Impact of sense of coherence on quality of life in patients with multiple sclerosis.

AIM: Aiming at finding an effective way of empowering patients with multiple sclerosis (MS) to cope with their disease, the objective of the study was to explore the impact of sense of coherence (SOC) on their health-related quality of life (HRQoL). METHODS: A total of 134/150 eligible MS patients followed-up at the Department of Neurology of the University Medical Centre Maribor, Slovenia, completed a multiple sclerosis quality of life 54 questionnaire (MSQoL-54) for assessment of HRQoL, and SOC-13-item questionnaire for assessment of SOC in 2013. Multiple linear regression was used to analyze the association between the SOC score and mental and physical subscores of MSQoL-54 adjusted to disease-related and sociodemographic characteristics as potential confounders. RESULTS: In a univariate analysis SOC score proved to be the strongest predictor of mental subscore of MSQoL-54 (b = 0.834; p < 0.001) explaining 35.6% of its variance. When adjusted for confounders, it retained its position as the most important predictor (b = 0.758; p < 0.001). On the other hand, SOC score was a slightly less important predictor of physical subscore of MSQoL-54, being the fourth strongest factor (b = 0.582; p < 0.001) in univariate analysis explaining 19.1% of the variance; however, when adjusted for confounders, its importance slightly increased by becoming the third most important predictor (b = 0.508; p < 0.001). CONCLUSION: Based on the results of the present study, we can propose SOC as an important and suitable intervention targeted outcome to consider in managing both aspects of MS difficulties.

Intracranial Vertebrobasilar Calcification in Patients with Ischemic Stroke is a Predictor of Recurrent Stroke, Vascular Disease, and Death: A Case-Control Study.

Intracranial artery calcification can be detected on nonenhanced brain computer tomography (NECT) and is a predictor of early vascular events. Here, we assessed the impact of vertebrobasilar artery calcification (VBC) on the long-term risk for recurrent stroke and vascular events. We performed a case-control trial of all consecutive stroke patients admitted to the University Hospital of Maribor, Slovenia over a period of 14 months. VBC was defined as presence of a hyperdense area within vertebrobasilar arteries that exceeds > 90 Hounsfield units as seen on NECT. Clinical follow-up information was obtained from the hospital documentation system and mortality registry of the district and included recurrent stroke, subsequent vascular events (myocardial infarction, heart failure, peripheral arterial occlusive disease), and death. We followed a total of 448 patients for a median of 1505 days (interquartile range, IQR 188-2479). Evidence for VBC was present in 243 (54.2%) patients. Median age was 76 years, recurrent stroke occurred in 33 (7.4%), any vascular events in 71 (15.8%), and death in 276 (61.6%). VBC was associated with a higher risk of recurrent stroke (hazard ratio, HR 3.13, 95% confidence interval (CI 1.35-7.20)) and vascular events (HR 2.05, 95% CI 1.21-3.47). Advanced age, male gender, and ischemic stroke involving the entire anterior circulation raised the likelihood for death. We conclude that the presence of VBC in patients with ischemic stroke is a short- and long-term prognostic factor for stroke recurrence and subsequent manifestation of acute vascular disease. Further understanding of the pathophysiology of VBC is warranted.

Management of multiple sclerosis patients in central European countries: current needs and potential solutions.

Multiple sclerosis (MS) experts in Europe are facing rapidly rising demands of excellence due to the increasing complexity of MS therapy and management. A central European expert board of MS experts met to identify needs and obstacles with respect to raising quality of MS care in central and Eastern European countries. There are substantial variations across countries regarding delivery of care and its cost structure, as well as access to treatment. To date, Eastern European countries are often less able to afford reimbursement of immunomodulatory agents than Western countries. Overall, approximately 40% of working-age patients are not working due to MS. Costs rise steeply with increasing disability; indirect costs constitute the bulk of the financial burden in patients with severe MS. Magnetic resonance imaging (MRI) assessment is meanwhile obligatory as the diagnostic interface in the management of MS patients. Recommended measures directed at improving quality of care include the collection of patient data in registries, enhanced education of healthcare professionals, implementation of national strategies aiming at reducing regional variation, optimization of approval processes, and removal of administrative barriers. Local partnerships with authorities such as those that represent the interests of employees can contribute to leverage the importance of epidemiological data. The need for education extends to (neuro)radiologists who are responsible for reporting MRI findings in expert quality. Dissemination of the Magnetic Resonance Imaging in MS (MAGNIMS) protocol would be an important step in this context. Also, clinical freedom of choice is rated as essential. Physicians should have access to a range of treatment options due to the complexity of disease. Guidelines such as the upcoming EAN-ECTRIMS clinical practice guideline also aim at providing a basis for argumentation in negotiations with national health authorities.

