Audiological Patterns in Patients with Autoimmune Hearing Loss.

INTRODUCTION: The aim of this study was to illustrate clinical and audiological patterns of hearing impairment in patients with autoimmune hearing loss (AIHL). METHODS: Fifty-three patients with AIHL were retrospectively recruited, and a tapering schema of steroid treatment was administered in all these patients. The diagnosis of AIHL was essentially based on clinical symptoms, such as recurrent, sudden (sensorineural hearing loss [SSHL]), fluctuating, or quickly progressing (<12 months) SSHL (uni-/bilateral), in association with the coexistence of autoimmune diseases, high antinuclear antibodies (ANA) and the presence of human leukocyte antigen (HLA) B27, B35, B51, C04, and C07. Logistic regression analysis was applied to correlate the clinical data and laboratory features of AIHL with final outcomes. RESULTS: The onset of AIHL was mainly progressive (49%), followed by SSHL (39.6%) or fluctuating (11.3%). The pure-tone audiogram showed more commonly a downsloping pattern (42.6% of ears), but also an upsloping, flat, cookie-bite, or inverse cookie-bite shape. Bilateral progressive AIHL was more frequently simultaneous (23 patients) than heterochronous (4 patients). Nineteen patients (35.8%) showed a favorable response to steroid therapy. The presence of recurrent, bilateral SSHL versus recurrent, unilateral SSHL had statistically negative effect on hearing recovery (OR = 0.042, p < 0.05). The heterochronous bilateral SSHL may have better prognosis than simultaneous bilateral SSHL (OR = 10.000, p = 0.099). The gender, age, concomitant autoimmune disease, high ANA, HLA alleles, tinnitus, and vestibular symptoms had no statistical effect on a favorable outcome of AIHL. CONCLUSIONS: A bilateral, simultaneous, and progressive hearing loss combined with downsloping audiogram occurred more often in patients with AIHL. Bilateral simultaneous SSHL with recurrences represents the worse prognostic form of AIHL.

Paternal age and specific neurological soft signs as reliable and valid neurobiological markers for the diagnosis of patients with schizophrenia.

Advanced parental age at delivery and neurological soft signs (NSS) constitute risk factors for schizophrenia. The aim of the current study was to develop a neurobiological diagnostic index by combining them, and without the contribution of clinical symptomatology. The study sample included 133 patients suffering from schizophrenia according to DSM-IV-TR (77 males and 56 females; aged 33.55 ± 11.22 years old) and 122 normal controls (66 males and 56 females; aged 32.89 ± 9.91 years old). The assessment included the Neurological Evaluation Scale (NES), and a number of scales assessing the clinical symptoms and adverse effects. The statistical analysis included exploratory t-test, Pearson Correlation coefficient (R) and Discriminant Function Analysis (DFA). Exploratory t-tests and Pearson's R suggested that sex, parental age and NSS constitute independent components. On the basis of DFA results, the Psychotic Neurological Index was developed. At the cut-off PNI score of 8.5, sensitivity was equal to 94.74 and specificity to 93.44. The current is probably the first study to report on an easily obtainable diagnostic neurobiological marker with identifiable properties which is absolutely independent from the clinical manifestations and could serve in distinguishing between patients with schizophrenia and healthy controls with high efficacy.

West Nile neuroinvasive disease. Report of four cases in Northern Greece, 2018.

West Nile virus (WNV) is a mosquito-borne RNA flavivirus which caused several epidemics worldwide. The year 2018 was a WNV record year for Europe, including Greece, with earlier and longer transmission season with higher than the previous number of cases. It has been proposed that some simple biochemical markers may be helpful for the recognition of WNV neuroinvasive disease, its differential from other neurological infectious diseases and prognosis. We describe four cases that suffered from WNV meningitis and/or encephalitis hospitalized in 2018 in a tertiary hospital in Thessaloniki, Greece, and investigate the importance of simple biomarkers for the recognition of WNV etiology.

A comparative study of color Doppler imaging and contrast-enhanced ultrasound for the detection of ulceration in patients with carotid atherosclerotic disease.

