ECONOMIC BURDEN OF MULTIPLE SCLEROSIS IN GEORGIA.

The purpose of this study is to estimate economic burden of multiple sclerosis in Georgia and to compare costs of patients with different course of disease and disability level. Hospital-based cohort study was conducted in the P.Sarajishvili Institute of Neurology and Medical Center Pineo to estimate direct medical costs in patients with MS treated between 2019-2020. The mean annual direct medical cost for MS patient on disease-modifying therapies (DMTs) was statistically higher than for non-DMTs patient and estimated as 23254.7Lari[7382.5$] (SD 9026.3; CIs:21133.7-25375.8) versus 1429.1lari [453.6 $] (SD 861.7, CIs; 1309.5-1548.6) (P<0.0001). MS places a huge economic burden on healthcare model and society in Georgia. DMTs are the main driver of cost.

European Academy of Neurology and European Stroke Organization consensus statement and practical guidance for pre-hospital management of stroke.

BACKGROUND AND PURPOSE: The reduction of delay between onset and hospital arrival and adequate pre-hospital care of persons with acute stroke are important for improving the chances of a favourable outcome. The objective is to recommend evidence-based practices for the management of patients with suspected stroke in the pre-hospital setting. METHODS: The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to define the key clinical questions. An expert panel then reviewed the literature, established the quality of the evidence, and made recommendations. RESULTS: Despite very low quality of evidence educational campaigns to increase the awareness of immediately calling emergency medical services are strongly recommended. Moderate quality evidence was found to support strong recommendations for the training of emergency medical personnel in recognizing the symptoms of a stroke and in implementation of a pre-hospital 'code stroke' including highest priority dispatch, pre-hospital notification and rapid transfer to the closest 'stroke-ready' centre. Insufficient evidence was found to recommend a pre-hospital stroke scale to predict large vessel occlusion. Despite the very low quality of evidence, restoring normoxia in patients with hypoxia is recommended, and blood pressure lowering drugs and treating hyperglycaemia with insulin should be avoided. There is insufficient evidence to recommend the routine use of mobile stroke units delivering intravenous thrombolysis at the scene. Because only feasibility studies have been reported, no recommendations can be provided for pre-hospital telemedicine during ambulance transport. CONCLUSIONS: These guidelines inform on the contemporary approach to patients with suspected stroke in the pre-hospital setting. Further studies, preferably randomized controlled trials, are required to examine the impact of particular interventions on quality parameters and outcome.

[QUALITY OF LIFE IN CARERS OF PATIENTS WITH MULTIPLE SCLEROSIS TAKING A DISEASE-MODIFYING MEDICATION: A PILOT STUDY].

A chronic physical disease not only has direct consequences for the chronically ill person but can also distort the life of the healthy family member. The aim of our study was to measure the health-related quality of life (QOL) in people caring for patients with relapsing-remitting form of multiple sclerosis (MS) and currently treated with disease-modifying drugs. Eligible patients were selected via Sarajishvili Institute of Neurology database for MS. 25 carers (mean age 40.7; 56% women, 56% partners) and 25 sex and age-matched controls completed 36-item Short Form Health Survey (SF-36), version 2. Carers also completed the Beck depression Inventory (BDI-II). Compared to carers, patients were found to have a lower QOL (P<0.05 for five dimensions). However, no significant difference was observed in SF-36 domains scores between carers and controls except general health score which was lower in carers (63.3 vs 75.6, p=0.016). A strong negative correlation was found between BDI and all SF-36 dimension scores of carers. The association remains unchanged even adjusted to carers other independent variables. Last year relapse rate was the only clinical variable correlated with carers QOL dimensions. Our pilot study demonstrated that QOL in carers of patients with relapsing-remitting MS receiving disease-modifying treatment is minimally affected. Further study with large sample size is warranted.

Education and training of European neurologists in dementia.

