Risk Factors and Clinical Outcomes of COVID-19 Infection in Multiple Sclerosis Patients: A Retrospective Study from a Single Center in Kosovo.

BACKGROUND Multiple sclerosis (MS) is treated with disease-modifying therapies (DMTs) that can increase susceptibility to viral infections. This retrospective study aimed to evaluate the presentation, management, and outcomes of patients with MS on DMTs admitted with symptoms of COVID-19 to a single center in Prishtina, Kosovo between March 2020 and April 2022. MATERIAL AND METHODS In this observational, single-center study, we included 282 patients with MS (mean age 37.8±11, 64.9% females), of whom 272 (96.4%) had confirmed COVID-19 infection, either through the presence of antibodies in the serum or a positive PCR test. RESULTS Most patients with COVID-19 infection were either asymptomatic or mildly symptomatic, while 11 patients were hospitalized due to moderate to severe symptoms. Among those with severe infection, 2 patients have died. Patients with moderate and severe COVID-19 had more advanced MS disease (P=0.001) and higher disability scales (P<0.001). In a logistic regression analysis, advanced MS remained significantly associated with worse symptoms, even after adjusting for other risk factors, with a relative risk (RR) of 2.8 (95% CI=1.1-6.6, P=0.018). MS patients on anti-CD20 DMTs more frequently experienced moderate and severe symptoms (RR=2.1, 95% CI=1.1-4.0, P=0.012). Anti-SARS-CoV-2 IgG was also lower in patients treated with anti-CD20. Notably, patients receiving vitamin D supplementation experienced a lower frequency of moderate to severe symptoms (P=0.007). CONCLUSIONS Patients with advanced MS exhibiting higher disability scales and those on anti-CD20 therapy faced an increased risk of experiencing more pronounced symptoms after COVID-19 infection. Patients on vitamin D supplementation had better clinical outcomes.

EVALUATION OF VISION-RELATED QUALITY OF LIFE IN PATIENTS AFTER VITRECTOMY FOLLOWING IDIOPATHIC EPIRETINAL MEMBRANE.

PURPOSE: To evaluate the impact of different intraocular tamponades on the vision-related quality of life (VRQOL) after idiopathic epiretinal membrane (IEM) surgery with epiretinal membrane peeling. METHODS: We prospectively enrolled 50 patients diagnosed with IEM who underwent pars plana vitrectomy. Patients were consecutively assigned to either the air tamponade (air) group (25 patients) or the balanced salt solution (BSS) tamponade group (25 patients). The following data were collected before and after surgery and compared between the two groups: VRQOL, best-corrected visual acuity, intraocular pressure, metamorphopsia, contrast sensitivity, and central macular thickness. RESULTS: Pars plana vitrectomy was performed in 50 eyes. At baseline, there were no significant differences between the two groups. At 6 months postoperatively, VRQOL ( P < 0.001), best-corrected visual acuity ( P < 0.001), central macular thickness ( P < 0.001), contrast sensitivity ( P < 0.001), and metamorphopsia ( P < 0.001) improved significantly in comparison with baseline, without significant differences between the air tamponade and BSS groups. CONCLUSION: Removing IEM significantly improved visual function and VRQOL. Despite improvements, this study showed no difference postoperatively whether air or BSS tamponade was used during surgery. As a result, air tamponade may not be a mandatory treatment for IEM surgery and provides no additional advantage compared with BSS tamponade.

Chemotherapy-Induced Peripheral Neuropathy (CIPN) in Patients Receiving 4-6 Cycles of Platinum-Based and Taxane-Based Chemotherapy: A Prospective, Single-Center Study from Kosovo.

