Expert consensus guidelines for community pharmacists in the management of diabetic peripheral neuropathy with a combination of neurotropic B vitamins.

This consensus guidance is for community pharmacists in diabetic peripheral neuropathy (DPN) management with a combination of neurotropic B vitamins. A multidisciplinary team including endocrinology, neurology, and pharmacy from Thailand discussed and aligned the practical scheme of DPN management in the community pharmacy setting, using the literature review and having face-to-face meeting. Five major statements have been endorsed as consensus recommendations for DPN care with strong acknowledgment. The aims of DPN management included reducing symptoms and the risk of complications, minimising adverse reactions from treatment regimens, and improving patients' knowledge and adherence to the treatment strategies. An initial screening process using a 7 items interview of Douleur Neuropathique 4 (DN4) questionnaire should be implemented to identify patients at risk of developing DPN. Subsequently, pharmacologic, and non-pharmacologic treatment should be employed based on patient-centered care. An interesting approach is combination of neurotropic B vitamins, which may be used as monotherapy or combination therapy to control DPN symptoms. The combined therapy potentially exhibits a synergistic effect and improves patient adherence. The consensus would be further considered in context of harmonisation of routine practice and country requirements.

Identifying obstructive sleep apnea in patients with epilepsy: A cross-sectional multicenter study.

OBJECTIVE: Several screening questionnaires for obstructive sleep apnea (OSA) have been introduced. No study has compared the performance of different questionnaire in the same patients with epilepsy. Herein, we compare the performance characteristics of four common questionnaires for assessing the probability of OSA in patients with epilepsy. METHODS: This cross-sectional multicenter study was conducted among adult epilepsy patients attending neurology and general medical clinics in Thailand. Before performing full polysomnography (PSG), all participants completed the STOP-BANG, STOP-BAG, SA-SDQ, and NoSAS questionnaires. OSA was defined by apnea/ hypopnea index (AHI) criteria of AHI: ≥ 5, ≥ 15, and ≥ 30. Discriminatory ability was assessed by area under the receiver operating characteristics (ROC) curve (AUC) and likelihood ratio. To improve discriminative ability, we created 3 ranges of the score to predict lower, middle, and higher probability of OSA as defined by each diagnostic criterion. RESULTS: A total 166 patients with epilepsy were included. OSA prevalence was 38%. Overall, NoSAS had higher AUC at all AHI criteria but not significantly higher than that of other scales. Using prediction cut-points for NoSAS of ≥ 4 and ≥ 8 to predict OSA defined by AHI ≥ 5, the likelihood ratios for the 3 ranges were 0.37, 2.22 and 9.81 respectively. CONCLUSION: Among the 4 scales, the 2-cut-point NoSAS score had the highest discriminatory ability at each AHI cutoff.

Obstructive sleep apnea and sudden unexpected death in epilepsy in unselected patients with epilepsy: are they associated?

PURPOSE: We aimed to determine (1) the frequency of high-risk sudden unexpected death in epilepsy (SUDEP) in patients with epilepsy who have had obstructive sleep apnea (OSA) in different stages of sleep using the revised SUDEP risk inventory (rSUDEP-7) score instrument and (2) the factors associated with high risk SUDEP in patients with epilepsy who have had OSA. METHODS: We conducted a cross-sectional study of consecutive subjects who are more than 15 years old without known sleep disorders, recruited from a single epilepsy clinic in a tertiary care facility. Participants underwent polysomnography. Scoring was performed by two blinded board-certified sleep physicians. The relationships between rSUDEP-7 scores and OSA measures were evaluated using Wilcoxon rank-sum test, chi-squared test, and quantile regression. RESULTS: Our study population consisted of 95 participants. Overall median (IQR) apnea-hypopnea index (AHI) of our populations was 2.3 (0.7,7.5) events rate per hour; 12 (75%) patients had moderate OSA and 4 (25%) patients had severe OSA. Nine patients had a rSUDEP-7 score of 5 to 7. There was no significant difference between total rSUDEP-7 score or rSUDEP-7 score of > 5 or < 5 and total AHI, supine AHI, non-supine AHI, NREM AHI, or REM AHI; similarly, (2) there was no significant difference in total rSUDEP-7 score between AHI of < 15 or > 15. CONCLUSION: Our study reveals no association between AHI score, OSA, and total rSUDEP-7 score or rSUDEP-7 score of > 5. The pathophysiology underlying SUDEP appears complex. We need further studies on SUDEP to help elucidate the cardiorespiratory mechanisms and predisposing factors.