OBJECTIVES: To evaluate the diagnostic accuracy of color Doppler imaging (CDI) and contrast-enhanced ultrasound (CEUS) for diagnosing carotid ulceration, having multi-detector computed tomography angiography (MDCTA) as the reference method. METHODS: Patients with carotid disease referred for ultrasound (US), either due to the occurrence of neurovascular symptoms or for screening purposes, were included in this study if at least one plaque causing moderate (50-69%) or severe (70-99%) internal carotid artery stenosis was detected. Carotid US with CDI technique, CEUS, and MDCTA were performed in all patients, investigating the presence of ulceration. The agreement between modalities was evaluated using kappa statistics. RESULTS: The study population included 54 patients (median age 62 years, inter-quartile range 16.2) and 66 carotid arteries. The mean degree of stenosis was 68.5% (SD 12.2%) while 47.1% of plaques were symptomatic. MDCTA characterized 28.8% of plaques as smooth, 45.5% irregular, and 24.3% ulcerated. Flow reversal was detected with CDI in 65.5% of ulcerations, while swirling of the microbubbles and neovessels adjacent to the ulcer were detected with CEUS in 17.64%. The agreement for ulceration diagnosis was moderate between CDI and CEUS (kappa 0.473) and between CDI and MDCTA (kappa 0.473) and very good between CEUS and MDCTA (kappa 0.921). The sensitivity, specificity, and positive and negative predictive values of CDI for the diagnosis of ulceration were 41.2%, 97.95%, 87.5%, 82.8% respectively, while CEUS respective measures were 94.1%, 97.95%, 94.1%, and 97.95%. CONCLUSION: CEUS outperformed CDI in terms of agreement with MDCTA and diagnostic accuracy for the diagnosis of ulcerated carotid plaque. KEY POINTS: • Superficial ulceration is a significant feature of carotid plaque vulnerability. • Color Doppler imaging has the potential to demonstrate carotid plaque ulceration but is characterized by limited sensitivity and moderate agreement with the reference method of multi-detector computed tomography angiography. • Contrast-enhanced ultrasound outperforms color Doppler imaging in terms of sensitivity for the detection of carotid plaque ulceration and in agreement with the reference method of multi-detector computed tomography angiography.

Does Quantification of Carotid Plaque Surface Irregularities Better Detect Symptomatic Plaques Compared to the Subjective Classification?

OBJECTIVES: To evaluate the interobserver agreement of color Doppler ultrasound (CDUS) and contrast-enhanced ultrasound (CEUS) for quantification of carotid plaque surface irregularities and to correlate objective and subjective measures with stroke occurrence. METHODS: This work was an observational study involving 54 patients with 62 internal carotid artery or carotid bulb plaques (31 symptomatic) undergoing CDUS and CEUS between February 2016 and February 2018, with retrospective interpretation of prospectively acquired data. Plaques were included if causing moderate (50%-69%) or severe (70%-99%) stenosis based on velocity criteria, and their surface was classified as smooth, irregular, or ulcerated based on CEUS. The surface irregularities were quantified in the form of a surface irregularity index by 2 observers, based on CDUS and CEUS. The surface irregularity index was evaluated for interobserver agreement with CDUS and CEUS and correlated with the occurrence of stroke, as was the subjective characterization of the plaque surface. RESULTS: Color Doppler ultrasound and CEUS showed good interobserver agreement (intraclass correlation coefficients, 0.979 and 0.952, respectively). Plaques were characterized as smooth in 30.6% of cases, irregular in 50%, and ulcerated in 19.4%. The subjective classification of the plaque surface did not correlate with stroke occurrence (P > .05, χ2 ). Surface irregularity index values were significantly higher for symptomatic plaques with both CDUS and CEUS (P < .05). CONCLUSIONS: Color Doppler ultrasound and CEUS can quantify carotid plaque surface irregularities with good interobserver agreement. The resulting quantitative measure was significantly higher in symptomatic plaques, whereas the subjective characterization of plaque surface failed to differ between symptomatic and asymptomatic plaques.

Extracranial internal carotid artery occlusive dissection - multimodality presentation in a case series.