BACKGROUND Chemotherapy-induced peripheral neuropathy (CIPN) is most commonly associated with platinum-based drugs, taxanes, and vinca alkaloids. This prospective study from a single center in Kosovo aimed to evaluate CIPN in 120 patients receiving 4-6 cycles of platinum-based and taxane-based chemotherapy. MATERIAL AND METHODS One hundred twenty patients underwent neurological examination and nerve conduction studies (NCS) before chemotherapy, and after 4 to 6 cycles of treatment. Sixty patients were treated with platinum-based chemotherapy, 30 were treated with taxane-based chemotherapy, and 22 patients received a combination of platinum- and taxane-based chemotherapy. The most commonly used platinum-based compounds were oxaliplatin and carboplatin, whereas the most commonly used taxane medications were paclitaxel and docetaxel. Presence of neuropathy was confirmed with neurological examination of electrophysiological criteria applicable for polyneuropathies. Total Neuropathy Score (TNSr) was used to combine clinical and electrophysiological values. RESULTS Around 90% of patients self-reported neuropathic symptoms, and in 60% of them polyneuropathy was present in NCS. All sensory and motor nerves had significantly lower amplitudes (P<0.01). Platinum-based agents caused more pronounced decrease in ulnar nerve compound motor action potential (CMAP) (P<0.05); when used solely or in combination with taxanes, they caused significant decrease in tibial nerve CMAP (P<0.01). TNSr did not reach statistical significance between groups; only clinical muscle strength showed pronounced weakness in the combined protocol (P<0.05). CONCLUSIONS These findings support previous studies and show that CIPN, including sensory and motor symptoms, is commonly associated with chemotherapy. Platinum-based chemotherapy agents were more commonly associated with ulnar and tibial nerve damage in this study population.

Divergent immunohistochemical expression of CD21 and CD23 by follicular dendritic cells with increasing grade of follicular lymphoma.

BACKGROUND: Ultrastructural and immunohistochemical differences have been described in FDCs of primary and secondary follicles, illustrating the highly compartmentalized structure of lymph follicles. Differences in FDC immunophenotype in different grades of FL may reflect some parallelism between reactive and neoplastic conditions in terms of FDC-B cell interaction and may be used as a valuable additional tool for grading FL. METHODS: A total of 60 paraffin blocks from patients with follicular lymphoma, 30 cases each of grade 1 and 3, were retrieved from our archive. Immunohistochemical analysis was carried out for CD21, CD23, cyclin A, and Ki-67. RESULTS: Our study demonstrates that during evaluation, six patterns of FDC distribution were distinguished. The intensity of stain for CD21 was not statistically significant in grade 1 and grade 3 FL (p = 0.340). In contrast, grade 3 FLs exhibited a significant decrease of CD23 expression by the FDCs (p < 0.001). By CD21 stain, there was no significant difference in the distribution of pattern 1 in grades 1 and 3 (p = 0.098). In contrast, in grade 3, this pattern was significantly less observed by CD23 stain (p = 0.016). The same was observed for pattern 2 for CD21 (p = 0.940) and CD23 (p = 0.010) and pattern 4 for CD21 (p = 0.305) and CD23 (p = 0.005), respectively. Distribution of pattern 5 was significantly different between grades 1 and 3 both for CD21 (p = 0.005) and CD23 (p < 0.001). Distribution of patterns 2 and 6 was not significantly different between grades 1 and 3 for CD21 and CD23. The values of cyclin A and Mib-1 were also significantly different between grades 1 and 3 (p < 0.001). CONCLUSIONS: The observed patterns of FDCs lead us to believe that similar to reactive lymph node follicles, neoplastic follicles in FL, at least in early stages, have an organized structure. Hypothetically, with CD21, CD23, and cyclin A immunohistochemistry, the sequence of events in FL progression may be traced.

Carotid IM-GSM is better than IMT for identifying patients with multiple arterial disease.

OBJECTIVE: Atherosclerosis is a systemic inflammatory disease that can affect more than one arterial bed simultaneously. The aim of this study was to determine the relationship between ultrasound markers of atherosclerosis and multiple arterial disease. DESIGN: We have included 87 currently asymptomatic carotid disease patients (mean age 69 ± 6 year, 34% females) in this study. Intima media thickness (IMT) and intima media-grey scale median (IM-GSM) were measured in the common carotid artery (CCA), and correlated with previous and/or current atherosclerotic vascular disease in the coronary, carotid and lower extremities. Patients were divided into three groups: (1) asymptomatic, (2) previous symptoms in one arterial territory and (3) previous symptoms in multiple arterial territories. RESULTS: Patients with previous disease in the coronary arteries had higher IMT (p = .034) and lower IM-GSM (p < .001), and those with prior stroke had lower IM-GSM (p = .007). Neither IMT nor IM-GSM was different between patients with and without previous lower extremity vascular disease. IM-GSM was significantly different between groups, it decreased significantly with increasing number of arterial territories affected (37.7 ± 15.4 vs. 29.3 ± 16.4 vs. 20.7 ± 12.9) p < .001, for asymptomatic, symptoms in one and in multiple arterial systems, respectively. Conventional IMT was not significantly different between groups p = .49. CONCLUSION: Carotid IMT was higher and IM-GSM lower in patients with symptomatic nearby arterial territories but not in those with peripheral disease. In contrast to conventional IMT, IM-GSM can differentiate between numbers of arterial territories affected by atherosclerosis, suggesting that it is a better surrogate for monitoring multiple arterial territory disease.