Newer glomerular filtration rate estimating equations for the full age spectrum based on serum creatinine and cystatin C in predicting mortality in patients with ischemic stroke.

BACKGROUND: Renal dysfunction is associated with increased risk of mortality. The novel Full Age Spectrum (FAS) equations estimating the glomerular filtration rate (GFR) based on serum creatinine (FAScrea) and cystatin C (FAScysC) are validated across the entire age spectrum and are superior markers of renal function compared to other equations. Possible association of these equations with mortality in patients with ischemic stroke is not known. PATIENTS AND METHODS: We included 390 patients (207 men, 183 women) in our observational cohort study who had suffered from an ischemic stroke and followed-up on for 3 years. Serum creatinine and cystatin C were measured at admission; GFR was estimated according to the FAScrea, CKD-EPIcrea, FAScysC and CKD-EPIcysC equations. The values of estimated GFRs were divided into quintiles. RESULTS: During the follow-up period, 173 (44.4%) patients died. The association of hazard ratios for FAScrea and CKD-EPIcrea with all-cause mortality was J-shaped and only significantly higher when comparing the fifth quintile hazard ratio for mortality with the first quintile (P < 0.001). For FAScysC and CKD-EPIcysC, hazard ratios increased from the first to the fifth quintile linearly. In an adjusted analysis, FAScrea and CKD-EPIcrea were not associated with all-cause mortality and the hazard ratios of the fifth quintile of FAScysC (P = 0.008) and CKD-EPIcysC (P = 0.042) were significantly associated with mortality compared to the first quintile. CONCLUSIONS: In patients with an ischemic stroke, estimated GFR based on serum cystatin (FAScysC and CKD-EPIcysC) was a better predictor of all-cause and cardiovascular mortality than estimated GFR based on serum creatinine.

Validation of The Slovenian Version of Multiple Sclerosis Quality of Life (MSQOL-54) Instrument.

PURPOSE: To cross-culturally adapt and validate Multiple Sclerosis Quality of Life-54 (MSQOL-54) instrument. METHODS: The study which enrolled 134 Slovenian multiple sclerosis (MS) patients was conducted from March to December 2013. The internal consistency of the MSQOL-54 instrument was evaluated by Cronbach's alpha coefficient (α), and its dimensionality assessed by the principal component analysis (PCA). RESULTS: The whole instrument had high internal consistency (α=0.88), as well as the majority of its twelve subscales (α=0.83-0.94). The results of the PCA showed two components with eigenvalue greater than 1, explaining 59.4% of the cumulative variance. Further results indicated good construct validity of the instrument with the physical health-related-quality-of-life subscales loading highly on the physical component, and mental health-related-quality-of-life subscales loading highly on the mental component. CONCLUSION: The Slovenian version of the MSQOL-54 instrument proved to be an internally consistent and accurate tool, well accepted by the Slovenian MS patients. The adequate psychometric properties warrant the scientifically sound version of the MSQOL-54 instrument, which is from now on at disposal to all health professionals dealing with MS patients in Slovenia.

Clinical role of von Willebrand factor in acute ischemic stroke.