Background: Carotid dissection is a rare disease, mainly affecting young and middle-aged patients potentially ending up in stroke. Multimodality imaging plays an essential role, both in terms of prompt and accurate diagnosis and follow-up of this entity. Patients and methods: We herein present a case series of patients with internal carotid artery dissection and compare the various imaging findings of ultrasonography, multidetector computed tomography angiography and magnetic resonance angiography, with a purpose to illustrate the value of multimodality imaging in the diagnosis of carotid dissection. Results: Ultrasound represents the first-line imaging modality for the evaluation of a suspected carotid pathology. Digital subtraction angiography is considered the gold standard method for evaluation of carotid luminal abnormalities and is currently reserved for those patients selected for endovascular surgery. Nevertheless, the widespread availability of modern cross-sectional techniques such as multi-detector computed tomography angiography and magnetic resonance angiography has made angiography marginalised. Computed tomography and magnetic resonance angiography offered accurate delineation of vascular lumen and providing valuable information for the vascular wall composition. Conclusions: Careful interpretation of imaging findings on various imaging modalities can lead to early and accurate diagnosis of carotid dissection.

Headache Linked to Intracranial Hypertension and Hypertrophic Pachymeningitis as the Initial and Dominant Presentation of Granulomatosis With Polyangiitis. Case Report and Review of the Recent Literature.

OBJECTIVE: The objective of this article is to report a rare case of headache as the initial symptom of granulomatosis with polyangiitis (GPA) and to review the recent literature. BACKGROUND: Granulomatosis with polyangiitis is a rare, systemic, autoimmune disease of unknown etiology. GPA has a wide spectrum of clinical symptomatology, including involvement of the nervous system, even as the initial manifestation. Symptoms of the peripheral nervous system used to dominate the clinical symptomatology. However, recent reports are focusing increasingly in granulomatous lesions of the central nervous system, and especially on the increased frequency of patients with hypertrophic pachymeningitis (HP). We report the case of a patient with headache linked to intracranial hypertension and hypertrophic pachymeningitis as the initial and dominant presentation of GPA and we review the recent literature. METHODS: A 54-year-old male, without any related medical history developed a severe headache. In the following 2 months, he gradually developed hoarseness and diplopia at the left and lower fields of vision. A brain MRI revealed wide-spread fattening and meningeal enhancement over the left hemisphere and the left cerebellar hemisphere. An endoscopy of the pharynx revealed the presence of a tumor-like mass in the left half of the nasopharynx. A biopsy showed inflammation with presence of polykaryocyte Langhans giant cells. The laboratory testing revealed important albuminuria and microhematuria, positive c-ANCA and negative p-ANCA. A diagnosis of GPA was established. RESULTS: A steroid treatment was administered initially, which improved the headache drastically, followed by the administration of a combination of cyclophosphamide and corticosteroid, which led to a gradual resolve of the remaining symptomatology. A follow-up brain MRI showed a decrease in meningeal enhancement, whereas a second one, 2 years later, was completely normal. CONCLUSIONS: HP was considered an extremely rare manifestation of GPA. However, recent studies are reporting an increased frequency of HP and are distinguishing a granulomatous and a vasculitic phenotype, with different localization and relapse rates, that may eventually constitute a different clinical spectrum of GPA.

Hyperglycemic Patterns in Acute Stroke Patients.

Background and objective Hyperglycemia following a stroke can independently aggravate the ischemic area. Ensuring adequate glucose management can help avoid complications and minimize mortality and disability in these patients. This study aimed to investigate hyperglycemic patterns in acute stroke patients. Materials and methods We conducted a non-interventional prospective observational study involving acute stroke patients by employing continuous glucose monitoring (CGM) for 72 hours after the onset of stroke symptoms. Admission glucose, patients' total mean glucose (TMG), and time in range (TIR) (70-140 mg/dl) were correlated with the hyperglycemic patterns elicited by the CGM system software. Data were analyzed using SPSS Statistics 26.0 (IBM Corp., Armonk, NY) with descriptive statistics, the Kruskal-Wallis test, and χ2 test. Results Our cohort comprised 105 diabetic and non-diabetic stroke patients. The hyperglycaemic patterns that we observed were as follows: (i) hyperglycemia from 23:00 to 10:00, (ii) 06.00 to 10.00, (iii) at night and after meals, iv) no pattern, v) unspecified patterns. Patients with nocturnal and morning hyperglycemia had admission glucose of 183 mg/dl, mean 72-hour glucose of 156 mg/dl, and TIR of 37%. Patients who did not develop a hyperglycemic pattern either had admission glucose of 131 mg/dl and TIR of 89% or had high admission glucose (197 mg/dl) and a short TIR (14%). Conventional pre-meal capillary glucose tests do not appear to detect these patients' hyperglycemic tendencies. Conclusions These results may indicate the necessity for more intensive measurements during the night or dawn in this patient population. Admission glucose could be considered a predictor of hyperglycemic patterns and contribute to the patient's care plan.