Monocyte and CD4+ T-cell antiviral and innate responses associated with HIV-1 inflammation and cognitive impairment.

OBJECTIVE: Mechanisms underlying immune activation and HIV-associated neurocognitive disorders (HAND) in untreated chronic infection remain unclear. The objective of this study was to identify phenotypic and transcriptional changes in blood monocytes and CD4 T cells in HIV-1-infected and uninfected individuals and elucidate processes associated with neurocognitive impairment. DESIGN: A group of chronically HIV-1-infected Thai individuals (n = 19) were selected for comparison with healthy donor controls (n = 10). Infected participants were further classified as cognitively normal (n = 10) or with HAND (n = 9). Peripheral monocytes and CD4 T cells were phenotyped by flow cytometry and simultaneously isolated for multiplex qPCR-targeted gene expression profiling directly ex vivo. The frequency of HIV-1 RNA-positive cells was estimated by limiting dilution cell sorting. RESULTS: Expression of genes and proteins involved in cellular activation and proinflammatory immune responses was increased in monocytes and CD4 T cells from HIV-1-infected relative to uninfected individuals. Gene expression profiles of both CD4 T cells and monocytes correlated with soluble markers of inflammation in the periphery (P < 0.05). By contrast, only modest differences in gene programs were observed between cognitively normal and HAND cases. These included increased monocyte surface CD169 protein expression relative to cognitively normal (P = 0.10), decreased surface CD163 expression relative to uninfected (P = 0.02) and cognitively normal (P = 0.06), and downregulation of EMR2 (P = 0.04) and STAT1 (P = 0.02) relative to cognitively normal. CONCLUSION: Our data support a model of highly activated monocytes and CD4 T cells associated with inflammation in chronic HIV-1 infection, but impaired monocyte anti-inflammatory responses in HAND compared with cognitively normal.

Phyloanatomic characterization of the distinct T cell and monocyte contributions to the peripheral blood HIV population within the host.

Human immunodeficiency virus (HIV) is a rapidly evolving virus, allowing its genetic sequence to act as a fingerprint for epidemiological processes among, as well as within, individual infected hosts. Though primarily infecting the CD4+ T-cell population, HIV can also be found in monocytes, an immune cell population that differs in several aspects from the canonical T-cell viral target. Using single genome viral sequencing and statistical phylogenetic inference, we investigated the viral RNA diversity and relative contribution of each of these immune cell types to the viral population within the peripheral blood. Results provide evidence of an increased prevalence of circulating monocytes harboring virus in individuals with high viral load in the absence of suppressive antiretroviral therapy. Bayesian phyloanatomic analysis of three of these individuals demonstrated a measurable role for these cells, but not the circulating T-cell population, as a source of cell-free virus in the plasma, supporting the hypothesis that these cells can act as an additional conduit of virus spread.

Infrequent HIV Infection of Circulating Monocytes during Antiretroviral Therapy.

Whereas human immunodeficiency virus (HIV) persists in tissue macrophages during antiretroviral therapy (ART), the role of circulating monocytes as HIV reservoirs remains controversial. Three magnetic bead selection methods and flow cytometry cell sorting were compared for their capacity to yield pure CD14+ monocyte populations. Cell sorting by flow cytometry provided the purest population of monocytes (median CD4+ T-cell contamination, 0.06%), and the levels of CD4+ T-cell contamination were positively correlated with the levels of integrated HIV DNA in the monocyte populations. Using cell sorting by flow cytometry, we assessed longitudinally the infection of monocytes and other cell subsets in a cohort of 29 Thai HIV-infected individuals. Low levels of HIV DNA were detected in a minority of monocyte fractions obtained before and after 1 year of ART (27% and 33%, respectively), whereas HIV DNA was readily detected in CD4+ T cells from all samples. Additional samples (2 to 5 years of ART) were obtained from 5 individuals in whom monocyte infection was previously detected. Whereas CD4+ T cells were infected at high levels at all time points, monocyte infection was inconsistent and absent in at least one longitudinal sample from 4/5 individuals. Our results indicate that infection of monocytes is infrequent and highlight the importance of using flow cytometry cell sorting to minimize contamination by CD4+ T cells.IMPORTANCE The role of circulating monocytes as persistent HIV reservoirs during ART is still controversial. Several studies have reported persistent infection of monocytes in virally suppressed individuals; however, others failed to detect HIV in this subset. These discrepancies are likely explained by the diversity of the methods used to isolate monocytes and to detect HIV infection. In this study, we show that only flow cytometry cell sorting yields a highly pure population of monocytes largely devoid of CD4 contaminants. Using this approach in a longitudinal cohort of HIV-infected individuals before and during ART, we demonstrate that HIV is rarely found in monocytes from untreated and treated HIV-infected individuals. This study highlights the importance of using methods that yield highly pure populations of cells as flow cytometry cell sorting to minimize and control for CD4+ T-cell contamination.