Individualizing Treatment Approaches for Epileptic Patients with Glucose Transporter Type1 (GLUT-1) Deficiency.

Monogenic and polygenic mutations are important contributors in patients suffering from epilepsy, including metabolic epilepsies which are inborn errors of metabolism with a good respond to specific dietetic treatments. Heterozygous variation in solute carrier family 2, facilitated glucose transporter member 1 (SLC2A1) and mutations of the GLUT1/SLC2A2 gene results in the failure of glucose transport, which is related with a glucose type-1 transporter (GLUT1) deficiency syndrome (GLUT1DS). GLUT1 deficiency syndrome is a treatable disorder of glucose transport into the brain caused by a variety of mutations in the SLC2A1 gene which are the cause of different neurological disorders also with different types of epilepsy and related clinical phenotypes. Since patients continue to experience seizures due to a pharmacoresistance, an early clinical diagnosis associated with specific genetic testing in SLC2A1 pathogenic variants in clinical phenotypes could predict pure drug response and might improve safety and efficacy of treatment with the initiation of an alternative energy source including ketogenic or analog diets in such patients providing individualized strategy approaches.

Influence of apelin-12 on troponin levels and the rate of MACE in STEMI patients.

BACKGROUND: During acute myocardial infarction, phosphorylated TnI levels, Ca2+ sensitivity and ATPase activity are decreased in the myocardium, and the subsequent elevation in Ca2+ levels activates protease I (caplain I), leading to the proteolytic degradation of troponins. Concurrently, the levels of apelin and APJ expression are increased by limiting myocardial injury. METHODS: In this prospective observational study, 100 consecutive patients with ST-elevation acute myocardial infarction were included. Patients meeting the following criteria were included in our study: (1) continuous chest pain lasting for >30 min, (2) observation of ST-segment elevation of more than 2 mm in two adjacent leads by electrocardiography (ECG), (3) increased cardiac troponin I levels, and (4) patients who underwent reperfusion therapy. We evaluated the levels of apelin-12 and troponin I on the first and seventh days after reperfusion therapy in all patients. RESULTS: Apelin-12 was inversely correlated with troponin I levels (Spearman's correlation = -0.40) with a p value <0.001. There was variability in the apelin values on the seventh day (Kruskal-Wallis test) based on major adverse cardiac events (MACE) (p = 0.012). Using ROC curve analyses, a cut-off value of >2.2 for the association of apelin with MACE was determined, and the AUC was 0.71 (95% CI, 0.58-0.84). Survival analysis using the Kaplan-Meier method showed a lower rate of MACE among patients with apelin levels >2.2 (p = 0.002), and the ROC curve analysis showed a statistically significant difference in the area under the curve (p = 0.004). CONCLUSION: The influence of apelin levels on troponin levels in the acute phase of STEMI is inversely correlated, whereas in the non-acute phase, low apelin values were associated with a high rate of MACE.

Normal ranges of left ventricular strain in children: a meta-analysis.

AIMS: The definition of normal values of two-dimensional speckle-tracking echocardiography derived left ventricular (LV) deformation parameters, is of critical importance for the routine application of this modality in children. The objectives of this study were to perform a meta-analysis of normal ranges for longitudinal, circumferential and radial strain/strain rate values and to identify confounders that may contribute to differences in reported measures. METHODS AND RESULTS: A systematic search was conducted. Studies describing normal healthy subjects and observational studies that used control groups as a comparison were included. Data were combined using a random-effect model. Effects of demographic, clinical and equipment variables were assessed through meta-regression. The search identified 1,192 subjects form 28 articles. Longitudinal strain (LS) normal mean values varied from -12.9 to -26.5 (mean, -20.5; 95% CI, -20.0 to -21.0). Normal mean values of circumferential strain (CS) varied from -10.5 to -27.0 (mean, -22.06; 95% CI, -21.5 to -22.5). Radial strain (RS) normal mean values varied from 24.9 to 62.1 (mean, 45.4; 95% CI, 43.0 to 47.8). Meta-regression showed LV end diastolic diameter as a significant determinant of variation for LS. Longitudinal systolic strain rate (LSRs) was significantly determined by the age and RS by the type of vendor used. CONCLUSION: Variations among different normal ranges were dependent on the vendor used, LV end-diastolic diameter and age. Vendor-independent software for analyzing myocardial deformation in children, using images from different vendors would be the ideal solution for strain measurements or else using the same system for patient's follow up.