Attitudes of Family Members and Caregivers Regarding Alzheimer's Disease Pre-Symptomatic Screening.

Background: In recent years, studies have examined the acceptability and attitudes that influence the intention to early screen for Alzheimer's disease (AD) in the general population, older people, carers, and asymptomatic individuals who report a family history of AD. However, it remains unclear what specific factors promote or reduce the acceptability of pre-symptomatic screening. Objective: The aim of this study is to explore the attitudes of family and non-family members as well as caregivers and non-caregivers toward the pre-symptomatic screening of AD. Methods: A total of 213 participants completed the Perceptions regarding pRE-symptomatic Alzheimer's Disease Screening (PRE-ADS) Questionnaire. Group comparisons using t-test and one-way ANOVA were used to examine differences in attitudes toward pre-symptomatic screening regarding age, family history, knowing someone with AD, influence of depression, and feelings of anxiety. The subscale "Acceptability of Screening" was developed to investigate the willingness to undergo pre-symptomatic screening. Results: Participants with a family history showed greater acceptance of pre-symptomatic screening while both caregivers and non-caregivers had similar attitudes. People with a family history as well as those with personal connections to dementia indicate a greater need for knowledge. The findings suggest that younger adults appear to perceive less harm from testing, whereas those who experience higher levels of anxiety and depression seem to perceive more testing harms. Conclusions: Comparing the attitudes of people with and without a family history as well as caregivers and non-caregivers toward pre-symptomatic screening of AD is critical to understand the differences between these groups and develop comprehensive screening programs.

Glucose Fluctuations in Acute Ischemic Stroke.

INTRODUCTION: The Oxfordshire Community Stroke Project denotes four subtypes of ischemic stroke (total and partial anterior infarct, posterior, and lacunar). Hyperglycemia has been associated with a larger infarct size and poor prognosis. AIM: The purpose of the study was to investigate the correlation of glucose fluctuations with the Oxford sub-categories and patient outcomes using a blinded continuous glucose monitoring system. METHODS: This is a non-interventional prospective observational study. Stroke patients with symptoms onset in the last 24h, participated in the study. A glucose sensor was placed for 72 hours. Disability was assessed using the modified Rankin Scale. Stroke subtypes were compared with total mean glucose and time in range using ANOVA analysis. Multiple ordinal logistic regression was employed to analyze outcomes and survival. RESULTS: The sample consisted of 105 diabetic and non-diabetic patients. The overall mean glucose was 127.06 mg/dL and the time in range (70-140 mg/dL) was 70.98%. There was no significant difference between the stroke sub-categories and the total mean glucose. For every one-point increase in the time in range, we expect a 1.5% reduction in the odds of having a worse outcome. Patients with total anterior infarct are 2.31 times more likely to have a worse outcome than lacunar patients. CONCLUSION: The utilization of the Oxford classification may not be necessary for managing acute ischemic stroke glucose levels. Achieving glucose regulation and an increase in time in range can be attained through meticulous control, potentially extending life expectancy. Continuous glucose monitors may aid in achieving this objective.

The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke.

