Machine learning using multimodal clinical, electroencephalographic, and magnetic resonance imaging data can predict incident depression in adults with epilepsy: A pilot study.

OBJECTIVE: This study was undertaken to develop a multimodal machine learning (ML) approach for predicting incident depression in adults with epilepsy. METHODS: We randomly selected 200 patients from the Calgary Comprehensive Epilepsy Program registry and linked their registry-based clinical data to their first-available clinical electroencephalogram (EEG) and magnetic resonance imaging (MRI) study. We excluded patients with a clinical or Neurological Disorders Depression Inventory for Epilepsy (NDDI-E)-based diagnosis of major depression at baseline. The NDDI-E was used to detect incident depression over a median of 2.4 years of follow-up (interquartile range [IQR] = 1.5-3.3 years). A ReliefF algorithm was applied to clinical as well as quantitative EEG and MRI parameters for feature selection. Six ML algorithms were trained and tested using stratified threefold cross-validation. Multiple metrics were used to assess model performances. RESULTS: Of 200 patients, 150 had EEG and MRI data of sufficient quality for ML, of whom 59 were excluded due to prevalent depression. Therefore, 91 patients (41 women) were included, with a median age of 29 (IQR = 22-44) years. A total of 42 features were selected by ReliefF, none of which was a quantitative MRI or EEG variable. All models had a sensitivity > 80%, and five of six had an F1 score ≥ .72. A multilayer perceptron model had the highest F1 score (median = .74, IQR = .71-.78) and sensitivity (84.3%). Median area under the receiver operating characteristic curve and normalized Matthews correlation coefficient were .70 (IQR = .64-.78) and .57 (IQR = .50-.65), respectively. SIGNIFICANCE: Multimodal ML using baseline features can predict incident depression in this population. Our pilot models demonstrated high accuracy for depression prediction. However, overall performance and calibration can be improved. This model has promise for identifying those at risk for incident depression during follow-up, although efforts to refine it in larger populations along with external validation are required.

Neurological manifestations in coronavirus disease 2019.

Coronavirus disease 2019 (COVID-19), an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is currently hitting the world in the form of a pandemic. Given that some reports suggest that this infection can also occur with neurologic manifestations, this narrative review addresses the basic and clinical aspects concerning the nervous system involvement associated with this disease. More than one third of patients hospitalized for COVID-19 can present with both central and peripheral neurological manifestations. The former include dizziness and headache, while the latter include taste and smell disturbances. Other reported neurological manifestations are cerebrovascular disease and epileptic seizures. According to published reports, neurological disorders are not uncommon in COVID-19 and can sometimes represent the first manifestation of the disease; therefore, neurologists should consider this diagnostic possibility in their daily practice. Since maybe not all COVID-19 neurological manifestations are due to SARS-CoV-2 direct effects, it is important to monitor the rest of the clinical parameters such as, for example, oxygen saturation. Similarly, follow-up of patients is advisable, since whether neurological complications may develop lately is thus far unknown.

La enfermedad del coronavirus 2019 (COVID-19), infección causada por el coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2), actualmente afecta al mundo en forma de una pandemia. Debido a que algunos reportes apuntan a que esta infección puede cursar también con manifestaciones neurológicas, en esta revisión narrativa se abordan los aspectos básicos y clínicos concernientes a la afectación del sistema nervioso por esta enfermedad. Más de un tercio de los pacientes hospitalizados por COVID-19 pueden presentar manifestaciones neurológicas, tanto centrales como periféricas. Entre las primeras se encuentran el mareo y la cefalea; y entre las segundas, las alteraciones del gusto y el olfato. Otras manifestaciones neurológicas reportadas son la enfermedad vascular cerebral y las crisis epilépticas. Según los informes publicados, los padecimientos neurológicos no son infrecuentes en COVID-19 y en ocasiones pueden representar la primera manifestación de la enfermedad, de modo que los neurólogos deberán considerar esta posibilidad diagnóstica en su práctica cotidiana. Dado que no todas las manifestaciones neurológicas de COVID-19 pudieran deberse a efectos directos de SARS-CoV-2, es importante monitorear el resto de los parámetros clínicos, por ejemplo, la oxigenación. De igual forma, es recomendable el seguimiento de los pacientes, ya que hasta el momento se ignora si las complicaciones neurológicas pueden desarrollarse tardíamente.

Neurocysticercosis: mimics and chameleons.

Neurocysticercosis is the most common parasitic neurological disease worldwide, yet in Europe, it remains relatively uncommon, with many practitioners rarely seeing a case. However, immigration and international travel mean that it is becoming increasingly recognised and diagnosed in developed countries. Being a treatable condition, it is essential to be familiar with the diagnosis and to appreciate its mimics and breadth of its possible clinical presentations.

