High-resolution MRI to noninvasively characterize drainage around the carotid artery into the cervical lymph nodes.

BACKGROUND AND PURPOSE: Previous studies have proposed multiple parallel channels for waste clearance from the brain, though many gaps remain in our understanding of these systems. In this study, we examined periarterial fluid drainage around intracranial and extracranial segments of the internal carotid arteries (ICAs) from the brain into the cervical lymph nodes using a noninvasive and clinical-based method. METHODS: Eighty-one subjects (45 females, aged 15-80 years old) with nonlesioned epilepsy underwent high-resolution 3-dimensional T2-weighted fluid-attenuated inversion recovery (FLAIR) MRI. We utilized a noninvasive and clinical-based method with a manual semiautomated approach to characterize the periarterial lymphatic system's maximum thickness and signal intensities along the ICAs using high-resolution 3-dimensional FLAIR imaging. We conducted group comparisons and correlation analyses to investigate sex- and age-based trends. Results were corrected with Bonferroni's test for multiple comparisons, and we performed power analysis for sample size calculations. RESULTS: Using high-resolution FLAIR images, we show evidence that fluid drainage emerges around the ICA petrous segment and joins lymphatic flow from cranial nerves in the upper neck, with this flow ultimately draining into the cervical lymph nodes bilaterally. Lymphatic signal at the petrous segment level was significantly thinner in females compared to males bilaterally (w = 413, p = .0001 on the right, w = 356, p < .0001 on the left). Lymphatic drainage around the petrous segments of the ICAs bilaterally was thicker with age in males but not in females. CONCLUSIONS: We describe the in vivo high-resolution imaging characteristics of periarterial fluid drainage along the vessel walls of ICAs. This represents a potentially major channel for brain waste clearance. We also report interesting sex- and age-based trends in these structures within our cohort.

Non-invasive MR imaging of human brain lymphatic networks with connections to cervical lymph nodes.

Meningeal lymphatic vessels have been described in animal studies, but limited comparable data is available in human studies. Here we show dural lymphatic structures along the dural venous sinuses in dorsal regions and along cranial nerves in the ventral regions in the human brain. 3D T2-Fluid Attenuated Inversion Recovery magnetic resonance imaging relies on internal signals of protein rich lymphatic fluid rather than contrast media and is used in the present study to visualize the major human dural lymphatic structures. Moreover we detect direct connections between lymphatic fluid channels along the cranial nerves and vascular structures and the cervical lymph nodes. We also identify age-related cervical lymph node atrophy and thickening of lymphatics channels in both dorsal and ventral regions, findings which reflect the reduced lymphatic output of the aged brain.

Detailed imaging of abducens nerve anatomy using contrast-enhanced 3D-TOF MR angiography.

PURPOSE: Cranial nerves (CNs), particularly CN IV and VI are difficult to visualize with conventional MRI techniques, particularly within the cavernous sinus region. The aim of this study was to evaluate the capacity of high-resolution contrast enhanced 3D time-of-flight (TOF) MR angiography using new generation 3 T imaging technology to provide detailed visualization of CN VI anatomy, particularly within the cavernous sinus and petroclival regions. METHODS: Two neuroradiologists conducted bilateral evaluation of CN VI visibility in 23 patients for nerve segments located in the petroclival segment (dural cave and Dorello's canal), and three divisions of the cavernous sinus. All images were collected using contrast enhanced TOF MR angiography using a new generation 3 T machine. RESULTS: Of the CN VI segments assessed, average visibility of CN VI was best achieved in Dorello's canal. Overall visibility of CN VI within the regions inspected was best achieved in the axial view, with the exception of the dural cave, which was best assessed using the coronal view. We also identified strong agreement in assessment of nerve visibility between the two reviewers. We also identified a putative CN6 duplication and a small schwannoma, highlighting the fidelity of our approach. CONCLUSION: Contrast enhanced 3D TOF MR angiography can visualize CN VI anatomy, particularly within the petrocavernosal region and cavernous sinus with simultaneous visualization of arterial and venous structures. This cannot be easily achieved using traditional MRI techniques. This imaging technique might be used with new generation machines to evaluate CN VI anatomy and pathologies within the petrocavernosal region and cavernous sinus, especially relating to vascular pathologies.

Newly Reported Studies on the Increase in Gastrointestinal Symptom Prevalence withCOVID-19 Infection: A Comprehensive Systematic Review and Meta-Analysis.