OBJECTIVE: To test the hypothesis that the size of a juxtaluminal black (hypoechoic) area (JBA) in ultrasound images of asymptomatic carotid artery plaques predicts future ipsilateral ischemic stroke. METHODS: A JBA was defined as an area of pixels with a grayscale value <25 adjacent to the lumen without a visible echogenic cap after image normalization. The size of a JBA was measured in the carotid plaque images of 1121 patients with asymptomatic carotid stenosis 50% to 99% in relation to the bulb (Asymptomatic Carotid Stenosis and Risk of Stroke study); the patients were followed for up to 8 years. RESULTS: The JBA had a linear association with future stroke rate. The area under the receiver-operating characteristic curve was 0.816. Using Kaplan-Meier curves, the mean annual stroke rate was 0.4% in 706 patients with a JBA <4 mm(2), 1.4% in 171 patients with a JBA 4 to 8 mm(2), 3.2% in 46 patients with a JBA 8 to 10 mm(2), and 5% in 198 patients with a JBA >10 mm(2) (P < .001). In a Cox model with ipsilateral ischemic events (amaurosis fugax, transient ischemic attack [TIA], or stroke) as the dependent variable, the JBA (<4 mm(2), 4-8 mm(2), >8 mm(2)) was still significant after adjusting for other plaque features known to be associated with increased risk, including stenosis, grayscale median, presence of discrete white areas without acoustic shadowing indicating neovascularization, plaque area, and history of contralateral TIA or stroke. Plaque area and grayscale median were not significant. Using the significant variables (stenosis, discrete white areas without acoustic shadowing, JBA, and history of contralateral TIA or stroke), this model predicted the annual risk of stroke for each patient (range, 0.1%-10.0%). The average annual stroke risk was <1% in 734 patients, 1% to 1.9% in 94 patients, 2% to 3.9% in 134 patients, 4% to 5.9% in 125 patients, and 6% to 10% in 34 patients. CONCLUSIONS: The size of a JBA is linearly related to the risk of stroke and can be used in risk stratification models. These findings need to be confirmed in future prospective studies or in the medical arm of randomized controlled studies in the presence of optimal medical therapy. In the meantime, the JBA may be used to select asymptomatic patients at high stroke risk for carotid endarterectomy and spare patients at low risk from an unnecessary operation.

Attitudes, Motivations, and Barriers to Pre-Symptomatic Alzheimer's Disease Screening: Development and Validation of the 'Perceptions regarding pRE-symptomatic Alzheimer's Disease Screening' (PRE-ADS) Questionnaire.

BACKGROUND: Pre-symptomatic screening methods for detecting a higher risk of Alzheimer's disease (AD) are gaining popularity; thus, more people are seeking these tests. However, to date, not much is known about the attitudes toward pre-symptomatic AD screening. OBJECTIVE: The goal of this study is to examine the psychometric properties of a tool for assessing the attitudes, barriers, and motivations to pre-symptomatic AD screening. METHODS: This is a cross-sectional study performed on 208 Greek participants (189 students and 19 caregivers) provided with an online questionnaire. Psychometric properties were assessed through the examination of its construct validity (principal component analysis) and internal consistency. RESULTS: Exploratory factor analysis revealed the presence of four factors. The first factor is labeled as "Perceived harms of testing" (10 items), the second "Acceptance of testing" (5 items), the third "Perceived benefits of testing" (6 items), and the fourth factor "Need for knowledge" (4 items). The reliability (internal consistency) of each factor separately was acceptable to good (0.70-0.87) while the internal consistency of the overall questionnaire (25 items) was good (Cronbach's α=0.82). CONCLUSION: PRE-ADS is a valid questionnaire that might help in the research of peoples' attitudes related to the pros and cons of pre-symptomatic screening for AD, and the development of effective counseling programs and prevention strategies. However, future research is required in the target population.

Exploring the Role of ACE2 as a Connecting Link between COVID-19 and Parkinson's Disease.

Coronavirus disease 2019 (COVID-19) is frequently accompanied by neurological manifestations such as headache, delirium, and epileptic seizures, whereas ageusia and anosmia may appear before respiratory symptoms. Among the various neurological COVID-19-related comorbidities, Parkinson's disease (PD) has gained increasing attention. Some cases of PD disease have been linked to COVID-19, and both motor and non-motor symptoms in Parkinson's disease patients frequently worsen following SARS-CoV-2 infection. Although it is still unclear whether PD increases the susceptibility to SARS-CoV-2 infection or whether COVID-19 increases the risk of or unmasks future cases of PD, emerging evidence sheds more light on the molecular mechanisms underlying the relationship between these two diseases. Among them, angiotensin-converting enzyme 2 (ACE2), a significant component of the renin-angiotensin system (RAS), seems to play a pivotal role. ACE2 is required for the entry of SARS-CoV-2 to the human host cells, and ACE2 dysregulation is implicated in the severity of COVID-19-related acute respiratory distress syndrome (ARDS). ACE2 imbalance is implicated in core shared pathophysiological mechanisms between PD and COVID-19, including aberrant inflammatory responses, oxidative stress, mitochondrial dysfunction, and immune dysregulation. ACE2 may also be implicated in alpha-synuclein-induced dopaminergic degeneration, gut-brain axis dysregulation, blood-brain axis disruption, autonomic dysfunction, depression, anxiety, and hyposmia, which are key features of PD.