Two kinds of apoplexy in the Colonial press. / Dos clases de apoplejía en la prensa novohispana.

In 1787, three Colonial physicians quoted from Le Clerc (1726-1798) in the Gazeta de México. The French author lists six specific cases where bloodletting is often fatal, including two kinds of apoplexy: the serous and the lacteal. Both conditions are nowadays unknown to the majority of specialists in clinical neurology, and we therefore conducted an historical review of these conditions.

Portal vein thrombosis in patients with cirrhosis: just a common finding or a predictor of poor outcome?

 Background & Aims. It is unclear whether portal vein thrombosis (PVT) unrelated to malignancy is associated with reduced survival or it is an epiphenomenon of advanced cirrhosis. The objective of this study was to assess clinical outcome in cirrhotic patients with PVT not associated with malignancy and determine its prevalence. MATERIAL AND METHODS: Retrospective search in one center from June 2011 to December 2014. RESULTS: 169 patients, 55 women and 114 men, median age 54 (19-90) years. Thirteen had PVT (7.6%). None of the patients received anticoagulant treatment. The PVT group was younger (49 [25-62] vs. 55 [19-90] years p = 0.025). Child A patients were more frequent in PVT and Child C in Non-PVT. Median Model for End Stage Liver Disease (MELD) score was lower in PVT (12 [8-21] vs. 19 [7-51] p ≤ 0.001) p ≤ 0.001). There was no difference between upper gastrointestinal bleeding and spontaneous bacterial peritonitis in the groups. Encephalopathy grade 3-4 (4 [30.8%] vs. 73 [46.8%] p = 0,007) and large volume ascites (5 [38.5%] vs. 89 [57.1%] p= 0,012) was more common in non-PVT. Survival was better for PVT (16.5 ± 27.9 vs. 4.13 ± 12.2 months p = 0.005). CONCLUSIONS: We found that PVT itself does not lead to a worse prognosis. The most reliable predictor for clinical outcome remains the MELD score. The presence of PVT could be just an epiphenomenon and not a marker of advanced cirrhosis.

[On roman philonium]. / Sobre el filonio romano.

The roman philonium (Philonium Romanum) is an example of pharmacological poetry. This opiate was conceived by Philo of Tarsus, who was active during the first century of the Common Era. His antidote was written in elegiac couplets. The conservation of these couplets is owed to Galen, who reproduced them in the ninth book of On the Composition of Medicines according to the Places. Most of this Galenic treatise has not been translated into Spanish. For the first time, we offer this prescription in our language from a French version of the fin de siècle. Additionally, we attempt an exegesis of Philo's poem.

[On Alexander's pneumothorax: A critical appraisal]. / El neumotórax de Alejandro Magno: una apreciación crítica.

According to the testimony of Ptolemy, which we know through Arrian, it has been assumed that Alexander the Great suffered a pneumothorax during his campaign against the Malli. In general, this assumption has been interpreted as a historical fact in medical literature. We consulted the same sources and concluded that it is unlikely that Alexander's arrow wound had given him a pneumothorax. In addition, we stressed the extra-historical content of classical sources.

[Neurological contribution of Manuel Acuña]. / Aportación neurológica de Manuel Acuña.

José María Barceló de Villagrán (1819-1872) was the first Professor of Topographic Anatomy in Mexico. The Mexican poet Manuel Acuña (1849-1873) was among his students. After the death of his mentor, Acuña wrote a monograph entitled"Topographic Anatomy. The Cephalo-Rachidian Cavity" (1893). For the first time we discuss the content and significance of this monograph.

[Apixaban as therapeutic option in nephropathy patients with heparin-induced thrombocytopenia (HIT)]. / Apixaban como opción terapéutica en el paciente nefrópata con trombocitopenia inducida por heparina (TIH).

Heparin-induced thrombocytopenia (HIT) is a prothrombotic condition caused by antibodies against the heparin-PF4 complex. This disorder is even more problematic in patients undergoing hemodialysis since they are repeatedly exposed to heparin. The diagnostic and therapeutic approach is particularly challenging in this population. We report the case of a woman with chronic kidney disease and a high pretest probability for heparin-induced thrombocytopenia who was acutely treated with apixaban, an oral selective factor Xa inhibitor.

[Peredo's Inferno: a Mexican physician-translator in the XIX century]. / El Infierno de Peredo: un médico y traductor mexicano del siglo XIX.

Manuel Peredo (1830-1890) participated fully in Mexico's national literary circles during the second half of the 19th century. Besides being recognized for his translation of Basch's Memories of Mexico, Peredo also translated the first tercets of Inferno's Canto XXXIII. Although forgotten today, his contribution is significant since it is the second Mexican translation of Dante, and particularly, the first Mexican translation of Canto XXXIII.

