NEW ORLEANS – The use of labetalol or atenolol in pregnancy is associated with significantly increased risk of having a small-for-gestational-age (SGA) baby; metoprolol and propranolol are not.

And none of these four beta-blockers are associated with increased risk of congenital cardiac anomalies, Angie Ng, MD, reported at the American Heart Association scientific sessions.

[email protected]

NEW ORLEANS – The use of labetalol or atenolol in pregnancy is associated with significantly increased risk of having a small-for-gestational-age (SGA) baby; metoprolol and propranolol are not.

And none of these four beta-blockers are associated with increased risk of congenital cardiac anomalies, Angie Ng, MD, reported at the American Heart Association scientific sessions.

[email protected]

NEW ORLEANS – The use of labetalol or atenolol in pregnancy is associated with significantly increased risk of having a small-for-gestational-age (SGA) baby; metoprolol and propranolol are not.

And none of these four beta-blockers are associated with increased risk of congenital cardiac anomalies, Angie Ng, MD, reported at the American Heart Association scientific sessions.

[email protected]

HOUSTON – The appropriate evaluation and treatment of infantile spasms often comes after significant delays that are largely attributable to lack of recognition of the condition, according to recent survey results.

“Parental suspicions that ‘something was wrong’ were often discounted by health care providers, and survey respondents frequently reported that health care providers (including neurologists) were unfamiliar with infantile spasms [IS],” wrote Johnson Lay and his collaborators, in presenting results of the recently-completed Assessment of Symptoms and Specialists in Infantile Spasms (ASSIST) study at the annual meeting of the American Epilepsy Society. It’s critically important not to discount parental concerns, senior author Shaun Hussain, MD, said in an interview about the study, which surveyed parents of children with IS: “Sometimes we get in the habit of reassuring patients too much.”

[email protected]

On Twitter @karioakes

HOUSTON – The appropriate evaluation and treatment of infantile spasms often comes after significant delays that are largely attributable to lack of recognition of the condition, according to recent survey results.

“Parental suspicions that ‘something was wrong’ were often discounted by health care providers, and survey respondents frequently reported that health care providers (including neurologists) were unfamiliar with infantile spasms [IS],” wrote Johnson Lay and his collaborators, in presenting results of the recently-completed Assessment of Symptoms and Specialists in Infantile Spasms (ASSIST) study at the annual meeting of the American Epilepsy Society. It’s critically important not to discount parental concerns, senior author Shaun Hussain, MD, said in an interview about the study, which surveyed parents of children with IS: “Sometimes we get in the habit of reassuring patients too much.”

[email protected]

On Twitter @karioakes

HOUSTON – The appropriate evaluation and treatment of infantile spasms often comes after significant delays that are largely attributable to lack of recognition of the condition, according to recent survey results.

“Parental suspicions that ‘something was wrong’ were often discounted by health care providers, and survey respondents frequently reported that health care providers (including neurologists) were unfamiliar with infantile spasms [IS],” wrote Johnson Lay and his collaborators, in presenting results of the recently-completed Assessment of Symptoms and Specialists in Infantile Spasms (ASSIST) study at the annual meeting of the American Epilepsy Society. It’s critically important not to discount parental concerns, senior author Shaun Hussain, MD, said in an interview about the study, which surveyed parents of children with IS: “Sometimes we get in the habit of reassuring patients too much.”

[email protected]

On Twitter @karioakes

My patients find it extremely difficult to determine the number of calories they consume on a daily basis. This activity can be laborious and time consuming, even when you have the right “app.”

So, when I tell my overweight and obese patients to restrict their caloric consumption to lose weight, the discussion usually begins with, “I know this might be difficult, but …” And it usually ends with me feeling a little less than anemic optimism.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

My patients find it extremely difficult to determine the number of calories they consume on a daily basis. This activity can be laborious and time consuming, even when you have the right “app.”

So, when I tell my overweight and obese patients to restrict their caloric consumption to lose weight, the discussion usually begins with, “I know this might be difficult, but …” And it usually ends with me feeling a little less than anemic optimism.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

My patients find it extremely difficult to determine the number of calories they consume on a daily basis. This activity can be laborious and time consuming, even when you have the right “app.”

