Covarying patterns of white matter lesions and cortical atrophy predict progression in early MS.

OBJECTIVE: We applied longitudinal 3T MRI and advanced computational models in 2 independent cohorts of patients with early MS to investigate how white matter (WM) lesion distribution and cortical atrophy topographically interrelate and affect functional disability. METHODS: Clinical disability was measured using the Expanded Disability Status Scale Score at baseline and at 1-year follow-up in a cohort of 119 patients with early relapsing-remitting MS and in a replication cohort of 81 patients. Covarying patterns of cortical atrophy and baseline lesion distribution were extracted by parallel independent component analysis. Predictive power of covarying patterns for disability progression was tested by receiver operating characteristic analysis at the group level and support vector machine for individual patient outcome. RESULTS: In the study cohort, we identified 3 distinct distribution types of WM lesions (cerebellar, bihemispheric, and left lateralized) that were associated with characteristic cortical atrophy distributions. The cerebellar and left-lateralized patterns were reproducibly detected in the second cohort. Each of the patterns predicted to different extents, short-term disability progression, whereas the cerebellar pattern was associated with the highest risk of clinical worsening, predicting individual disability progression with an accuracy of 88% (study cohort) and 89% (replication cohort), respectively. CONCLUSION: These findings highlight the role of distinct spatial distribution of cortical atrophy and WM lesions predicting disability. The cerebellar involvement is shown as a key determinant of rapid clinical deterioration.

Increased cerebrospinal fluid albumin and immunoglobulin A fractions forecast cortical atrophy and longitudinal functional deterioration in relapsing-remitting multiple sclerosis.

BACKGROUND: Currently, no unequivocal predictors of disease evolution exist in patients with multiple sclerosis (MS). Cortical atrophy measurements are, however, closely associated with cumulative disability. OBJECTIVE: Here, we aim to forecast longitudinal magnetic resonance imaging (MRI)-driven cortical atrophy and clinical disability from cerebrospinal fluid (CSF) markers. METHODS: We analyzed CSF fractions of albumin and immunoglobulins (Ig) A, G, and M and their CSF to serum quotients. RESULTS: Widespread atrophy was highly associated with increased baseline CSF concentrations and quotients of albumin and IgA. Patients with increased CSFIgA and CSFIgM showed higher functional disability at follow-up. CONCLUSION: CSF markers of blood-brain barrier integrity and specific immune response forecast emerging gray matter pathology and disease progression in MS.

Postoperative rehabilitation after deep brain stimulation surgery for movement disorders.

Deep brain stimulation (DBS) is a highly efficient, evidence-based therapy for a set of neurological and psychiatric conditions and especially movement disorders such as Parkinson's disease, essential tremor and dystonia. Recent developments have improved the DBS technology. However, no unequivocal algorithms for an optimized postoperative care exist so far. The aim of this review is to provide a synopsis of the current clinical practice and to propose guidelines for postoperative and rehabilitative care of patients who undergo DBS. A standardized work-up in the DBS centers adapted to each patient's clinical state and needs is important, including a meticulous evaluation of clinical improvement and residual symptoms with a definition of goals for neurorehabilitation. Efficient and complete information transfer to subsequent caregivers is essential. A coordinated therapy within a multidisciplinary team (trained in movement disorders and DBS) is needed to achieve the long-range maximal efficiency. An optimized postoperative framework might ultimately lead to more effective results of DBS.

Isotopic response, Köbner phenomenon and Renbök phenomenon following herpes zoster.