Association of comorbid-socioeconomic clusters with mortality in late onset epilepsy derived through unsupervised machine learning.

BACKGROUND AND OBJECTIVES: Late-onset epilepsy is a heterogenous entity associated with specific aetiologies and an elevated risk of premature mortality. Specific multimorbid-socioeconomic profiles and their unique prognostic trajectories have not been described. We sought to determine if specific clusters of late onset epilepsy exist, and whether they have unique hazards of premature mortality. METHODS: We performed a retrospective observational cohort study linking primary and hospital-based UK electronic health records with vital statistics data (covering years 1998-2019) to identify all cases of incident late onset epilepsy (from people aged ≥65) and 1:10 age, sex, and GP practice-matched controls. We applied hierarchical agglomerative clustering using common aetiologies identified at baseline to define multimorbid-socioeconomic profiles, compare hazards of early mortality, and tabulating causes of death stratified by cluster. RESULTS: From 1,032,129 people aged ≥65, we identified 1048 cases of late onset epilepsy who were matched to 10,259 controls. Median age at epilepsy diagnosis was 68 (interquartile range: 66-72) and 474 (45%) were female. The hazard of premature mortality related to late-onset epilepsy was higher than matched controls (hazard ratio [HR] 1.73; 95% confidence interval [95%CI] 1.51-1.99). Ten unique phenotypic clusters were identified, defined by 'healthy' males and females, ischaemic stroke, intracerebral haemorrhage (ICH), ICH and alcohol misuse, dementia and anxiety, anxiety, depression in males and females, and brain tumours. Cluster-specific hazards were often similar to that derived for late-onset epilepsy as a whole. Clusters that differed significantly from the base late-onset epilepsy hazard were 'dementia and anxiety' (HR 5.36; 95%CI 3.31-8.68), 'brain tumour' (HR 4.97; 95%CI 2.89-8.56), 'ICH and alcohol misuse' (HR 2.91; 95%CI 1.76-4.81), and 'ischaemic stroke' (HR 2.83; 95%CI 1.83-4.04). These cluster-specific risks were also elevated compared to those derived for tumours, dementia, ischaemic stroke, and ICH in the whole population. Seizure-related cause of death was uncommon and restricted to the ICH, ICH and alcohol misuse, and healthy female clusters. SIGNIFICANCE: Late-onset epilepsy is an amalgam of unique phenotypic clusters that can be quantitatively defined. Late-onset epilepsy and cluster-specific comorbid profiles have complex effects on premature mortality above and beyond the base rates attributed to epilepsy and cluster-defining comorbidities alone.

Barriers to access and unmet needs to neuromyelitis optica spectrum disorders care in an Argentinean cohort.

INTRODUCTION: Neuromyelitis optica spectrum disorder (NMOSD) is a rare but severe neuroimmunological condition associated with a significant financial burden. NMOSD is also associated with increased health care utilization, including neurology outpatient visits, magnetic resonance imaging (MRI) use, long-term medication, among others. We aimed to evaluate real-world patient experiences in access to care and NMOSD burden in an Argentinean cohort. METHODS: This cross-sectional study used a self-administered survey and was conducted in Argentina (2022). Patients with NMOSD were divided into three groups: private health insurance (PHI), social health insurance (SHI), and public health insurance (PHI, Ministry of Public Health). Differences in access and health care barriers were assessed. RESULTS: One hundred patients with NMOSD (74 women) with a mean age at diagnosis of 38.7 years were included. Their EDSS was 2.8 and they were followed for 5.2 years. Of them, 51%, 11%, and 13% were employed (full-time: 57.5%), currently unemployed and retired by NMOSD, respectively. 55% of them visited between 2-3 specialists before NMOSD diagnosis. Aquaporin-4-antibody and/or myelin oligodendrocyte glycoprotein-antibody testing was requested in 91% (health insurance covered this partially in 15.3% and 32.9% of the time the test was entirely paid by patient/family). Patients with NMOSD receiving private medical care reported greater access to MRI, outpatient visits, and fewer issues to obtain NMOSD medications compared to those treated at public institutions. A longer mean time to MRI and neurology visit was found in the PHI group when compared with the other two subgroups. Regression analysis showed that private insurance (OR=3.84, p=0.01) was the only independent factor associated with appropriate access to NMOSD medications in Argentina. CONCLUSION: These findings suggest that barriers to access and utilization of NMOSD care services in Argentina are common. NMOSD patients experienced problems to receive NMOSD medication properly, especially those from the public sector.

[The Emperor's physician before and after the Empire]. / El médico imperial antes y después del Imperio.

S. Basch (1837-1905) succeeded F. Semeleder as personal physician to the Mexican emperor. The newly appointed imperial physician had been a pupil of Brücke (1819-1892) in Vienna. After the death of the emperor, Basch returned to Europe, where he would study under the guidance of K. Ludwig (1816-1895). Thereafter he invented the sphygmomanometer in Berlin.