So, when I tell my overweight and obese patients to restrict their caloric consumption to lose weight, the discussion usually begins with, “I know this might be difficult, but …” And it usually ends with me feeling a little less than anemic optimism.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

HOUSTON—The International League Against Epilepsy (ILAE) has approved a new seizure classification. Robert S. Fisher, MD, PhD, Director of the Epilepsy Center at Stanford University in California and Chair of the ILAE’s Seizure Classification Task Force, described the classification at the 70th Annual Meeting of the American Epilepsy Society.

The existing classification, published in 1981, worked well, but its limitations became apparent over time, Dr. Fisher said. For example, certain seizure types (eg, tonic) only existed in the generalized seizure category, even though they can occur focally. In addition, it was impossible to classify a seizure without knowing its onset, and some common seizures could not be classified at all.

The 2017 ILAE Seizure Classification addresses those limitations and updates certain terms to make them clearer to patients and people who do not specialize in seizure classification. “Some patients construe the word ‘simple’ to mean easy, and they feel that their seizures are not simple at all,” Dr. Fisher said. “So, a simple partial seizure is now going to be called a focal aware seizure. A complex partial seizure is a focal impaired awareness seizure.”

Impairment of consciousness has always played a key role in classifying seizures. The 2017 classification uses awareness as a surrogate marker of consciousness. Awareness can be used to classify focal, but not generalized onset, seizures in the new classification.

Focal seizures optionally may be further classified as motor or nonmotor. Nonmotor seizure types include behavior arrest, autonomic, cognitive, emotional, and sensory. Motor seizure types include atonic seizures, automatisms, clonic seizures, epileptic spasms, hyperkinetic seizures, myoclonic seizures, and tonic seizures.New generalized seizures include absence with eyelid myoclonia, epileptic spasms, myoclonic–atonic (as in Doose syndrome), and myoclonic–tonic–clonic (as in juvenile myoclonic epilepsy). A combined seizure type—focal to bilateral tonic–clonic—previously was known as secondarily generalized tonic–clonic.

Rules for Classifying Seizures

When classifying seizures, physicians should decide whether seizure onset is focal or generalized, using an 80% confidence level. Neurologists may classify focal seizures by degree of awareness or omit awareness as a classifier. If awareness is impaired at any point during a focal seizure, it is a focal impaired awareness seizure.

The first prominent sign or symptom of a focal seizure should be used for classification, not counting transient behavior arrest. A focal seizure is only considered a behavior arrest seizure if behavior arrest is the prominent feature of the entire seizure.

Clinicians are encouraged to add descriptions of other signs and symptoms, but these additions do not alter the seizure type (eg, focal emotional seizure with tonic right arm activity and hyperventilation). Seizures may be unclassified due to inadequate information or inability to place them in other categories, Dr. Fisher said.

Implications of Seizure Type

Seizure type may suggest a particular treatment, prognosis, restriction of an activity like driving, or an underlying disease process. The ILAE task force initially was interested in developing an entirely new seizure classification based anatomy, brain networks, or pathophysiology. “But we quickly realized that we just did not know enough about the underlying science,” Dr. Fisher said. Instead, they updated the existing, primarily observational classification.

The ILAE plans to publish the classification in an upcoming isssue of Epilepsia. A mapping table will allow neurologists to match old and new seizure terms.

—Jake Remaly

HOUSTON—The International League Against Epilepsy (ILAE) has approved a new seizure classification. Robert S. Fisher, MD, PhD, Director of the Epilepsy Center at Stanford University in California and Chair of the ILAE’s Seizure Classification Task Force, described the classification at the 70th Annual Meeting of the American Epilepsy Society.

The existing classification, published in 1981, worked well, but its limitations became apparent over time, Dr. Fisher said. For example, certain seizure types (eg, tonic) only existed in the generalized seizure category, even though they can occur focally. In addition, it was impossible to classify a seizure without knowing its onset, and some common seizures could not be classified at all.

The 2017 ILAE Seizure Classification addresses those limitations and updates certain terms to make them clearer to patients and people who do not specialize in seizure classification. “Some patients construe the word ‘simple’ to mean easy, and they feel that their seizures are not simple at all,” Dr. Fisher said. “So, a simple partial seizure is now going to be called a focal aware seizure. A complex partial seizure is a focal impaired awareness seizure.”