Assessment of Atherosclerosis in Ischemic Stroke by means of Ultrasound of Extracranial/Intracranial Circulation and Serum, Urine, and Tissue Biomarkers.

It is a common practice to take into consideration age, diabetes, smoking, treated and untreated systolic blood pressure, total cholesterol, and high-density lipoprotein cholesterol for the prediction of atherosclerosis and stroke. There are, however, ultrasound markers in use for the assessment of atherosclerosis and the evaluation of stroke risk. Two areas of investigation are of interest: the carotid artery and the intracranial arterial circulation. Again, within the domain of the carotid artery, two ultrasonic markers have attracted our attention: intima media thickness of the carotid artery and the presence of carotid plaque with its various focal characteristics. In the domain of intracranial circulation, the presence of arterial stenosis and the recruitment of collaterals are considered significant ultrasonic markers for the above-mentioned purpose. On the other hand, a series of serum, urine, and tissue biomarkers are found to be related to atherosclerotic disease. Future studies might address the issue of whether the addition of proven ultrasonic carotid indices to the aforementioned serum, urine, and tissue biomarkers could provide the vascular specialist with a better assessment of the atherosclerotic load and solidify their position as surrogate markers for the evaluation of atherosclerosis and stroke risk.

Genetic Associations Between Modifiable Risk Factors and Alzheimer Disease.

Importance: An estimated 40% of dementia is potentially preventable by modifying 12 risk factors throughout the life course. However, robust evidence for most of these risk factors is lacking. Effective interventions should target risk factors in the causal pathway to dementia. Objective: To comprehensively disentangle potentially causal aspects of modifiable risk factors for Alzheimer disease (AD) to inspire new drug targeting and improved prevention. Design, Setting, and Participants: This genetic association study was conducted using 2-sample univariable and multivariable mendelian randomization. Independent genetic variants associated with modifiable risk factors were selected as instrumental variables from genomic consortia. Outcome data for AD were obtained from the European Alzheimer & Dementia Biobank (EADB), generated on August 31, 2021. Main analyses were conducted using the EADB clinically diagnosed end point data. All analyses were performed between April 12 and October 27, 2022. Exposures: Genetically determined modifiable risk factors. Main Outcomes and Measures: Odds ratios (ORs) and 95% CIs for AD were calculated per 1-unit change of genetically determined risk factors. Results: The EADB-diagnosed cohort included 39 106 participants with clinically diagnosed AD and 401 577 control participants without AD. The mean age ranged from 72 to 83 years for participants with AD and 51 to 80 years for control participants. Among participants with AD, 54% to 75% were female, and among control participants, 48% to 60% were female. Genetically determined high-density lipoprotein (HDL) cholesterol concentrations were associated with increased odds of AD (OR per 1-SD increase, 1.10 [95% CI, 1.05-1.16]). Genetically determined high systolic blood pressure was associated with increased risk of AD after adjusting for diastolic blood pressure (OR per 10-mm Hg increase, 1.22 [95% CI, 1.02-1.46]). In a second analysis to minimize bias due to sample overlap, the entire UK Biobank was excluded from the EADB consortium; odds for AD were similar for HDL cholesterol (OR per 1-SD unit increase, 1.08 [95% CI, 1.02-1.15]) and systolic blood pressure after adjusting for diastolic blood pressure (OR per 10-mm Hg increase, 1.23 [95% CI, 1.01-1.50]). Conclusions and Relevance: This genetic association study found novel genetic associations between high HDL cholesterol concentrations and high systolic blood pressure with higher risk of AD. These findings may inspire new drug targeting and improved prevention implementation.