The patient journey with NMOSD: From initial diagnosis to chronic condition.

Objective: To better understand the patient experience with neuromyelitis optica spectrum disorder (NMOSD) through the course of the illness. Background: NMOSD is a rare autoimmune disorder that causes recurrent inflammatory attacks of the optic nerve, spinal cord, and brain. Knowledge and awareness of NMOSD in the general medical community are often limited, resulting in potential delays in diagnosis and treatment. Design/methods: We developed a comprehensive 101-question survey to understand the patient's perspective on their journey from initial presentation to present condition. The survey covered basic demographics, symptoms, medical tests used to reach a diagnosis, and the patient's psychosocial responses to their diagnosis. The survey included questions to determine internal consistency in responses. We shared the survey with members of the Neuromyelitis Optica (NMO) Clinic Facebook group and received responses from 151 patients. All data collected were self-reported and presented as summary statistics. Results: The majority of survey responses were from patients who were female (83%) and White (76%), Asian (7%), or African American (7%). Initial symptoms of disease included fatigue, pain, stiffness/spasticity, bladder and bowel dysfunction, cognitive/emotional symptoms, and visual disturbances. Initial reactions to NMOSD diagnosis were frequently fear, anxiety, and/or depression. Mean (SD) time to diagnosis was 2.2 (3.2) years. First contact with a medical professional was felt to be not helpful or somewhat helpful for many patients (71%), in part due to uncertain diagnosis and/or treatment. However, once referred to specialists (primarily neurologists), the majority of patients (87%) reported finding a professional who could help. Tests leading to diagnosis included magnetic resonance imaging, lumbar puncture, and blood tests for autoantibodies including aquaporin-4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG). While approximately 30% of patients still felt challenged for a variety of reasons, most patients reported that having a diagnosis and being under the care of a specialist contributed to a comprehensive plan with hope for their future. Conclusions: The NMOSD patient journey frequently begins with anxiety, fear, and frustration. Finding the right specialist and identifying appropriate screening tests can lead to earlier diagnosis and progression toward better patient outcomes.

Future of Neurology & Technology: Stereo-electroencephalography in Presurgical Epilepsy Evaluation.

Stereo-electroencephalography (SEEG) is not only a sophisticated and highly technological investigation but a new and better way to conceptualize the spatial and temporal dynamics of epileptic activity. The first intracranial investigations with SEEG were carried out in France in the mid-twentieth century; however, its use in North America is much more recent. Given its significantly lower risk of complications and its ability to sample both superficial and deep structures as well as both hemispheres simultaneously, SEEG has become the preferred method to conduct intracranial EEG monitoring in most comprehensive epilepsy centers in North America. SEEG is an invasive neurophysiological methodology used for advanced pre-surgical work-up in the 20% of drug-resistant patients with more complex focal epilepsy in whom non-invasive investigations do not allow to decide on surgical candidacy. SEEG uses stereotactically-implanted depth electrodes to map the origin and propagation of epileptic seizures by creating a three-dimensional representation of the abnormal electrical activity in the brain. SEEG analysis takes into account the background, interictal, and ictal activity, as well as the results of cortical electrical stimulation procedures, to reliably delineate the epileptogenic network. By means of a clinical vignette, this article will walk general neurologists, but especially neurology trainees through the immense potential of this methodology. In summary, SEEG enables to accurately identify the epileptogenic zone in patients with drug-resistant focal epilepsy who otherwise would be not amenable to surgical treatment, the best way to improve seizure control and achieve seizure-freedom in this patient population.

The use of patient-reported measures in epilepsy care: the Calgary Comprehensive Epilepsy Program experience.

The regular use of patient-reported measures (PRMs) has been associated with greater patient satisfaction and outcomes. In this article, we will review the Calgary Comprehensive Epilepsy Program's successful experience with PRMs in both clinical and research settings, as well as our current challenges and future directions. Our experience will illustrate that is feasible and convenient to implement PRMs, and especially electronic PRMs (ePRMs), into epilepsy clinics. These PRMs have direct clinical and research applications. They inform clinical decision making through readily interpretable scales to which clinicians can expeditiously respond. Equally, they are increasingly forming an integral and central component of intervention and outcomes-based research. However, implementation studies are necessary to address knowledge gaps and facilitate adoption and dissemination of this approach. A natural symbiosis of the clinical and research realms is precision medicine. The foundations of precision-based interventions are now being set whereby we can maximize the quality of life and psychosocial functioning on an individual level. As illustrated in this article, this exciting prospect crucially depends on the routine use of ePRMs in the everyday care of people with epilepsy. Increasing ePRMs uptake will clearly be a catalyst propelling precision epilepsy from aspiration to clinical reality.