Linear skin diseases may follow Blaschko's lines, Langer's relaxed skin tension lines or head zones (dermatomes), thus indicating an embryogenic, hematogenic or neuronal aspect in their pathogenesis. Köbner phenomenon describes the eruption of an inflammatory skin disease following mechanical alteration of the skin. Renbök phenomenon describes an area of non-involvement in an otherwise generalized skin disease. Wolf's isotopic response may be understood as a special subtype of Köbner phenomenon, in which one skin disease triggers a second one. Pathogenically unrelated skin diseases may follow a zosteriform distribution, if they are linked to a preceding herpes zoster by Köbner phenomenon, Renbök phenomenon or an isotopic response. We report three instructive patients diagnosed with Wegener's granulomatosis, cutaneous graft-versus-host disease and lichen planus, whose skin manifestations were following or sparing a zosteriform distribution pattern. Köbner phenomenon, Renbök phenomenon or Wolf's isotopic response may link pathogenically unrelated skin diseases to a zosteriform pattern, which may present diagnostic difficulties even for dermatologists.

Changes in microcirculation as early markers for infection in preterm infants--an observational prospective study.

In adults with severe sepsis, the disturbances of the sublingual microcirculation can be quantified with orthogonal polarization spectral imaging. We investigated the cutaneous microcirculation of preterm infants with proven infection (PosInf) and with suspected but unproven infection (NegInf). In 25 infants, orthogonal polarization spectral images were obtained daily, videos of the images were blinded, and analyzed off-line. Functional small vessel density (FSVD) was prospectively calculated from day 3 to day 30 of life. There were 17 episodes of proven and nine episodes of suspected but unproven nosocomial late onset infection. Four infants remained healthy. The data were analyzed for the 5 d before the start of antibiotics (day -5 until day -1). FSVD varied widely, but in the PosInf-group, we found a 10% decline from day -5 to day -1 (p = 0.013). There was no significant change over time in the NegInf-group (p = 0.58). Thus, in infants with proven infection, FSVD decreases already 1 d before changes in laboratory parameters. However, these changes in FSVD during infection are not represented by absolute values, but must be identified by daily intraindividual observation.

Proactive therapy of atopic eczema--an evidence-based concept with a behavioral background.

Atopic eczema is a highly pruritic, chronic inflammatory skin disease with a high socioeconomic burden. Different individually relevant exacerbating factors influence the clinical course of the disease. Current therapeutic paradigms call for maintaining or enhancing the epidermal barrier by continuous emollient therapy, which is combined with anti-inflammatory topical treatment applied to all affected areas as they appear. An alternative approach is proactive therapy, which involves long-term, low-dose intermittent topical anti-inflammatory therapy for previously affected areas with subclinical inflammation. The immunodermatological background to this approach is the ongoing epidermal barrier dysfunction, the residual inflammatory skin infiltrate and the persistent immunological abnormalities which are all present but clinically invisible. This manuscript summarizes the immunodermatological and behavioral background, the study data of controlled clinical trials and our personal experience in a special atopic dermatitis clinic. The clinical advantages of proactive therapy are fewer exacerbations, an improved quality of life and--in severe cases--lower treatment costs.

Functional vessel density in the first month of life in preterm neonates.

Changes in microcirculation have been recognized as central to many disease processes. The aim of this study was to evaluate factors, which influence the microcirculation of the skin during the first month of life in premature infants. Red blood cell (RBC) velocity, vessel diameter, and functional small vessel density (FSVD) were measured daily for the first 30 d on the upper arm in preterm infants with gestational age <30 wk. Orthogonal polarization spectral (OPS) images were analyzed off-line with the Capi- Scope-Image program. In 25 infants, FSVD decreased significantly from week 1 (mean +/- SD 236 +/- 33 cm/cm2) to week 4 (207 +/- 30 cm/cm2) and correlated directly with Hb levels and incubator temperature. Vessel diameters and RBC velocity did not change significantly, nor did clinical parameters such as blood pressure, heart rate or body temperature. Microvascular parameters were not dependent on gestational or postnatal age. The microcirculation of the skin might be an easily accessible window to obtain better understanding of circulatory changes in the postnatal period. Our data are essential as basis for further studies in this field. Hb levels and possible incubator temperatures have a substantial influence on functional small vessel density and therefore need to be taken in account.