BACKGROUND AND AIM: Although constitutional and respiratory symptoms such as cough and fever are the most common symptoms in patients infected with COVID-19, gastrointestinal (GI) tract involvement has been observed by endoscopic biopsies. Multiple GI symptoms, including diarrhea, nausea or vomiting and abdominal pain, have also been reported. This review aims to present the currently available data regarding the GI symptoms of COVID-19 patients, and to compare the frequency of GI symptoms in early stage (Eastern) mostly Chinese data to the current stage (Western) non-Chinese data. METHODS: We performed a systematic literature search to identify both published studies by using PubMed, Google Scholar, and CNKI (Chinese medical search engine), and yet unpublished studies through medRxiv and bioRxiv. We also reviewed the cross references of the detected articles. We conducted a Medical Subject Headings (MeSH) search up until 20 September 2020. We pooled the prevalence of symptoms of diarrhea, anorexia, nausea, vomiting, and abdominal pain by using the Freeman-Tukey's transforming random effect model. RESULTS: A total of 118 studies were included in the systematic review and 44 of them were included in the meta-analysis. There was a significant heterogeneity between the studies; therefore, the random effects model was used. The pooled prevalence estimate of any GI symptoms reported was found to be 0.21 (95%CI, 0.16-0.27). Anorexia was the most commonly reported GI symptom at 18% (95%CI, 0.10-0.27) followed by diarrhea at 15% (95%CI, 0.12-0.19). Diarrhea, abdominal pain, nausea/vomiting, and respiratory symptoms were more common in non-Chinese studies. The prevalence of abdominal pain was lower in the "inpatient-only" studies when compared with studies that included outpatients only and those including both inpatients and outpatients. CONCLUSIONS: In this comprehensive systematic review and meta-analysis study, we observed higher rates of diarrhea, nausea/vomiting, and abdominal pain in COVID-19 infected patients among non-Chinese studies compared to Chinese studies. We also observed a higher prevalence of GI symptoms in Chinese studies than was reported previously. Non-respiratory symptoms, including GI tract symptoms, should be more thoroughly and carefully evaluated and reported in future studies.

Turkish version of the Tilburg Frailty Indicator.

BACKGROUND: Recently frailty has drawn significant interest as an important predictor of several clinically relevant outcomes. There is no widely accepted instrument for the assessment of frailty and most of the current ones evaluate only physical features. The Tilburg Frailty Indicator (TFI) is a valid and reliable instrument which enables multidimensional assessment of frailty. We aimed to adapt and evaluate the Turkish version of the TFI. METHODS: We translated and culturally adapted the English version of the TFI into Turkish using standard guidelines. We enrolled consecutive patients who were 70 years old or older and were admitted to our outpatient geriatrics clinic. We used Cronbach's alpha values to evaluate the internal consistency and also assessed inter-observer and test-retest variability using intraclass correlation coefficient (ICC). RESULTS: The Cronbach's alpha reliability coefficients of the instrument ranged from 0.65 to 0.72 and item-total correlation ranged between -0.05 and 0.57. There was a good agreement between two assessments (ICC=0.99) and between two observers (ICC=0.99). CONCLUSION: We have shown the reliability of the Turkish version of the TFI as a tool to evaluate frailty in a multidimensional manner among the Turkish outpatient population.

Low glomerular filtration rate as an associated risk factor for sarcopenic muscle strength: is creatinine or cystatin C-based estimation more relevant?

INTRODUCTION: We aimed to evaluate the association of a decreased glomerular-filtration-rate (GFR <60 ml/min/1.73 m2), estimated using Modification of Diet in Renal Disease (MDRD), creatinine- and cystatin C-based (CKDEPI-CR and CKDEPI-CC) Chronic Kidney Disease Epidemiology Collaboration equations with handgrip strength (HGS). METHODS: Community-dwelling males aged ≥60 years admitted to outpatient clinic were included. We used MDRD, CKDEPI-CR, and CKDEPI-CC formulas for GFR estimation and corrected these for body surface area. Muscle strength was assessed by HGS. RESULTS: 209 men (mean age 67.8 ± 6.4) were enrolled. Sixty-two patients (29.7%) had sarcopenic HGS. Subjects with sarcopenic HGS were older, had higher rate of a GFR < 60 ml/min/1.73 m2, had lower mid-upper arm circumference; tended to have lower creatine kinase, albumin, CKDEPI-CC-GFR levels; and higher BUN/creatinine ratio and cystatin C. Multivariate logistic regression analysis revealed a CKDEPI-CC lower than 60 ml/min/1.73 m2 as the only independent factor underlying sarcopenic HGS. Higher age tended to have an independent association. Only higher age was independently associated with low HGS when other estimations were used (p = 0.013 and p = 0.021 when MDRD and CKDEPI-CR were used, respectively). CONCLUSIONS: There is a strong association of a GFR level of <60 ml/min/1.73 m2 with sarcopenic HGS, when CKDEPI-CC formula is used.

Prevalence of potentially inappropriate prescribing among older adults: A comparison of the Beers 2012 and Screening Tool of Older Person's Prescriptions criteria version 2.

