological measures were analysed by descriptive and logistic regression techniques. RESULTS: At 1 year from injury, 26 patients (76%) had recovered consciousness and eight patients (24%) had not. In univariate analyses, a detectable P300, a reactive EEG and lower DRS scores were found at entry assessment more frequently (p < 0.05) in patients who later recovered consciousness than in those who did not. Logistic regression analysis revealed that P300 was the only factor contributing to prediction of conscious recovery with an area under the ROC curve of 0.94 (95% CI, 0.80-0.99). CONCLUSIONS: P300 is a strong predictor of conscious recovery in VS.

A novel method for producing target cells and assessing cytotoxic T lymphocyte activity in outbred hosts.

BACKGROUND: Cytotoxic T lymphocytes play a crucial role in the immunological control of microbial infections and in the design of vaccines and immunotherapies. Measurement of cytotoxic T lymphocyte activity requires that the test antigen is presented by target cells having the same or compatible class I major histocompatibility complex antigens as the effector cells. Conventional assays use target cells labeled with 51chromium and infer cytotoxic T lymphocyte activity by measuring the isotope released by the target cells lysed following incubation with antigen-specific cytotoxic T lymphocytes. This assay is sensitive but needs manipulation and disposal of hazardous radioactive reagents and provides a bulk estimate of the reporter released, which may be influenced by spontaneous release of the label and other poorly controllable variables. Here we describe a novel method for producing target in outbred hosts and assessing cytotoxic T lymphocyte activity by flow cytometry. RESULTS: The method consists of culturing skin fibroblasts, immortalizing them with a replication defective clone of simian virus 40, and finally transducing them with a bicistronic vector encoding the target antigen and the reporter green fluorescent protein. When used in a flow cytometry-based assay, the target cells obtained with this method proved valuable for assessing the viral envelope protein specific cytotoxic T lymphocyte activity in domestic cats acutely or chronically infected with feline immunodeficiency virus, a lentivirus similar to human immunodeficiency virus and used as animal model for AIDS studies. CONCLUSION: Given the versatility of the bicistronic vector used, its ability to deliver multiple and large transgenes in target cells, and its extremely wide cell specificity when pseudotyped with the vesicular stomatitis virus envelope protein, the method is potentially exploitable in many animal species.

P300-Based Brain-Computer Interface Communication: Evaluation and Follow-up in Amyotrophic Lateral Sclerosis.

To describe results of training and 1-year follow-up of brain-communication in a larger group of early and middle stage amyotrophic lateral sclerosis (ALS) patients using a P300-based brain-computer interface (BCI), and to investigate the relationship between clinical status, age and BCI performance. A group of 21 ALS patients were tested with a BCI-system using two-dimensional cursor movements. A four choice visual paradigm was employed to training and test the brain-communication abilities. The task consisted of reaching with the cursor one out of four icons representing four basic needs. Five patients performed a follow-up test 1 year later. The clinical severity in all patients were assessed with a battery of clinical tests. A comparable control group of nine healthy subjects was employed to investigate performance differences. Nineteen patients and nine healthy subjects were able to achieve good and excellent cursor movements' control, acquiring at least communication abilities above chance level; during follow-up the patients maintained their BCI-skill. We found mild cognitive impairments in the ALS group which may be attributed to motor deficiencies, while no relevant correlation has been found between clinical data and BCI performance. A positive correlation between age and the BCI-skill in patients was found. Time since training acquisition and clinical status did not affect the patients brain-communication skill at early and middle stage of the disease. A brain-communication tool can be used in most ALS patients at early and middle stage of the disease before entering the locked-in stage.

Cerebral metabolic effects of fluoxetine, fluvoxamine, paroxetine and sertraline in the conscious rat.

The selective serotonin reuptake inhibitors (SSRI) exert a wide range of neurochemical and therapeutic activities. To investigate the neural effectors of SSRIs, we measured the regional cerebral metabolic rates for glucose (rCMRglc) in 56 brain regions of Fischer-344 rats 30 min after intraperitoneal injection of 0.4, 4 or 40 mg/kg of fluoxetine or fluvoxamine or after 4 mg/kg of paroxetine or sertraline. Both shared and drug-specific effects were detected. While all four SSRIs similarly reduced rCMRglc in a network of subcortical brain regions including the amygdala, locus coeruleus, basal ganglia and hypothalamic paraventricular nuclei, fluvoxamine, paroxetine and sertraline reduced rCMRglc also in the hippocampus and sertraline in the lateral habenula. The topography and the relation to dose of rCMRglc reductions by SSRIs differ from those of other classes of antidepressants, thus suggesting that SSRIs may specifically modulate brain areas involved in the physiological responses to stress.

Immunotherapy with internally inactivated virus loaded dendritic cells boosts cellular immunity but does not affect feline immunodeficiency virus infection course.

Immunotherapy of feline immunodeficiency virus (FIV)-infected cats with monocyte-derived dendritic cells (MDCs) loaded with aldrithiol-2 (AT2)-inactivated homologous FIV was performed. Although FIV-specific lymphoproliferative responses were markedly increased, viral loads and CD4+ T cell depletion were unaffected, thus indicating that boosting antiviral cell-mediated immunity may not suffice to modify infection course appreciably.

Evaluation of feline monocyte-derived dendritic cells loaded with internally inactivated virus as a vaccine against feline immunodeficiency virus.

Dendritic cells are the only antigen-presenting cells that can present exogenous antigens to both helper and cytolytic T cells and prime Th1-type or Th2-type cellular immune responses. Given their unique immune functions, dendritic cells are considered attractive "live adjuvants" for vaccination and immunotherapy against cancer and infectious diseases. The present study was carried out to assess whether the reinjection of autologous monocyte-derived dendritic cells loaded with an aldithriol-2-inactivated primary isolate of feline immune deficiency virus (FIV) was able to elicit protective immune responses against the homologous virus in naive cats. Vaccine efficacy was assessed by monitoring immune responses and, finally, by challenge with the homologous virus of vaccinated, mock-vaccinated, and healthy cats. The outcome of challenge was followed by measuring cellular and antibody responses and viral and proviral loads and quantitating FIV by isolation and a count of CD4(+)/CD8(+) T cells in blood. Vaccinated animals exhibited clearly evident FIV-specific peripheral blood mononuclear cell proliferation and antibody titers in response to immunization; however, they became infected with the challenge virus at rates comparable to those of control animals.

AIDS vaccination studies using an ex vivo feline immunodeficiency virus model: protection from an intraclade challenge administered systemically or mucosally by an attenuated vaccine.

Feline immunodeficiency virus (FIV) infection of domestic cats represents a valuable system through which to investigate criteria for antilentiviral vaccines in a natural host species. Here, we examined whether vaccination with a strain of FIV attenuated as a result of prolonged growth in vitro could protect against a fully virulent, highly heterologous intraclade challenge. The results indicated that the vaccine virus produced a low-grade infection with no detectable pathological effects and afforded a long-lasting sterilizing immunity if the challenge was delivered intraperitoneally as cell-free virus but not against a cell-associated intravaginal challenge. In the latter case, however, the replication and pathological consequences of the challenge virus were markedly suppressed. Together with similar results obtained in rhesus monkey models, these findings should give impulse to the development of attenuated FIV vaccines to be tested in controlled studies in field cats. Field studies may provide answers to some of the existing safety concerns surrounding attenuated AIDS vaccines in humans.