BACKGROUND: An elevated level of von Willebrand factor (VWF) is associated with an increased risk for coronary heart disease and ischemic stroke. The objective of the study was to determine whether the level of VWF is associated with the cardioembolic subtype of ischemic stroke, stroke severity, and clinical outcome. PATIENTS AND METHODS: In this study 108 patients suffering from acute ischemic stroke (AIS) were included. According to the etiology of the stroke, patients were classified into the subtype of cardioembolic (CE) stroke and the group with non-CE stroke. Patients with non-CE stroke were further classified into subtype of large vessel disease, subtype of small vessel disease and subtype of cryptogenic stroke. Laboratory tests were performed in the acute phase and VWF was determined for all patients. The National Institutes of Health Stroke Scale (NIHSS) was applied on admission and the modified Rankin scale (MRS) at discharge. RESULTS: The only significant factor which predicted CE stroke was age (B = 0.077; standard error, SE = 0.026; P = 0.003). The level of VWF was not significantly higher in the group with the cardioembolic stroke compared to the group with non-CE stroke. Patients assessed by NIHSS on admission as the most disabled had significantly higher levels of VWF (B = 0.006; SE = 0.003; P = 0.045). Those with higher scores of MRS at discharge also had significantly increased levels of VWF (B = 0.006; SE = 0.003; P = 0.028). CONCLUSION: Among the patients with ischemic stroke, levels of VWF were not increased in those with CE stroke. High levels of VWF were associated with greater severity of stroke as well as with poor clinical outcome.

Single fiber EMG as a prognostic tool in myasthenia gravis.

INTRODUCTION: Single fiber electromyography (SFEMG) is the most sensitive diagnostic tool for diagnosis of myasthenia gravis (MG). Its prognostic value is not known. METHODS: We retrospectively analyzed the clinical course of 232 MG patients who presented with only mild symptoms and had SFEMG of the orbicularis oculi muscle. We correlated their SFEMG results with the severity of their later clinical course. RESULTS: During the observation period 39 patients (17%) developed severe disease exacerbations, and 193 (83%) remained stable. Patients with severe disease exacerbation had a significantly higher mean jitter value (P < 0.0001), a greater percentage of fibers with increased jitter (P < 0.0001), and/or impulse blocking (P < 0.0001) on SFEMG. CONCLUSIONS: The extent of the SFEMG abnormalities in this study correlated with the later clinical course of MG. Muscle Nerve 54: 1034-1040, 2016.

Cystatin C, creatinine, estimated glomerular filtration, and long-term mortality in stroke patients.

Renal dysfunction is associated with mortality in patients after ischemic stroke. Cystatin C is a potentially superior marker of renal function compared to creatinine and estimated glomerular filtration rate (GFR). In our observational cohort study, 390 Caucasian patients suffered from acute ischemic stroke (mean age 70.9 years; 183 women and 207 men) were included and prospectively followed up to maximal 56 months. Serum creatinine and cystatin C were measured at admission to the hospital; GFR was estimated according to CKD-EPI creatinine and CKD-EPI creatinine/cystatin equations. According to values of serum creatinine, estimated GFR and serum cystatin C patients were divided into quintiles. In the follow-up period, 191 (49%) patients died. For serum cystatin C and estimated GFR based on creatinine and cystatin C, the mortality and the hazard ratios for long-term mortality increased from the first to the fifth quintile nearly linearly. The associations of serum creatinine and estimated GFR categories based on creatinine with long-term mortality were J-shaped. As compared with lowest quintile of serum cystatin C, the fifth quintile was associated with long-term mortality significantly also after multivariate adjustment (age, gender, initial stroke severity, known risk factors for stroke mortality). In contrast, in adjusted analysis serum creatinine and estimated GFR (CKD-EPI creatinine and CKD-EPI creatinine/cystatin) were not associated with long-term mortality. In summary, serum cystatin C was independently and better associated with the risk of long-term mortality in patients suffering from ischemic stroke than were creatinine and estimated GFR using both CKD-EPI equations.

A prospective study about impact of renal dysfunction and morbidity and mortality on cardiovascular events after ischemic stroke.