Posterior cerebral artery dissection after excessive caffeine consumption in a teenager.

Arterial ischemic stroke is a rare but significant cause of neurological deficits in childhood. Even though there is a variety of risk factors, identifying the etiology can sometimes be a hard diagnostic challenge. Arteriopathies in general, and more specifically, arterial dissection is one of the uncommon pathologies that can cause incidents of pediatric stroke. We report a rare case of a young adolescent with posterior cerebral artery dissection after excessive consumption of caffeine, contained in energy drinks, only hours before the onset of neurological symptoms. A complete neuroimaging evaluation (MRI, intracranial US and digital subtraction angiography) at the admission and during the follow-ups supported the diagnosis of arterial dissection possibly caused by caffeine overconsumption.

Assess of Combinations of Non-Pharmacological Interventions for the Reduction of Irritability in Patients with Dementia and their Caregivers: A Cross-Over RCT.

INTRODUCTION: Dementia is a very common disorder that affects people over 65 years old all over the world. Apart from the cognitive decline, Behavioral and Psychological Symptoms of Dementia (BPSD) are a crucial matter in dementia, because they affect up to 90% of the patients during the course of their illness. Irritability has been found to be a common BPSD and one of the most distressing behaviors for the caregivers. The aim of the current study was to explore the efficacy of a combination of non-pharmacological interventions to treat irritability. METHODS: Sixty patients with different types and stages of dementia with irritability were participated in a cross-over RCT. Three non-pharmacological interventions were used; (a) Validation Therapy (VT)/Psycho-educational program, (b) Aromatherapy/massage and (c) Music Therapy (MT). The study assessed the three non-pharmacological interventions in order to find the most effective combination of the interventions. This study did not compare pharmacological and non-pharmacological treatments. The interventions lasted for five days. There was no drop-out rate. All patients were assessed at baseline using Mini Mental State of Examination (MMSE), Addenbrooke's Cognitive Examination Revised (ACE-R), Geriatric Depression Scale (GDS), Functional Rating Scale for symptoms in dementia (FRSSD), and Neuropsychiatric Inventory (NPI) (sub questions for irritability). Only NPI used for the assessment after each intervention. The analyses used categorical variables, Wilcoxon signed-rank test, Chi-square test and z value score. RESULTS: The most effective combination of non-pharmacological interventions was Aromatherapy/massage (p = 0.003)-VT plus Psycho-educational program (p = 0.014) plus MT (p = 0.018). The same combination was the most effective for the caregivers' burden, too (p = 0.026). CONCLUSIONS: The above combination of non-pharmacological interventions can reduce irritability in patients with dementia and caregivers' burden.

Non-Pharmacological Interventions for Wandering/Aberrant Motor Behaviour in Patients with Dementia.

BACKGROUND: Aberrant motor behaviour or wandering refers to aimless movement without a specific purpose. Wandering is common in patients with dementia and leads to early institutionalization and caregivers' burden. Non-pharmacological interventions should be also considered as a first-line solution for the wandering because current pharmacological treatment has serious side-effects. METHODS: A cross-over randomised controlled trial (RCT) with 60 participants of all stages and different types of dementia was conducted in Greece. The sample was randomly assigned in 6 different groups of 10 participants each. Every intervention lasted for 5 days, and there were 2 days as a wash-out period. There was no drop-out rate. The measurements used were the Mini Mental State Examination (MMSE), Addenbrooke's Cognitive Examination Revised (ACE-R), Geriatric Depression Scale (GDS), Functional Rating Scale for Symptoms in Dementia (FRSSD), and Neuropsychiatric Inventory (NPI). The interventions that were evaluated were reminiscence therapy (RT), music therapy (MT), and physical exercise (PE). RESULTS: NPI scores were reduced in the group receiving PE (p = 0.006). When MT (p = 0.018) follows PE, wandering symptoms are reduced further. RT should follow MT in order to reduce wandering more (p = 0.034). The same combination was effective for the caregivers' burden as well; PE (p = 0.004), MT (p = 0.036), RT (p = 0.039). CONCLUSIONS: An effective combination that can reduce wandering symptoms in all stages and types of dementia was found: The best order was PH-MT-RT. The same combination in the same order reduced caregivers' burden.