0.075% capsaicin lotion for the treatment of painful diabetic neuropathy: A randomized, double-blind, crossover, placebo-controlled trial.

OBJECTIVE: A randomized, double-blinded, crossover, placebo controlled trial was conducted to evaluate the efficacy and safety of 0.075% capsaicin lotion for treating painful diabetic neuropathy (PDN). PATIENTS AND METHODS: PDN subjects were randomized to receive 0.075% capsaicin/placebo for 8 weeks, then crossing over to the other treatment after a 4-weeks washout period. Primary endpoint was the change in visual analog scale score of pain severity. Secondary outcomes were score changes in Neuropathic Pain Scale, short-form McGill Pain Questionnaires, and proportions of patients with pain score reductions of 30% and 50%, and adverse events. RESULTS: A total of 42 subjects were enrolled, 27 completed at least an 8-week treatment period. Intention-to-treat analysis showed no significant improvement in pain control with capsaicin lotion compared with placebo for all pain measures and proportion of patients who had 30% or 50% pain relief, respectively. Per protocol analysis were consistent. Capsaicin lotion was well tolerated but local skin reactions were common. CONCLUSION: In patients with PDN, the efficacy of 0.075% capsaicin lotion was similar to placebo but was well tolerated. More work is needed to assess different capsaicin formulations.

Normalization of Soluble CD163 Levels After Institution of Antiretroviral Therapy During Acute HIV Infection Tracks with Fewer Neurological Abnormalities.

Background: Myeloid activation contributes to cognitive impairment in chronic human immunodeficiency virus (HIV) infection. We explored whether combination antiretroviral therapy (cART) initiation during acute HIV infection impacts CD163 shedding, a myeloid activation marker, and in turn, implications on the central nervous system (CNS). Methods: We measured soluble CD163 (sCD163) levels in plasma and cerebrospinal fluid (CSF) by enzyme-linked immunosorbent assay in Thais who initiated cART during acute HIV infection (Fiebig stages I-IV). Examination of CNS involvement included neuropsychological testing and analysis of brain metabolites by magnetic resonance spectroscopy. Chronic HIV-infected or uninfected Thais served as controls. Results: We examined 51 adults with acute HIV infection (Fiebig stages I-III; male sex, >90%; age, 31 years). sCD163 levels before and after cART in Fiebig stage I/II were comparable to those in uninfected controls (plasma levels, 97.9 and 93.6 ng/mL, respectively, vs 99.5 ng/mL; CSF levels, 6.7 and 6.4 ng/mL, respectively, vs 7.1 ng/mL). In Fiebig stage III, sCD163 levels were elevated before cART as compared to those in uninfected controls (plasma levels, 135 ng/mL; CSF levels, 10 ng/mL; P < .01 for both comparisons) before normalization after cART (plasma levels, 90.1 ng/mL; CSF levels, 6.5 ng/mL). Before cART, higher sCD163 levels during Fiebig stage III correlated with poor CNS measures (eg, decreased N-acetylaspartate levels), but paradoxically, during Fiebig stage I/II, this association was linked with favorable CNS outcomes (eg, higher neuropsychological test scores). After cART initiation, higher sCD163 levels during Fiebig stage III were associated with negative CNS indices (eg, worse neuropsychological test scores). Conclusion: Initiation of cART early during acute HIV infection (ie, during Fiebig stage I/II) may decrease inflammation, preventing shedding of CD163, which in turn might lower the risk of brain injury.

Characterization of Cellular Immune Responses in Thai Individuals With and Without HIV-Associated Neurocognitive Disorders.