The aim of this study was to describe the present involvement of neurologists in dementia management in European countries. Data were obtained from a questionnaire that members of The European Federation of Neurological Societies Scientific Panel on Dementia responded to. Information was obtained from 25 countries in Europe. A progressive decrease in the teaching activity from medical school to board-certified neurologists was reported. Teaching of medical students in dementia is obligatory in most countries, whereas there is no formal obligatory education in dementia after graduation from medical school. Further, in only half of the countries that responded to the questionnaire, obligatory courses in dementia are part of the training in neurology. Except for one country, the post-graduate training programs of board-certified neurologists do not include dementia as an obligatory topic. In only 10 of 25 countries, guidelines for neurologists on dementia evaluation have been published in local language. It is recommended to include obligatory teaching and training in dementia in the catalogue of minimum requirements for specialist training in neurology and this teaching should also be part of the ongoing update of certified neurologists.

Stroke with internal carotid artery stenosis.

BACKGROUND: Stroke patterns in patients with different degrees of carotid stenosis have not been systematically studied. OBJECTIVE: To determine first-ever stroke subtypes in nonselected patients with extracranial internal carotid artery (ICA) stenosis, based on a primary care hospital stroke registry. METHODS: One hundred seventy-three patients who experienced their first-ever stroke and who had 50% or greater (North American Symptomatic Carotid Endarterectomy Trial method) ipsilateral extracranial ICA stenosis, corresponding to 6.5% of 2649 patients with anterior circulation stroke included in the Lausanne Stroke Registry, were studied. All these patients underwent Doppler ultrasonography, carotid angiography (conventional or magnetic resonance angiography), neuroimaging (computed tomography or magnetic resonance imaging), and other investigations from the standard protocol of the Lausanne Stroke Registry. RESULTS: We found the following types of infarct in the middle cerebral artery territory: anterior pial in 54 (31%) of the patients; subcortical, 34 (20%); posterior pial, 32 (19%); large hemispheral, 20 (12%); and border zone, 17 (10%). There were multiple pial in 14 (8%) and multiple deep infarcts in 2 (1%) of the patients. Moderate (50%-69%) ICA stenosis was significantly associated with large hemispheral infarcts and a normal contralateral ICA (P =.04 and P =.02, respectively). Seventy percent to 89% of ICA stenosis was associated with prior transient ischemic attacks (P =.02). After adjusting for cardioembolism, border zone infarcts showed a strong trend to appear mostly in patients with 90% to 99% ICA stenosis (P =.06). CONCLUSIONS: The association of a large hemispheral infarct with moderate ICA stenosis suggests a large embolism and/or an inadequate collateral supply. While an embolism may also contribute, the association of border zone infarcts with 90% to 99% ICA stenosis emphasizes the significance of hemodynamic disturbance in the pathogenesis of these types of infarct.

Cognitive correlates of leukoaraiosis in the early stages of Alzheimer's disease.

To reveal cognitive correlates of leukoaraiosis (LA) in the early stages of Alzheimer's disease (AD) and to exclude confounding effects of aging, brain atrophy, education and dementive illness on cognition, we carefully selected a sample of 37 probable AD patients (NINCDS-ADRDA criteria, Hachinski ischemic score < 5) with similar indices of age, educational level, degree of brain atrophy and dementia severity (CDR 0.5, CDR 1 and MMSE score no lower than 20), and compared the results of neuropsychological testing of patients with and without LA. All patients underwent magnetic resonance imaging. LA was detected in 17 out of 37 cases. There were no significant differences between subjects with and without LA (Student's t-test, p>0.05) in tests that evaluate language, verbal intelligence and visuospatial functions, while the patients with LA showed poorer performance (p<0.05) in the tests evaluating verbal memory, attention/concentration and executive functions. The results obtained suggest that the patients with LA in the early stages of AD revealed dorsolateral prefrontal dysfunction syndrome due to disconnection of cortico-subcortical circuits. We found this syndrome to be more prenounced than it has been described in the non-demented elderly with LA. It may be that in patients suffering from degenerative illness, the brain has fewer compensatory reserves than in cases of "normal" aging, and it is more sensitive to ischemic damage caused by cerebral amyloid, arteriosclerotic or fibro-hyalinotic angiopathy. This typical neuropsychological syndrome is revealed only in the initial stage of AD in patients with LA. The follow-up progress of the atrophic-degenerative illness leads to overlapping of the specific neuropsychological syndrome by global cognitive impairment.