Ultrasound assessment of carotid plaque echogenicity response to statin therapy: a systematic review and meta-analysis.

OBJECTIVE: To evaluate in a systematic review and meta-analysis model the effect of statin therapy on carotid plaque echogenicity assessed by ultrasound. METHODS: We have systematically searched electronic databases (PubMed, MEDLINE, EMBASE and Cochrane Center Register) up to April, 2015, for studies evaluating the effect of statins on plaque echogenicity. Two researchers independently determined the eligibility of studies evaluating the effect of statin therapy on carotid plaque echogenicity that used ultrasound and grey scale median (GSM) or integrated back scatter (IBS). RESULTS: Nine out of 580 identified studies including 566 patients' carotid artery data were meta-analyzed for a mean follow up of 7.2 months. A consistent increase in the echogenicity of carotid artery plaques, after statin therapy, was reported. Pooled weighted mean difference % (WMD) on plaque echogenicity after statin therapy was 29% (95% CI 22%-36%), p<0.001, I2=92.1%. In a meta-regression analysis using % mean changes of LDL, HDL and hsCRP as moderators, it was shown that the effects of statins on plaque echogenicity were related to changes in hsCRP, but not to LDL and HDL changes from the baseline. The effect of statins on the plaque was progressive; it showed significance after the first month of treatment, and the echogenicity continued to increase in the following six and 12 months. CONCLUSIONS: Statin therapy is associated with a favorable increase of carotid plaque echogenicity. This effect seems to be dependent on the period of treatment and hsCRP change from the baseline, independent of changes in LDL and HDL.

Atherosclerotic Calcification Detection: A Comparative Study of Carotid Ultrasound and Cone Beam CT.

BACKGROUND AND AIM: Arterial calcification is often detected on ultrasound examination but its diagnostic accuracy is not well validated. The aim of this study was to determine the accuracy of carotid ultrasound B mode findings in detecting atherosclerotic calcification quantified by cone beam computed tomography (CBCT). METHODS: We analyzed 94 carotid arteries, from 88 patients (mean age 70 ± 7 years, 33% females), who underwent pre-endarterectomy ultrasound examination. Plaques with high echogenic nodules and posterior shadowing were considered calcified. After surgery, the excised plaques were examined using CBCT, from which the calcification volume (mm3) was calculated. In cases with multiple calcifications the largest calcification nodule volume was used to represent the plaque. Carotid artery calcification by the two imaging techniques was compared using conventional correlations. RESULTS: Carotid ultrasound was highly accurate in detecting the presence of calcification; with a sensitivity of 88.2%. Based on the quartile ranges of calcification volumes measured by CBCT we have divided plaque calcification into four groups: <8; 8-35; 36-70 and >70 mm3. Calcification volumes ≥8 were accurately detectable by ultrasound with a sensitivity of 96%. Of the 21 plaques with <8 mm3 calcification volume; only 13 were detected by ultrasound; resulting in a sensitivity of 62%. There was no difference in the volume of calcification between symptomatic and asymptomatic patients. CONCLUSION: Carotid ultrasound is highly accurate in detecting the presence of calcified atherosclerotic lesions of volume ≥8 mm3; but less accurate in detecting smaller volume calcified plaques. Further development of ultrasound techniques should allow better detection of early arterial calcification.

Combined electrical and global markers of dyssynchrony predict clinical response to cardiac resynchronization therapy.