HIV-associated neurocognitive disorder (HAND) remains a challenge despite antiretroviral therapy (ART), and has been linked to monocyte/macrophage (M/M) migration to the brain. Due to the potential impact of T cell effector mechanisms in eliminating activated/HIV-infected M/M, T cell activation may play a role in the development of HAND. We sought to investigate the relationship between cognition and both CD8+ T cell activation (HLA-DR+/CD38+) and HIV-specific CD8+ T cell responses at the time of HIV diagnosis and 12 months postinitiation of ART. CD8+ T cell activation was increased in HAND compared to cognitive normal (NL) individuals and correlated directly with plasma viral load and inversely with the cognitive status. In addition, Gag-specific cytolytic activity (CD107a/b+) was decreased in HAND compared with NL individuals and correlated with their neurological testing, suggesting a potential role of cytotoxic CD8+ T cells in the mechanism of HAND development.

Brief Report: CD14+ Enriched Peripheral Cells Secrete Cytokines Unique to HIV-Associated Neurocognitive Disorders.

Monocytes play a vital role in HIV-associated neurocognitive disorder (HAND), postulated to transport HIV into the brain and secrete pro-inflammatory cytokines. We analyzed cytokines released by cultured peripheral blood mononuclear cells enriched with the CD14 marker isolated from HIV-infected individuals with HAND and normal cognition (NC) in combination antiretroviral therapy naive and after 1 year on treatment. Interleukin-8 and monocyte chemoattractant protein-1 levels were higher in HAND compared with NC at baseline (P = 0.002 and P < 0.0001). These cytokines remained higher in HAND patients 1 year after combination antiretroviral therapy and were significant when NC patients who were initially HAND were excluded (P = 0.012 and P = 0.002). Both correlated with baseline CD14 peripheral blood mononuclear cell HIV DNA levels supporting the role of HIV DNA reservoir size and monocyte cytokines in HAND persistence.

Sex differences in soluble markers vary before and after the initiation of antiretroviral therapy in chronically HIV-infected individuals.

OBJECTIVE: To evaluate differences in soluble inflammatory markers between chronically HIV-infected men and women, with or without cognitive impairment, and in response to treatment. DESIGN: Soluble biomarkers were measured in cryopreserved plasma and cerebrospinal fluid (CSF) of 60 treatment-naïve individuals (25 men and 35 women) with chronic HIV infection and 18 HIV-uninfected controls (9 men and 9 women) from Thailand. Following enrollment, participants began combination antiretroviral therapy and were evaluated for expression of these markers after 48 weeks. METHODS: Plasma and CSF levels of 19 soluble biomarkers (IFN-γ, TNFα, TNF-RII, IL-1α, IL-1ß, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-15, MCP-1, t-Tau, IP-10, neopterin, IFNα, I-FABP, and sCD14) were measured using either a multiparameter or standard ELISA assay. RESULTS: Prior to combination antiretroviral therapy, women with impaired cognition had elevated levels of neopterin and TNF-RII compared with women with normal cognition in both the plasma and CSF; however, levels did not differ between cognitively impaired or normal men. In a secondary outcome-hypothesis generating analysis, sex differences were also pronounced in plasma levels of MCP-1, IL-10, I-FABP, and sCD14 in response to treatment. Neopterin, IP-10, TNFα, TNF-RII, IFNα, MCP-1, IL-8, I-FABP, and sCD14 plasma levels remained elevated following 48 weeks of therapy in both sexes compared with uninfected controls. CONCLUSION: We provide evidence of sustained immune activation after 48 weeks of treatment and identify possible sex differences in biomarkers previously linked to cognitive impairment, chronic inflammation, and gut integrity that may contribute to immunological differences between sexes in relationship to disease progression and response to therapy.

Neuronal-Glia Markers by Magnetic Resonance Spectroscopy in HIV Before and After Combination Antiretroviral Therapy.

