Long-term safety of OnabotulinumtoxinA treatment in chronic migraine patients: a five-year retrospective study.

Background: Real-world studies have shown the sustained therapeutic effect and favourable safety profile of OnabotulinumtoxinA (BoNTA) in the long term and up to 4 years of treatment in chronic migraine (CM). This study aims to assess the safety profile and efficacy of BoNTA in CM after 5 years of treatment in a real-life setting. Methods: We performed a retrospective chart review of patients with CM in relation to BoNTA treatment for more than 5 years in 19 Spanish headache clinics. We excluded patients who discontinued treatment due to lack of efficacy or poor tolerability. Results: 489 patients were included [mean age 49, 82.8% women]. The mean age of onset of migraine was 21.8 years; patients had CM with a mean of 6.4 years (20.8% fulfilled the aura criteria). At baseline, patients reported a mean of 24.7 monthly headache days (MHDs) and 15.7 monthly migraine days (MMDs). In relation to effectiveness, the responder rate was 59.1% and the mean reduction in MMDs was 9.4 days (15.7 to 6.3 days; p < 0.001). The MHDs were also reduced by 14.9 days (24.7 to 9.8 days; p < 0.001). Regarding the side effects, 17.5% experienced neck pain, 17.3% headache, 8.5% eyelid ptosis, 7.5% temporal muscle atrophy and 3.2% trapezius muscle atrophy. Furthermore, after longer-term exposure exceeding 5 years, there were no serious adverse events (AE) or treatment discontinuation because of safety or tolerability issues. Conclusion: Treatment with BoNTA led to sustained reductions in migraine frequency, even after long-term exposure exceeding 5 years, with no evidence of new safety concerns.

MAB-MIG: registry of the spanish neurological society of erenumab for migraine prevention.

BACKGROUND: Erenumab was approved in Europe for migraine prevention in patients with ≥ 4 monthly migraine days (MMDs). In Spain, Novartis started a personalized managed access program, which allowed free access to erenumab before official reimbursement. The Spanish Neurological Society started a prospective registry to evaluate real-world effectiveness and tolerability, and all Spanish headache experts were invited to participate. We present their first results. METHODS: Patients fulfilled the ICHD-3 criteria for migraine and had ≥ 4 MMDs. Sociodemographic and clinical data were registered as well as MMDs, monthly headache days, MHDs, prior and concomitant preventive treatment, medication overuse headache (MOH), migraine evolution, adverse events, and patient-reported outcomes (PROs): headache impact test (HIT-6), migraine disability assessment questionnaire (MIDAS), and patient global improvement change (PGIC). A > 50% reduction of MMDs after 12 weeks was considered as a response. RESULTS: We included 210 patients (female 86.7%, mean age 46.4 years old) from 22 Spanish hospitals from February 2019 to June 2020. Most patients (89.5%) suffered from chronic migraine with a mean evolution of 8.6 years. MOH was present in 70% of patients, and 17.1% had migraine with aura. Patients had failed a mean of 7.8 preventive treatments at baseline (botulinum toxin type A-BoNT/A-had been used by 95.2% of patients). Most patients (67.6%) started with erenumab 70 mg. Sixty-one percent of patients were also simultaneously taking oral preventive drugs and 27.6% were getting simultaneous BoNT/A. Responder rate was 37.1% and the mean reduction of MMDs and MHDs was -6.28 and -8.6, respectively. Changes in PROs were: MIDAS: -35 points, HIT-6: -11.6 points, PIGC: 4.7 points. Predictors of good response were prior HIT-6 score < 80 points (p = 0.01), ≤ 5 prior preventive treatment failures (p = 0.026), absence of MOH (p = 0.039), and simultaneous BoNT/A treatment (p < 0.001). Twenty percent of patients had an adverse event, but only two of them were severe (0.9%), which led to treatment discontinuation. Mild constipation was the most frequent adverse event (8.1%). CONCLUSIONS: In real-life, in a personalized managed access program, erenumab shows a good effectiveness profile and an excellent tolerability in migraine prevention in our cohort of refractory patients.

Impact of adrenomedullin levels on clinical risk stratification and outcome in subarachnoid haemorrhage.