BACKGROUND: The aim of our prospective study was to define the impact of renal dysfunction on future cardiovascular events and total mortality in 390 patients suffering from ischemic stroke. METHODS: A quantitative measurement of neurologic deficit according to National Institutes of Health Stroke Scale (NIHSS) score was performed. Blood parameters were measured. Diabetes, hypertension and smoking habits were defined. Estimated glomerular filtration rate was calculated. RESULTS: 153 (39.2%) patients had renal dysfunction. In the follow-up period in 36 (9.2%) patients acute coronary syndrome, in 102 (26.2%) recurrent ischemic stroke and in 44 (11.3%) peripheral arterial disease were documented. 191 (49%) patient died, 118 (30.3%) of whom died of cardiovascular events. Patients who died were older, had higher prevalence of renal dysfunction and NIHSS score. The Kaplan-Meier survival analysis showed that total mortality (p < 0.003) and cardiovascular mortality (p < 0.01) were higher in patients with renal dysfunction. According to Cox's regression analysis, renal dysfunction was the predictor of cardiovascular events, cardiovascular and total mortality. CONCLUSIONS: Patients with ischemic stroke and renal dysfunction are at higher risk for long term cardiovascular and total mortality. The patients with ischemic stroke and renal dysfunction are also at higher risk of new cardiovascular morbidity. Renal dysfunction should be added to the other known prognostic factors in patients with ischemic stroke. Our results also emphasize the importance of identification and management of renal dysfunction in stroke patients.

Stroke and renal dysfunction.

Stroke is the most frequent neurological disease and represents a continuously evolving medical and social problem. Chronic kidney disease (CKD) is also an important worldwide public health problem. Renal dysfunction carries a substantial risk of cardiovascular morbidity and mortality and an independent, graded association between renal function and cardiovascular events was found. In the last 15years the link between CKD and cerebrovascular disease has become more apparent. Patients with end stage renal disease treated with maintenance hemodialysis have a much higher incidence of stroke than the general population and stroke is one of the major causes of death in these patients. Nowadays ischemic subtype of stroke is present in approximately 70% of dialysis patients. In population based studies conflicting results have been reported about the association between stroke and CKD before replacement therapy. However, in high risk patients, defined by the presence of either cardiovascular disease or cardiovascular risk factors, different stages of CKD are clearly associated with subsequent stroke. In patients with stroke the exact prevalence of renal dysfunction is not known. Reported prevalence from a few published studies is up to 38% and it is higher than that in age-matched control groups. Furthermore, in patients suffering from stroke renal dysfunction is associated with short and long term mortality. The most effective treatment of stroke in patients with CKD is not known and further studies are needed.

Calcifications of vertebrobasilar arteries on CT: detailed distribution and relation to risk factors in 245 ischemic stroke patients.

INTRODUCTION: Intracranial atherosclerosis is responsible for a substantial proportion of strokes worldwide but its detailed morphology in the vertebrobasilar arteries (VBA) is unknown. SUBJECT AND METHODS: Cases with ischemic strokes were retrospectively sought from the hospital database. Native CT scans were assessed for vessel area and intracranial artery calcifications (ICACs) in VBA. The calcifications were classified as focal (FCs), crescent, and circular. RESULTS: 245 patients (mean age: 77.1 ± 10.2 years, 57.6% females) had visible ICACs. Calcifications were found in 75.9%, 63.3%, and 17.1% in the left vertebral artery (LVA), the right vertebral artery (RVA), and the basilar artery (BA), respectively. FCs were present in 91.0%, 90.3%, and 100.0%; crescents in 30.3%, 29.0%, and 7.1%, and circulars in 6.4%, 4.8%, and 0.0% ) and 46 (27.4%) for RVA and LVA, respectively. Risk factors associated with vertical dispersion of ICACs were male gender (OR : 2.69, 1.38-5.28) and diabetes of the RVA, LVA, and BA, respectively. FCs in dorsolateral quadrant were least prevalent in both vertebral arteries (VAs): 46 (29.8%(OR : 2.28, 1.04-4.99). CONCLUSIONS: FCs in VAs are least prevalent in dorsolateral quadrants. The vertical dispersion of ICACs seems to be associated with the male gender and diabetes.