AIM: To date, there is no study comparing the Beers 2012 and Screening Tool of Older Person's Prescriptions (STOPP) version 2 criteria, nor reporting a comparison of the prevalence of potentially inappropriate Prescribing (PIM) with STOPP version 2. We aimed to evaluate the prescriptions of patients admitted to a geriatric outpatient clinic with these tools, and to document the factors related to PIM use. METHODS: Older patients (aged ≥65 years) admitted to the outpatient clinic of a university hospital were retrospectively evaluated for PIM with Beers 2012 and STOPP version 2 criteria. Age; sex; chronic disease and number of drugs; and functional, depression and nutritional statuses were studied with regression analysis as possible factors related to PIM. RESULTS: The study included 667 participants (63.1% women, mean age 77.6 ± 6.3 years). The mean number of drugs was 6.1 ± 3.4. PIM prevalence detected by STOPP version 2 was higher than that of the Beers 2012 criteria (39.1% vs 33.3%, respectively; P < 0.001; Z = -3.5) with moderate agreement in between (kappa = 0.44). Antipsychotics, over-the-counter vitamin/supplements, aspirin, selective-serotonin-reuptake-inhibitors and anticholinergics were the leading drug classes for PIM. The extent of polypharmacy (P < 0.001, OR 1.29, 95% CI 1.20-1.38) was the most important variable related to PIM, along with the multiple comorbidities (P = 0.005, OR 1.16, 95% CI 1.05-1.30). Higher level of functionality was inversely associated with PIM (P = 0.009, OR 0.90, 95% CI 0.83-0.97). CONCLUSIONS: Inappropriate prescription prevalence of ~40% by STOPP version 2 was similar to the global worldwide prevalence - yet at the upper end. STOPP version 2 was more successful than Beers 2012 to detect PIM. Patients with multiple drug use, multiple comorbidities and more dependency were more likely to have PIM requiring special attention during prescription. Geriatr Gerontol Int 2017; 17: 1245-1251.

Attitudes of neurology specialists toward older adults.

OBJECTIVE: Attitude of healthcare providers toward older people is very important in the aging world. Neurologists contact older adults very frequently. We aimed to investigate the attitudes of neurologists toward older adults. MEASUREMENTS: We recorded participants age; sex; duration of clinical practice in neurology; existence of older adult relatives; and history of geriatrics education, nursing home visits, older adult patient density in their clinical practice, and participation in voluntary public activities. UCLA Geriatrics Attitude Scale was used to evaluate participants' attitudes. RESULTS: A total of 100 neurologists participated in this study. Seventy-seven percent had positive, 3 % had neutral, and 20 % had negative attitudes. Twenty-seven percent of the participants had history of geriatrics education, and these participants tended to have a higher rate of positive attitudes. Neurologists with positive attitudes tended to be older than those with negative attitudes. Participants with history of living with older adult relatives had lower rates of positive attitudes. The most common diagnoses of the patients the participants encountered were stroke and dementia. Independent factors associated with positive attitudes were history of geriatrics education and older age. History of living with older relatives tended to have a negative effect. Most of the negative items of the attitude scale were associated with the natural course and behavior of the common diseases in neurology practice. CONCLUSIONS: Generalization of geriatrics education may translate into a better understanding and improved care for older patients. Development of instruments and implementation of qualitative studies to assess attitudes of neurologists toward older adults are needed.

Frequency of Nerve Root Sleeve Cysts in Autosomal Dominant Polycystic Kidney Disease.

BACKGROUND: There is sporadic data about the occurrence of spinal meningeal cysts in patients with autosomal dominant polycystic kidney disease (ADPKD). We suggest that there is a relationship with the frequency and size of spinal meningeal cysts and headache, intracranial aneurysms, and cerebrospinal fluid leakage in patients with ADPKD. AIM: To investigate the relationship with spinal meningeal cyst, cerebrospinal fluid leakage, and headache in patients with ADPKD. STUDY DESIGN: Cross-sectional study. METHODS: We enrolled 50 patients with ADPKD and 37 healthy volunteers. This cross-sectional study included patients with ADPKD and matched healthy volunteers. Magnetic resonance imaging myelography was performed using the 3D-T2 HASTE technique in an MRI scanner. We questioned our subjects regarding presence of headache and evaluated headache severity using a visual analog scale. The relationship between the number and size of spinal meningeal cysts with headache, intracranial aneurysms, and liver cysts was also investigated. RESULTS: Spinal meningeal cysts were more numerous and larger in patients than in controls (14.8±11.6 vs. 6.4±4.6 cysts respectively, p<0.001, 68.3±49.3 vs. 25.4±20.1 mm, p<0.001, respectively). Spinal cyst number and size were similar in APDKD patients with or without intracranial aneurysms. Headache score was correlated with the size and number of spinal meningeal cysts. This was valid only in patients with ADPKD. CONCLUSION: Abnormality involving the vessel wall in ADPKD may explain the increased number of spinal meningeal cysts in ADPKD. Moreover, leakage of cerebrospinal fluid secondary to spinal meningeal cyst may be responsible for recurrent severe headache by causing spontaneous intracranial hypotension in these patients.