OBJECTIVE: Combination antiretroviral therapy (cART) can suppress plasma HIV RNA to undetectable levels; yet reports indicate persistent HIV-associated neurocognitive disorders (HAND) among treated individuals. We sought to investigate imaging correlates of incomplete cognitive recovery among individuals with chronic HIV. METHODS: We used single voxel proton magnetic resonance spectroscopy in 4 regions of the brain to measure changes in neuronal and glia biomarkers in cART-naive subjects before (n = 59, 27 with HAND) and after 12 months of cART. RESULTS: At baseline, we observed elevated total choline (CHO) in the basal ganglia (BG, P = 0.002) and in the posterior cingulate gyrus (PCG, P = 0.022) associated with HIV infection. Myo-inositol (MI) was elevated in the frontal white matter (FWM, P = 0.040). N-acetylaspartate was elevated in the BG (P = 0.047). Using a mixed model approach among all HIV-infected individuals, at 6 months, we observed decreased n- acetylaspartate in FWM (P = 0.031), decreased creatine in PCG (P = 0.026) and increased MI in frontal gray matter (FGM, P = 0.023). At 12 months, we observed an increase in BG MI (P = 0.038) and in FGM (P = 0.021). Compared to those with normal cognition, HAND cases had higher FGM MI (P = 0.014) at baseline. At 12 months, individuals that remained cognitively impaired compared with those without HAND exhibited elevated CHO in the PCG (P = 0.018) and decreased glutamate in both FWM (P = 0.027) and BG (P = 0.013). CONCLUSIONS: cART started during chronic HIV is associated with reduced neuronal-glia and inflammatory markers. Alterations in CHO are noted among individuals who remain impaired after 12 months of cART.

Global Outcomes of Epilepsy Surgery in Drug-Resistant Focal Epilepsy: A Longitudinal Survey.

Objective: Epilepsy surgery has been established for treatment of drug-resistant focal epilepsy. We aimed to determine long-term outcomes of epileptic surgery in various aspects including seizure outcome, quality of life, and psychosocial consequences after surgery. Material and Method: A single center, cross-sectional study was conducted. The patients with drug-resistant focal epilepsy who underwent epileptic surgery for at least one year were recruited. Results: Thirty-seven adult drug-resistant epilepsy patients after epileptic surgery were enrolled with an average follow-up period of 5.8 years. Twenty-three (62.2%) had temporal lobe epilepsy (TLE) and 14 (37.8%) had neocortical epilepsy. Four were (10.8%) compatible with lesional negative refractory epilepsy. Hippocampal sclerosis was the most common etiology (45.9%), followed by focal cortical dysplasia/gliosis (21.6%) and brain tumor (21.6%). The three commonest postoperative complications were any medical illnesses (18.9%), memory impairment (18.9%), and visual filed defect (13.5%). Twenty patients (54.1%) had no complications. Seizure outcomes, employment status, quality of life, depression, frank psychosis, and number of antiepileptic drug (AED) between pre- and post-surgical period (interviewing time) were compared. Engel Class I (seizure freedom) was persistently achieved in 19 (51.4%) patients. There were nine (24.3%) patients in Engel Class II, eight (21.6%) in Engel Class III, and one (2.7%) in Engel Class IV. Seizure outcome, quality of life, and self-assessment were improved after epileptic surgery at any age groups, duration of epilepsy, epileptogenic zone, and side of operation. In some subgroups, it was found that income was increased and number of AED was reduced. However, depression and frank psychosis did not change the outcome. On self-assessment, global impression of change in memory showed 27% improvement and 32.4% no change. For language and communication skills, 29.7% was improved but 21.6% was worsened. Conclusion: In this longitudinal study, epilepsy surgery showed improvement in seizure control, quality of life, and some neuropsychological aspects.

The Development of Sleep Questionnaires Thai Version (ESS, SA-SDQ, and PSQI): Linguistic Validation, Reliability Analysis and Cut-Off Level to Determine Sleep Related Problems in Thai Population.

Background: The Epworth Sleepiness Scale (ESS), Sleep Apnea Scale of Sleep Disorders Questionnaire (SA-SDQ), and Pittsburgh Sleep Quality Index (PSQI) are widely used in English speaking countries for sleep problem screening. However, there is no officially validated Thai-version of sleep questionnaires available. Objective: To provide standard Thai version of three sleep questionnaires and find cut-off level to screening sleep problems in Thai population. Material and Method: We used Mapi Research Institute Methods for translation from original language to Thai questionnaire. Then, test-retest reliability analysis was performed. Finally, we collected data from patients who underwent polysomnography in Phramongkutklao Sleep Lab Centre between June and August 2011. Cut-off value to screen population at risk for sleep-related disorder was researched. Results: The questionnaires were translated with very good inter-rater agreement. Cut-off of ESS, SA-SDQ, and PSQI suggested sleep disorders would be 9, 27, and 6.5 respectively. Conclusion: Sleep disorder questionnaires including ESS, SA-SDQ, and PSQI were translated into Thai with high validity, reliability, and accuracy.

The Changes in Mean Platelet Volume after Using of Antiplatelet Drugs in Acute Ischemic Stroke: A Randomized Controlled Trial.