PURPOSE: To use classification tree analysis to identify risk factors for nonsurvival in a neurological patients with subarachnoid haemorrhage (SAH) and to propose a clinical model for predicting of mortality. METHODS: Prospective study of SAH admitted to a Critical Care Department and Stroke Unit over a 2-year period. Middle region of pro-ADM plasma levels (MR-proADM) was measured in EDTA plasma within the first 24 hours of hospital admission using the automatic immunofluorescence test. A regression tree was made to identify prognostic models for the development of mortality at 90 days. RESULTS: Ninety patients were included. The mean MR-proADM plasma value in the samples analysed was 0.78 ± 0.41 nmol/L. MR-proADM plasma levels were significantly associated with mortality at 90 days (1.05 ± 0.51 nmol/L vs 0.64 ± 0.25 nmol/L; P < .001). Regression tree analysis provided an algorithm based on the combined use of clinical variables and one biomarker allowing accurate mortality discrimination of three distinct subgroups with high risk of 90-day mortality ranged from 75% to 100% (AUC 0.9; 95% CI 0.83-0.98). CONCLUSIONS: The study established a model (APACHE II, MR-proADM and Hunt&Hess) to predict fatal outcomes in patients with SAH. The proposed decision-making algorithm may help identify patients with a high risk of mortality.

Wilson's disease: A new perspective review on its genetics, diagnosis and treatment.

Wilson's disease (WD) is an autosomal recessive disorder which is caused by poor excretion of copper in mammalian cells. In this review, various issues such as effective characterization of ATP7B genes, scope of gene network topology in genetic analysis, pattern recognition using different computing approaches and fusion possibilities in imaging and genetic dataset are discussed vividly. We categorized this study into three major sections: (A) WD genetics, (B) diagnosis guidelines and (3) treatment possibilities. We addressed the scope of advanced mathematical modelling paradigms for understanding common genetic sequences and dominating WD imaging biomarkers. We have also discussed current state-of-the-art software models for genetic sequencing. Further, we hypothesized that involvement of machine and deep learning techniques in the context of WD genetics and image processing for precise classification of WD. These computing procedures signify changing roles of various data transformation techniques with respect to supervised and unsupervised learning models.

Long-term Survival after Carotid Endarterectomy in a Population with a Low Coronary Heart Disease Fatality: Implications for Decision Making.

BACKGROUND: According to the current guidelines, long-term survival is an important factor influencing decision making in patients with severe asymptomatic carotid stenosis. Nevertheless, data are lacking for populations with a low incidence of coronary heart disease, the main cause of death among these patients. We aimed to assess the long-term survival after carotid endarterectomy (CEA) in a Mediterranean hospital. METHODS: Retrospective analysis was conducted of 291 consecutive patients (main age 69 years, 78.7% men) who underwent a CEA for symptomatic (n = 147, 50.5%) or asymptomatic (n = 144, 49.5%) carotid stenosis in 2005-2014 at the Hospital del Mar (Barcelona, Spain). A Kaplan-Meier life table was done and a multivariable Cox regression model was built for the analysis of the long-term survival-associated risk factors. RESULTS: The immediate combined mortality and/or neurological morbidity rate was 2.7%. The mean follow-up was 55 months (complete in 99.7%). During follow-up 62 patients (21.3%) died, being cancer the most frequent cause (35.5%). Cumulative 3- and 5-year survival rates were 89% and 81%, respectively. Independent risk factors (Cox regression) related to survival included age (hazards ratio [HR] 1.09, P < 0.001), an American Society of Anesthesiologists class IV score (HR 4.04, P = 0.015), and the preoperative hemoglobin value (HR 0.73, P < 0.001). The discrimination of the resulting model was 0.719 (95% confidence interval 0.644-0.794). Previous symptomatic carotid stenosis was not related to long-term survival. CONCLUSIONS: The long-term survival of patients submitted to CEA in our series lies in the lower limit of the estimated range by other groups and is markedly related to cancer. Our study suggests that predictive models for survival are influenced by regional characteristics.

Expansion of the NKG2C+ natural killer-cell subset is associated with high-risk carotid atherosclerotic plaques in seropositive patients for human cytomegalovirus.