Polyneuropathy in hemodialysis patients: the most sensitive electrophysiological parameters and dialysis adequacy.

BACKGROUND: Polyneuropathy (PNP) is a common complication in hemodialysis (HD) patients. Electrophysiological parameters are quantitative indices of its severity. The aim of our study was to find the prevalence of pathologic electrophysiological parameters, to assess their prevalence in relation to duration of HD treatment and age, to establish which parameters are the most sensitive in demonstrating PNP and to find an association between them and HD adequacy. PATIENTS AND METHODS: We included 84 (50 men, 34 women) HD patients (average age 47.32 years; average dialysis duration 62.56 months) and divided them into three groups according to the duration of HD treatment. Each group was further divided into two subgroups according to age. We included electrophysiological parameters for evaluation of motor and sensory nerve functions (Medelec Sapphire Premiere device). HD adequacy was measured with urea kinetic modeling (Kt/V). RESULTS: PNP was found in 77 (91.6%) HD patients and was more common in men (P < 0.016). The association between the number of pathologic electrophysiological parameters and age (P < 0.0001), duration of HD treatment (P < 0.009) and HD adequacy (P < 0.0001) was statistically significant. The most sensitive electrophysiological parameter was the latency of the F wave (pathologic values of F wave latency in the lower limbs in 86% patients and in the upper limbs in 49%). Sensory conduction velocities and the amplitudes of the orthodromic sensory action potentials and the M wave were also sensitive parameters. The F wave latency of different nerves was associated with dialysis adequacy. CONCLUSIONS: PNP is frequent in HD patients and is associated with age and duration of dialysis treatment. The most sensitive electrophysiological parameter of PNP is F wave latency, which may also be used as a parameter of dialysis adequacy.

Atherosclerosis in hemodialysis patients: traditional and nontraditional risk factors.

AIM: To determine the significance of the relationship between some traditional risk factors (age, arterial hypertension, smoking, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides) and some nontraditional risk factors (lipoprotein[a], apolipoprotein A, apolipoprotein B, homocysteine, calcium, phosphorus, parathyroid hormone) and asymptomatic atherosclerosis in hemodialysis patients. METHODS: Ninety-one hemodialysis patients were included in the study. Using B-mode ultrasonography, we measured intima-media thickness and plaque occurrence in the carotid arteries in these patients. Biochemical parameters were determined in all participants according to standard laboratory procedure, systolic and diastolic blood pressure was measured, and information on smoking habits was obtained by questionnaire. RESULTS: A correlation between intima-media thickness and age of the hemodialysis patients was found. Intima-media thickness values also correlated with total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B. Compared to those without plaques, patients with plaques were statistically significantly older; had higher concentrations of total cholesterol, low-density lipoprotein cholesterol, triglycerides, and apolipoprotein B; and had lower concentrations of high-density lipoprotein cholesterol. The number of plaques correlated with age, total cholesterol, low-density lipoprotein cholesterol, triglycerides, and apolipoprotein B. Using multivariate models (linear or logistic regression) of traditional and nontraditional risk factors, a relationship was found between intima-media thickness, plaque occurrence, number of plaques, and age of the hemodialysis patients. With the same multivariate statistical analysis of nontraditional risk factors, a relationship was found only between intima-media thickness, plaque occurrence, number of plaques and apolipoprotein B. CONCLUSION: The results indicate that hemodialysis patients showed advanced atherosclerosis that is associated with traditional as well as nontraditional risk factors such as apolipoprotein B.

Predictive value of carotid intima media thickness in hemodialysis patients.