AIM: To assess potential additional value of global left ventricular (LV) dyssynchrony markers in predicting cardiac resynchronization therapy (CRT) response in heart failure (HF) patients. METHODS: We included 103 HF patients (mean age 67 ± 12 years, 83% male) who fulfilled the guidelines criteria for CRT treatment. All patients had undergone full clinical assessment, NT-proBNP and echocardiographic examination. Global LV dyssynchrony was assessed using total isovolumic time (t-IVT) and Tei index. On the basis of reduction in the NYHA class after CRT, patients were divided into responders and non-responders. RESULTS: Prolonged t-IVT [0.878 (range, 0.802-0.962), p = 0.005], long QRS duration [0.978 (range, 0.960-0.996), p = 0.02] and high tricuspid regurgitation pressure drop [1.047 (range, 1.001-1.096), p = 0.046] independently predicted response to CRT. A t-IVT ≥ 11.6 s/min was 67% sensitive and 62% specific (AUC 0.69, p = 0.001) in predicting CRT response. Respective values for a QRS ≥ 151 ms were 66% and 62% (AUC 0.65, p = 0.01). Combining the two variables had higher specificity (88%) in predicting CRT response. In atrial fibrillation (AF) patients, only prolonged t-IVT [0.690 (range, 0.509-0.937), p = 0.03] independently predicted CRT response. CONCLUSION: Combining prolonged t-IVT and the conventionally used broad QRS duration has a significantly higher specificity in identifying patients likely to respond to CRT. Moreover, in AF patients, only prolonged t-IVT independently predicted CRT response.

Baló Concentric Sclerosis Mimicking Encephalitis with Seizures and Progressive Aphasia in a 26-Year-Old Woman: A Challenging Diagnostic Dilemma.

Introduction: Baló's concentric sclerosis (BCS) is a rare subtype of multiple sclerosis characterized by inflammatory demyelination within the central nervous system. Case Presentation: This case report presents a challenging diagnostic scenario involving a 26-year-old woman diagnosed with BCS. Despite treatment, her condition did not ameliorate, and magnetic resonance imaging (MRI) findings remained unchanged. A subsequent stereotactic biopsy revealed tumefactive Balo disease, highlighting the intricate diagnostic and therapeutic issues surrounding BCS. Conclusion: The juxtacortical location of the BCS lesion, as observed in our case, suggests an unfavourable prognosis due to treatment-resistant seizures.

A 14-Year-Old Male Patient with Kawasaki Disease Presented with Stroke after COVID-19.

According to several studies, children represent only about 2% of the patients affected by the current SARS-CoV-2, and most often, they are asymptomatic. However, there is a concern about a vascular inflammatory disease which is similar to Kawasaki disease observed in children and adolescents weeks after infection. We report a case of Kawasaki disease presented with ischemic stroke in a 14-year-old male patient following SARS-Cov-2 infection.

Complete revascularization for patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease: a meta-analysis of randomized trials.

INTRODUCTION: Despite the recent findings in randomized clinical trials (RCTs) with limited sample sizes and the updates in clinical guidelines, the current available data for the complete revascularization (CR) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) at the time of primary percutaneous coronary intervention (PCI) are still contradictory. AIM: The aim of this meta-analysis of the existing RCTs was to assess the efficacy of the CR versus revascularization of infarct-related artery (IRA) only during primary PCI in patients with STEMI and multivessel disease (MVD). PATIENTS AND METHODS: We searched PubMed, MEDLINE, Embase, Scopus, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases aiming to find RCTs for patients with STEMI and MVD which compared CR with IRA-only. Random effect risk ratios (RRs) were calculated for efficacy and safety outcomes. RESULTS: Ten RCTs with 3291 patients were included. The median follow-up duration was 17.5 months. Major adverse cardiac events (RR=0.57; 0.43-0.76; P<0.0001), cardiac mortality (RR=0.52; 0.31-0.87; P=0.014), and repeat revascularization (RR=0.50; 0.30-0.84; P=0.009) were lower in CR compared with IRA-only strategies. However, there was no significant difference in the risk of all-cause mortality, recurrent nonfatal myocardial infarction, stroke, major bleeding events, and contrast-induced nephropathy. CONCLUSION: For patients with STEMI and MVD undergoing primary PCI, the current evidence suggests that the risk of major adverse cardiac events, repeat revascularization, and cardiac death is reduced by CR. However, the risk for all-cause mortality and PCI-related complications is not different from the isolated culprit lesion-only treatment. Although these findings support the cardiac mortality and safety benefit of CR in stable STEMI, further large trials are required to provide better guidance for optimum management of such patients.

Accuracy of Conventional Diagnostic Methods for Identifying Structural Changes in Patients with Focal Epilepsy.