VITATOPS, the VITAmins TO prevent stroke trial: rationale and design of a randomised trial of B-vitamin therapy in patients with recent transient ischaemic attack or stroke (NCT00097669) (ISRCTN74743444).

BACKGROUND: Epidemiological studies suggest that raised plasma concentrations of total homocysteine (tHcy) may be a common, causal and treatable risk factor for atherothromboembolic ischaemic stroke, dementia and depression. Although tHcy can be lowered effectively with small doses of folic acid, vitamin B(12) and vitamin B(6), it is not known whether lowering tHcy, by means of B vitamin therapy, can prevent stroke and other major atherothromboembolic vascular events. AIM: To determine whether the addition of B-vitamin supplements (folic acid 2 mg, B(6) 25 mg, B(12) 500 microg) to best medical and surgical management will reduce the combined incidence of stroke, myocardial infarction (MI) and vascular death in patients with recent stroke or transient ischaemic attack (TIA) of the brain or eye. DESIGN: A prospective, international, multicentre, randomised, double blind, placebo-controlled clinical trial. SETTING: One hundred and four medical centres in 20 countries on five continents. SUBJECTS: Eight thousand (6600 recruited as of 5 January, 2006) patients with recent (<7 months) stroke (ischaemic or haemorrhagic) or TIA (brain or eye). RANDOMISATION: Randomisation and data collection are performed by means of a central telephone service or secure internet site. INTERVENTION: One tablet daily of either placebo or B vitamins (folic acid 2 mg, B(6) 25 mg, B(12) 500 mug). PRIMARY OUTCOME: The composite of stroke, MI or death from any vascular cause, whichever occurs first. Outcome and serious adverse events are adjudicated blinded to treatment allocation. SECONDARY OUTCOMES: TIA, unstable angina, revascularisation procedures, dementia, depression. STATISTICAL POWER: With 8000 patients followed up for a median of 2 years and an annual incidence of the primary outcome of 8% among patients assigned placebo, the study will have at least 80% power to detect a relative reduction of 15% in the incidence of the primary outcome among patients assigned B vitamins (to 6.8%/year), applying a two-tailed level of significance of 5%. CONCLUSION: VITATOPS aims to recruit and follow-up 8000 patients between 1998 and 2008, and provide a reliable estimate of the safety and effectiveness of folic acid, vitamin B(12), and vitamin B(6) supplementation in reducing recurrent serious vascular events among a wide range of patients with TIA and stroke throughout the world.

Massive haemorrhagic transformation in cardioembolic stroke: the role of arterial wall trauma and dissection.

The pathogenesis of massive haemorrhagic transformation is not well established. Fatal haemorrhagic transformation associated with in situ dissection after acute middle cerebral artery (MCA) occlusion in a patient with atrial fibrillation is reported. An 80 year old woman with atrial fibrillation developed mild hemiparesis and aphasia. Brain CT and MRI at 4 and 5 hours, respectively, of symptom onset showed proximal MCA trunk occlusion with developing striatocapsular infarct and hypoperfusion in the superficial MCA territory. A few hours later, she developed massive bleeding into the ischaemic area and died. Pathological examination showed MCA trunk dissection, surrounded by a subarachnoid clot which communicated with the cerebral haematoma. It is suggested that direct arterial wall trauma as a result of cardioembolic MCA occlusion caused bleeding into the infarct. Secondary in situ dissection may be an overlooked mechanism of haemorrhagic transformation.