OBJECTIVE: To measure the changes of mean platelet volume (MPV) after using four antiplatelet drugs in acute non-cardioembolic ischemic stroke patients and assess the association of antiplatelets and MPV and stroke outcome. MATERIAL AND METHOD: Ischemic stroke survivors with National Institute of Health Stroke Scale (NIHSS) 8 were randomly allocated intofour groups, receiving aspirin, clopidogrel, combined aspirin and dipyridamole, and cilostazol. The change of MPV NIHSS, and modified Rankin Scale (mRS) were recorded at baseline and week 4 in all studied groups. MPV was measured using the standard automated blood test for complete blood count. RESULTS: Twenty-one subjects were included in this study. They comprised of five cases in each antiplatelet group, except for aspirin, which had six subjects. Male was 57%, and hypertension was the most common risk factor (61.9%). Most of participants (76%) had small vessel disease. At 4-week, MPVwas reduced and NIHSS, mRS were improved in every studied group. Clopidogrel sign ficantly reduced NIHSS score (p = 0.003), and it produced the greatest reduction in MPV compared to others. CONCLUSION: Every type of antiplatelets included in this study reduced MPV NIHSS, and mRS in acute non-cardioembolic stroke patients. Clopidogrel improved NIHSS the most.

Loss of CCR2 expressing non-classical monocytes are associated with cognitive impairment in antiretroviral therapy-naïve HIV-infected Thais.

HIV DNA in monocytes has been linked to HIV-associated neurocognitive disorders (HAND), however, characterization of monocyte subsets associated with HAND remains unclear. We completed a prospective study of antiretroviral therapy-naïve, HIV-infected Thais, with varying degrees of cognitive impairment, compared to HIV-uninfected controls. Monocyte subsets' CCR2, CCR5 and CD163 expression were profiled and inflammatory markers in plasma and cerebrospinal fluid (CSF), measured. Lower numbers of CCR2(+)non-classical monocytes were associated with worse neuropsychological test performance (r=0.43, p=0.024). CCR2(+)non-classical monocyte count inversely correlated with CSF neopterin (r=-0.43, p=0.035) and plasma TNF-α levels (r=-0.40, p=0.041). These data benchmark CCR2(+)non-classical monocytes as an independent index of cognitive impairment.

Absence of Cerebrospinal Fluid Signs of Neuronal Injury Before and After Immediate Antiretroviral Therapy in Acute HIV Infection.

BACKGROUND: It is unknown whether neuronal injury begins during acute human immunodeficiency virus (HIV) infection, and whether immediate initiation of combination antiretroviral therapy (cART) prevents neuronal injury. METHODS: Cerebrospinal fluid (CSF) neurofilament light chain (NFL), a measure of axonal injury, was assessed before and after cART initiation in individuals starting treatment during acute or chronic HIV infection. Nonparametric statistics examined relationships between NFL and disease progression, neuroinflammation, and cognitive performance. RESULTS: Before treatment, subjects with acute infection had lower CSF NFL levels, with elevations for their age in 1 of 32 subjects with acute infection (3.1%) and 10 of 32 with chronic infection (31%) (P = .006). This persisted after cART initiation, with 1 of 25 acute (4%) and 4 of 9 chronic subjects (44%) showing elevated NFL levels (P = .01). In acute infection, pre-cART NFL levels were inversely correlated with proton magnetic resonance spectroscopic findings of N-acetylaspartate/creatine in frontal gray matter (r = -0.40; P = .03), frontal white matter (r = -0.46; P = .01), and parietal gray matter (r = -0.47; P = .01); correlations persisted after treatment in the frontal white matter (r = -0.51; P = .02) and parietal gray matter (r = -0.46; P = .04). CONCLUSIONS: CSF NFL levels are not elevated in untreated acute HIV infection or after 6 months of immediately initiated cART but are abnormal in chronic HIV infection before and after treatment. In acute HIV infection, CSF NFL levels are inversely associated with neuroimaging markers of neuronal health.

Association between brain volumes and HAND in cART-naïve HIV+ individuals from Thailand.