BACKGROUND: Epilepsy is a neurological disorder characterized by abnormal firing of nerve impulses in the brain. AIM: This study aims to investigate the frequency of appearance of pathological changes in conventional examination methods (electroencephalography-EEG, brain computerized tomography -CT or brain magnetic resonance imaging - MRI) in patients with epilepsy, and relationship between clinical manifestations and localization of changes in CT or MRI. METHODS: In this study we have included 110 patients with focal epilepsy who fulfilled the inclusion criteria out of 557 initially diagnosed patients. Detailed clinical examination together with brain imaging (CT and MRI) and electroencephalography examination was performed. We have evaluated the accuracy of each diagnostic method to localize the epileptic focus. Diagnosis of epilepsy was determined by the ILAE (International League Against Epilepsy) criteria of the year 1989, and classification of epileptic seizures was made according to the ILAE classification 2010. RESULTS: Electroencephalography presented changes in 60.9% of patients; brain CT in 42.1%, and MRI in 78% of the patients. The results of our study showed that clinical manifestations were not always conveyed with pathological changes in conventional examining methods performed. Of the total of 79 patients with changes in imaging (8 with changes in CT and 71 in MRI), 79.7% presented a clinical picture compatible with the region in which morphological changes were found, while in 20.3% of patients the presented morphological changes were not aligned with the clinical picture. CONCLUSION: In patients with epilepsy, conventional examination methods do not always find pathological changes, while clinical manifestations of epilepsy did not always coincide with the location of changes in imaging. Further studies are needed to see if there is clear border between focal and generalized epilepsy.

Hypertension on admission is associated with a lower risk of early seizures after stroke.

PURPOSE: Despite the common occurrence of early seizures (ES) after stroke, the relationship between risk factors and this complication of stroke is not well established. In this study we have examined the relationship between clinical measures on admission and ES after stroke. METHODS: We included 1073 patients (mean age 69 ± 12, 51.6% females) with ischemic and haemorrhagic stroke. The frequency of seizure occurrence within 2 weeks of stroke was determined. We used a logistic regression model to analyse the effect of blood pressure on admission and other clinical factors (age, gender, diabetes, atrial fibrillation and dyslipidemia) on the occurrence of ES after stroke. RESULTS: ES occurred after 4.1% and 4.0% of ischemic and haemorrhagic strokes respectively. Compared to patients with high blood pressure on admission, those with low and normal blood pressure had a higher risk of ES after stroke (2.9% vs.7.5% vs. 7.6%, p=0.001). Also the mean age of patients with post-stroke ES was lower (62.5 vs. 69.3, p<0.001). In a logistic regression analysis, low/normal blood pressure remained independently associated with ES after stroke with OR of 2.46 (95% CI 1.38-4.63, p=0.006). CONCLUSION: ES after stroke was equally frequent in patients with ischemic and haemorrhagic stroke. Low/normal blood pressure on admission and younger patient age were risk factors for ES after stroke.

Comparison of drug-eluting balloon versus drug-eluting stent treatment of drug-eluting stent in-stent restenosis: A meta-analysis of available evidence.

BACKGROUND: In-stent restenosis (ISR) remains an important concern despite the recent advances in the drug-eluting stent (DES) technology. The introduction of drug-eluting balloons (DEB) offers a good solution to such problem. OBJECTIVES: We performed a meta-analysis to assess the clinical efficiency and safety of DEB compared with DES in patients with DES-ISR. METHODS: A systematic search was conducted and all randomized and observational studies which compared DEB with DES in patients with DES-ISR were included. The primary outcome measure-major adverse cardiovascular events (MACE)-as well as individual events as target lesion revascularization (TLR), stent thrombosis (ST), myocardial infarction (MI), cardiac death (CD) and all-cause mortality, were analyzed. RESULTS: Three randomized and 4 observational studies were included with a total of 2052 patients. MACE (relative risk [RR]=1.00, 95% confidence interval (CI) 0.68 to 1.46, P=0.99), TLR (RR=1.15 [CI 0.79 to 1.68], P=0.44), ST (RR=0.37[0.10 to 1.34], P=0.13), MI (RR=0.97 [0.49 to 1.91], P=0.93) and CD (RR=0.73 [0.22 to 2.45], P=0.61) were not different between patients treated with DEB and with DES. However, all-cause mortality was lower in patients treated with DEB (RR=0.45 [0.23 to 0.87, P=0.019) and in particular when compared to only first generation DES (RR 0.33 [0.15-0.74], P=0.007). There was no statistical evidence for publication bias. CONCLUSIONS: The results of this meta-analysis showed that DEB and DES have similar efficacy and safety for the treatment of DES-ISR.