OBJECTIVE: Human cytomegalovirus (HCMV), a pathogen involved in the development and progression of atherosclerosis, promotes in some individuals a marked reconfiguration of the natural killer (NK)-cell compartment whose hallmark is a persistent expansion of a peripheral blood NK-cell subset expressing the CD94/NKG2C NK receptor. We aimed to evaluate whether the HCMV-associated NK-cell compartment reconfiguration is related to carotid atherosclerotic plaque (CAP) instability. APPROACH AND RESULTS: NK receptor expression (ie, LILRB1, NKG2A, NKG2C, and killer immunoglobulin-like receptors [KIR]) by peripheral NK and T cells was evaluated in 40 patients with HCMV+ with CAP, including nonatherosclerotic strokes (n=15) and healthy subjects (n=11) as controls. High-risk CAP (n=16), defined as carotid stenosis >50% with ipsilateral neurological symptomatology in the previous 180 days, compared with non-high-risk CAP had higher %NKG2C+ NK cells (29.5 ± 22.4% versus 16.3 ± 13.2%; P=0.026; odds ratio, 1.053; 95% confidence interval, 1.002-1.106; P=0.042), with a corresponding reduction in the NKG2A+ NK subset (31.7 ± 17.8% versus 41.8 ± 15.8%; P=0.072). The proportions of NKG2C+ NK cells in high-risk CAP were inversely correlated with the CD4+/CD8+ ratio (R(Spearman)=-0.629; P=0.009) and directly with high-sensitivity C-reactive protein levels (R(Pearson) = 0.591; P=0.012), consistent with higher subclinical systemic inflammation. The intraplaque inflammatory infiltrate, evaluated in 27 CAP obtained after endarterectomy, showed a higher presence of subintimal CD3+ lymphocytes in those patients with HCMV-induced changes in the peripheral NK- and T-cell compartments. CONCLUSIONS: The expansion of NKG2C+ NK cells in patients with CAP seems to be associated with an increased risk of plaque destabilization in some patients with chronic HCMV infection.

Incidencia de la hiponatremia y de sus causas en pacientes neurológicos / Incidence of hyponatremia and its causes in neurological patients

Introducción La hiponatremia se considera el trastorno electrolítico más frecuentemente hallado entre pacientes hospitalizados y parece ser un factor pronóstico en dicha hospitalización. Métodos Se realizó un estudio prospectivo observacional en pacientes ingresados de forma consecutiva en el Hospital del Mar de Barcelona, durante un período de 3 meses. Se realizó un ionograma en sangre y orina, así como la osmolalidad en plasma y orina, al ingreso y tras 3–5 días en aquellos que presentaban hiponatremia. Resultados De los 130 pacientes incluidos, 19 (14,6%) presentaron hiponatremia. Las causas de hiponatremia fueron las siguientes: administración de sueros hipotónicos, 4 (21%); medicación antihipertensiva, 4 (21%); síndrome de secreción inadecuada de hormona antidiurética, 4 (21%); síndrome pierde sal cerebral, 2 (10%); estado edematoso causado por hepatopatía, uno (5%), pérdidas digestivas, 2 (10%), cardiopatia hipertensiva, 1 (5%) y 1 paciente sin diagnóstico etiológico (5%). La mortalidad fue de uno (5%) y 0 (0%) entre los pacientes con y sin hiponatremia, respectivamente. Conclusión La hiponatremia es un trastorno común entre pacientes neurológicos hospitalizados, y la falta de diagnóstico podría ser interpretada como un empeoramiento del cuadro neurológico (AU)

Introduction Hyponatremia is considered the most frequent electrolyte disorder found in hospitalized patients and seems to be a prognostic factor during hospitalization. Methods A prospective observational study was carried out in consecutive neurological patients admitted to our hospital over a 3-month period. Blood and urinary ionogram and osmolality were determined at entry and 3–5 days after admission in all patients with hyponatremia. Results Of the 130 patients admitted, 19 (14.6%) had hyponatremia. The causes of hyponatremia were as follows: inappropriate fluid replacement in 4 patients (21%), antihypertensive drugs in 4 (21%), syndrome of inappropriate secretion of antidiuretic hormone in 4 (21%), cerebral salt wasting syndrome in 2 (10%), and edematous status caused by liver disease in one and digestive loss in one (5%) each. Mortality was one (5%) and 0 (0%) among patients with and without hyponatremia, respectively.Conclusion Hyponatremia is common in hospitalized neurological patients and can be misdiagnosed as a worsening of the main illness (AU)

[Incidence of hyponatremia and its causes in neurological patients]. / Incidencia de la hiponatremia y de sus causas en pacientes neurológicos.

INTRODUCTION: Hyponatremia is considered the most frequent electrolyte disorder found in hospitalized patients and seems to be a prognostic factor during hospitalization. METHODS: A prospective observational study was carried out in consecutive neurological patients admitted to our hospital over a 3-month period. Blood and urinary ionogram and osmolality were determined at entry and 3-5 days after admission in all patients with hyponatremia. RESULTS: Of the 130 patients admitted, 19 (14.6%) had hyponatremia. The causes of hyponatremia were as follows: inappropriate fluid replacement in 4 patients (21%), antihypertensive drugs in 4 (21%), syndrome of inappropriate secretion of antidiuretic hormone in 4 (21%), cerebral salt wasting syndrome in 2 (10%), and edematous status caused by liver disease in one and digestive loss in one (5%) each. Mortality was one (5%) and 0 (0%) among patients with and without hyponatremia, respectively. CONCLUSION: Hyponatremia is common in hospitalized neurological patients and can be misdiagnosed as a worsening of the main illness.

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