Atherosclerosis is accelerated in hemodialysis patients. Intima media thickness (IMT) is a strong predictor for cardiovascular events in the general population. Using B-mode ultrasonography, IMT in the common carotid arteries was measured in 99 nondiabetic hemodialysis patients (44 women and 55 men, mean age 53.1 years and mean dialysis duration 45.8 months). During a follow-up of 42.4 +/- 19.5 months, 33 patients died, 19 (57.6%) of them of cardiovascular causes. In these 19 patients IMT was significantly higher (0.89 vs. 0.69 mm) than in those who survived. Correlation between cardiovascular mortality and IMT was found. Patients were divided in relationship to the tertiles of IMT and the risk for cardiovascular death was progressively higher from the first tertile of IMT onward (P < 0.0006). IMT turned out to be an independent predictor of cardiovascular death (P < 0.025). According to our results IMT may be usefully applied for cardiovascular mortality risk stratification in nondiabetic hemodialysis patients.

Cardiac troponin T (cTnT) in hemodialysis patients with asymptomatic and symptomatic atherosclerosis.

BACKGROUND: Cardiovascular mortality is higher in hemodialysis (HD) patients than in the general population. Cardiac troponin T (cTnT) is established as a sensitive marker of myocardial injury in the general population. Less is known about the association between cTnT and intima-media thickness (IMT) and presence of plaques in carotid arteries (asymptomatic atherosclerosis) and prognostic value of cTnT for cardiovascular mortality (symptomatic atherosclerosis) in HD patients. METHODS: In our study 90 HD patients (mean age 56.2 +/- 13.3 years) were followed after determination of cTnT level. Outcome after 21 months was chosen as the end point. In 52 randomly selected HD patients, IMT was measured with B-mode ultrasonography. Plaque occurrence and their numbers were also determined. RESULTS: In 24 (26.6%) patients, cTnT values were >0.1 microg/L (positive test for myocardial injury). During follow-up, 13 patients died from cardiovascular causes and their cTnT values were significantly higher (0.12 vs. 0.06 microg/L; p <0.001) than in those who survived. Correlation between cardiovascular mortality and cTnT was found (p <0.001). The cut-off level of 0.1 microg/L resulted in survival rates of 92% and 64% (p=0.0006). The IMT values of carotid artery were significantly higher (0.85 vs. 0.70 mm; p <0.011) in patients with elevated cTnT. All patients with elevated cTnT had plaques and the number of plaques was significantly higher in these patients (p <0.0001). CONCLUSIONS: cTnT was frequently elevated in our HD patients and was associated with higher cardiovascular mortality and a predictor of cardiovascular outcome. Patients with elevated cTnT showed advanced asymptomatic atherosclerosis in carotid arteries.

Atherosclerosis in patients with end-stage renal failure prior to initiation of hemodialysis.

BACKGROUND: In dialysis patients cardiovascular mortality is 10 to 20 times higher than in general population. It remains uncertain whether atherosclerosis of dialysis patients is effectively accelerated because many of dialysis patients have more or less marked vascular lesions already at the start of dialysis treatment. SUBJECTS AND METHODS. Using B-mode ultrasonography (ATL HDI 3000), we compared intima-media thickness (IMT) and plaque occurrence (indicators of atherosclerosis) in the common carotid arteries (CC), in the area of bifurcation (CB) and in the proximal part of internal carotid arteries (CI) in 28 hemodialysis patients (14 men and 14 women; mean age 49.4 years; mean duration of HD treatment 66.6 months) with that in 28 age-sex matched patients prior to initiation of hemodialysis. We also investigated possible differences in atherosclerotic risk factors in both groups. RESULTS: The IMT values of CC (0.71 vs. 0.70 mm; p = 0.937), CB (0.81 vs. 0.77 mm; p = 0,423) and CI (0.72 vs. 0.71 mm; p = 0.935) were not significantly different in dialysis patients and patients starting dialysis treatment. We also found no difference in plaque occurrence (61% vs. 54%; p = 0.787) and in atherosclerotic risk factors (hypertension, smoking, lipids) between both groups. CONCLUSIONS: In our study we found no difference in atherosclerotic lesions in carotid arteries between dialysis patients and patients with end-stage renal failure starting dialysis treatment. Patients with chronic renal failure are at high risk for cardiovascular diseases so we should intervene earlier and more actively long before dialysis treatment in order to reduce the atherosclerotic risk factors.