This study aimed to determine the effects of human immunodeficiency virus (HIV) on brain structure in HIV-infected individuals with and without HIV-associated neurocognitive disorders (HAND). Twenty-nine HIV-uninfected controls, 37 HIV+, treatment-naïve, individuals with HAND (HIV+HAND+; 16 asymptomatic neurocognitive impairment (ANI), 12 mild neurocognitive disorder (MND), and 9 HIV-associated dementia HAD), and 37 HIV+, treatment-naïve, individuals with normal cognitive function (HIV+HAND-) underwent magnetic resonance imaging (MRI) and neuropsychological assessment. The HIV-infected participants had a mean (SD) age of 35 (7) years, mean (interquartile range (IQR)) CD4 count of 221 (83-324), and mean (IQR) log10 plasma viral load of 4.81 (4.39-5.48). Six regions of interest were selected for analyses including total and subcortical gray matter, total white matter, caudate, corpus callosum, and thalamus. The HIV+/HAND+ group exhibited significantly smaller brain volumes compared to the HIV-uninfected group in subcortical gray and total gray matter; however, there were no statistically significant differences in brain volumes between the HIV+HAND+ and HIV+HAND- groups or between HIV+/HAND- and controls. CD4 count at time of combination antiretroviral therapy (cART) initiation was associated with total and subcortical gray matter volumes but not with cognitive measures. Plasma viral load correlated with neuropsychological performance but not brain volumes. The lack of significant differences in brain volumes between HIV+HAND+ and HIV+HAND- suggests that brain atrophy is not a sensitive measure of HAND in subjects without advanced immunosuppression. Alternatively, current HAND diagnostic criteria may not sufficiently distinguish patients based on MRI measures of brain volumes.

Non-motor symptoms in Thai patients with Parkinson's disease studied at Phramongkutklao Hospital.

BACKGROUND: Non-motor symptoms (NMS) ofParkinson's disease (PD) have been recently recognized to be as disabling as motor symptoms in PD. However these symptoms are still under recognized causing delay in treatment and inadequate management. This study aimed to identify NMS in Thai PD patients using the NMS screening questionnaire (NMSQuest). MATERIAL AND METHOD: Patients with idiopathic Parkinson's disease visiting the neurology clinic in 2008 were enrolled. NMSQuest-Thai version (NMSQ-T) was applied to patients to identify NMS. RESULTS: Collected data from questionnaires completed by 165 probable idiopathic PD was analyzed. The demographic profiles showed mean age of 68.6 years with mean disease duration 5.4 years, and male 56.4%. Patients had Hoehn & Yahrstaging, stage-2: 43%, stage-3: 24.8%, stage-I: 24.2% and stage-4: 7.9%. The average dosage oflevodopa was 456.4 mg/d. Mean total NMSQ-T score was 9.5. Most prevalent of non-motor symptom was nocturia (64.2%). The domains which gained most positive answers were urinary domain (54.55%). Inter-domain correlations were significantly found in all, except the sexual domain. Multivariate analysis revealed the duration ofPD and stages were significantly correlated with the total score ofNMS. Only three percent denied having any non-motor symptoms. CONCLUSION: Almost all Thai PD had NMS. Urinary domain is the most prevalent in our series. Screening using NMSQ-Tto recognize NMS would be a helpful tool to improve the quality of life in Thai Parkinson 's disease.

Behavioral and psychological symptoms of dementia.

OBJECTIVE: To identify the frequency of behavioral and psychological symptoms of dementia (BPSD) and to explore the different characteristics between subgroup and severity of dementia. MATERIAL AND METHOD: Sixty-seven patients with Alzheimer's disease, vascular dementia, and mixed dementia were recruited to our cross-sectional study. Neuropsychiatric batteries including the Mini Mental Status Examination-Thai 2002, Thai Geriatric Depression Scale, 23 items from Alzheimer's Disease co-operative Study activities of daily living inventory, Behavioralpathology in Alzheimer's disease rating scale, and Pittsburg Sleep Quality Index were tested. RESULTS: The most common behavioral and psychological symptoms of dementia (BPSD) were sleep problems (100%), paranoid/delusion (59.7%), diurnal disturbance (49.2%) and aggressiveness (46.3%). Hallucination and affective problems were more severe in AD than in VaD/mixed dementia. Sleep problems were identified more severe in mild dementia than moderate-to-severe dementia. With longer duration of having dementia, exceptfor affective problem, there was no diffemence in behavioral and psychological symptoms observed compared to the shorter dementia group. CONCLUSION: Behavioral and psychological symptoms were very common in Alzheimer disease, vascular dementia, and mixed dementia. Since these symptoms cause cognitive and functional decline, institutionalization, caregiver distress and increase direct costs ofcare, the problem must be identified and addressed.