Hypoglycemia-induced hemiparesis in a diabetic woman after childbirth.

A 24-year-old female with type 1 diabetes mellitus presented with hemiparesis induced by hypoglycemia. She was hospitalized because she has noticed a weakness of her right hand and leg three days after childbirth. On physical examination she had an expressive dysphasia and right side hemiparesis with facial drop. Hypoglycemia is rarely associated with hemiparesis and it is often overlooked, especially when it happens in patients at higher risk of other diseases frequently associated with hemiparesis. Although sporadical cases of hypoglycemia-induced hemiparesis were reported, the clear pathophysiology behind this is not well determined. However, any individual case is important in order to increase the awareness of hypoglycemia as an important etiology of this condition.

Common carotid intima-media features determine distal disease phenotype and vulnerability in asymptomatic patients.

OBJECTIVES: There is a growing awareness of the importance of carotid plaque features evaluation in stroke prediction. Carotid intima-media thickness (IMT) and recently its echogenicity were used for stroke prediction, although their clinical relevance was not well determined. The aim of this study was to assess the relationship between common carotid artery (CCA) ultrasound markers of atherosclerosis and distal, bifurcation and internal carotid artery (ICA), plaque features. METHODS: We analyzed 137 carotid arteries in 87 asymptomatic patients with known carotid disease (mean age 69 ± 6 year, 34.5% females). Intima media thickness (IMT) and its gray scale median (IM-GSM) were measured at the CCA. Plaque textural features including gray scale median (GSM), juxtaluminal black area (JBA-mm(2)) without a visible cap, and plaque coarseness, at bifurcation and ICA were also determined. CCA measurements were correlated with those of the distal plaques. RESULTS: An increased IMT in CCA correlated with plaque irregularities in the bifurcation and ICA (r=0.53, p<0.001), while IM-GSM was closely related to plaque echogenicity (GSM) (r=0.76, p<0.001), and other textural plaque features. Both, IMT and IM-GSM correlated weakly with stenosis severity (r=0.27, p=0.001 and r=-0.18, p=0.026) respectively. CONCLUSION: In asymptomatic patients, measurements of CCA reflect distal, bifurcation and ICA disease, with IMT reflecting plaque irregularities and IM-GSM as markers of textural plaque abnormalities. Integrating measurements of both IMT and IM-GSM in a model could be used as a better marker of disease vulnerability over and above each measure individually.

Vulnerable plaques in the contralateral carotid arteries in symptomatic patients: a detailed ultrasound analysis.

BACKGROUND AND AIM: Carotid plaques may represent a generalized atherosclerotic syndrome or a localized disease. The aim of this study was to assess the morphological and textural features of carotid plaques located contralateral to the symptomatic side and compare them with the symptomatic side and with plaques from asymptomatic patients. METHODS: We studied 66 arteries in 39 patients (mean age 70 ± 7 year, 33% females). Arterial plaques were classified as either symptomatic (n = 30), contralateral to symptomatic (n = 25) or asymptomatic (n = 11). We compared several plaque features between these groups including the mean values of the grey scale median (GSM), entropy, juxtaluminal black area (JBA) without visible echogenic cap, GSM of the JBA and surface irregularity. RESULTS: The plaques contralateral to symptomatic arteries had similar morphological and textural features to those in the symptomatic arteries. In contrast, they had more vulnerable morphological and textural features than those in asymptomatic arteries: less smooth plaques (12% vs. 55%) and instead more often mildly irregular (60% vs 36%) or markedly irregular (28% vs. 9%; p = 0.03), lower GSM (26.2 ± 8 vs. 49.4 ± 14, p < 0.001) and lower GSM of the JBA (5.0 ± 3.6 vs. 11.4 ± 2.1, p = 0.008). The frequency of entropy and plaque calcification was similar in all groups. CONCLUSION: Symptomatic patients with carotid artery disease seem to have similar morphological and textural features of vulnerability in the symptomatic and the contralateral carotid arteries, which are profound compared with asymptomatic carotid arteries. These findings support the concept of generalized carotid atherosclerotic pathology rather than incidental unilateral disease, and also emphasize a need for aggressive measures for plaque stabilization, particularly in symptomatic patients.