Impairment of consciousness has always played a key role in classifying seizures. The 2017 classification uses awareness as a surrogate marker of consciousness. Awareness can be used to classify focal, but not generalized onset, seizures in the new classification.

Focal seizures optionally may be further classified as motor or nonmotor. Nonmotor seizure types include behavior arrest, autonomic, cognitive, emotional, and sensory. Motor seizure types include atonic seizures, automatisms, clonic seizures, epileptic spasms, hyperkinetic seizures, myoclonic seizures, and tonic seizures.New generalized seizures include absence with eyelid myoclonia, epileptic spasms, myoclonic–atonic (as in Doose syndrome), and myoclonic–tonic–clonic (as in juvenile myoclonic epilepsy). A combined seizure type—focal to bilateral tonic–clonic—previously was known as secondarily generalized tonic–clonic.

Rules for Classifying Seizures

When classifying seizures, physicians should decide whether seizure onset is focal or generalized, using an 80% confidence level. Neurologists may classify focal seizures by degree of awareness or omit awareness as a classifier. If awareness is impaired at any point during a focal seizure, it is a focal impaired awareness seizure.

The first prominent sign or symptom of a focal seizure should be used for classification, not counting transient behavior arrest. A focal seizure is only considered a behavior arrest seizure if behavior arrest is the prominent feature of the entire seizure.

Clinicians are encouraged to add descriptions of other signs and symptoms, but these additions do not alter the seizure type (eg, focal emotional seizure with tonic right arm activity and hyperventilation). Seizures may be unclassified due to inadequate information or inability to place them in other categories, Dr. Fisher said.

Implications of Seizure Type

Seizure type may suggest a particular treatment, prognosis, restriction of an activity like driving, or an underlying disease process. The ILAE task force initially was interested in developing an entirely new seizure classification based anatomy, brain networks, or pathophysiology. “But we quickly realized that we just did not know enough about the underlying science,” Dr. Fisher said. Instead, they updated the existing, primarily observational classification.

The ILAE plans to publish the classification in an upcoming isssue of Epilepsia. A mapping table will allow neurologists to match old and new seizure terms.

—Jake Remaly

HOUSTON—The International League Against Epilepsy (ILAE) has approved a new seizure classification. Robert S. Fisher, MD, PhD, Director of the Epilepsy Center at Stanford University in California and Chair of the ILAE’s Seizure Classification Task Force, described the classification at the 70th Annual Meeting of the American Epilepsy Society.

The existing classification, published in 1981, worked well, but its limitations became apparent over time, Dr. Fisher said. For example, certain seizure types (eg, tonic) only existed in the generalized seizure category, even though they can occur focally. In addition, it was impossible to classify a seizure without knowing its onset, and some common seizures could not be classified at all.

The 2017 ILAE Seizure Classification addresses those limitations and updates certain terms to make them clearer to patients and people who do not specialize in seizure classification. “Some patients construe the word ‘simple’ to mean easy, and they feel that their seizures are not simple at all,” Dr. Fisher said. “So, a simple partial seizure is now going to be called a focal aware seizure. A complex partial seizure is a focal impaired awareness seizure.”

Impairment of consciousness has always played a key role in classifying seizures. The 2017 classification uses awareness as a surrogate marker of consciousness. Awareness can be used to classify focal, but not generalized onset, seizures in the new classification.

Focal seizures optionally may be further classified as motor or nonmotor. Nonmotor seizure types include behavior arrest, autonomic, cognitive, emotional, and sensory. Motor seizure types include atonic seizures, automatisms, clonic seizures, epileptic spasms, hyperkinetic seizures, myoclonic seizures, and tonic seizures.New generalized seizures include absence with eyelid myoclonia, epileptic spasms, myoclonic–atonic (as in Doose syndrome), and myoclonic–tonic–clonic (as in juvenile myoclonic epilepsy). A combined seizure type—focal to bilateral tonic–clonic—previously was known as secondarily generalized tonic–clonic.

Rules for Classifying Seizures

When classifying seizures, physicians should decide whether seizure onset is focal or generalized, using an 80% confidence level. Neurologists may classify focal seizures by degree of awareness or omit awareness as a classifier. If awareness is impaired at any point during a focal seizure, it is a focal impaired awareness seizure.

The first prominent sign or symptom of a focal seizure should be used for classification, not counting transient behavior arrest. A focal seizure is only considered a behavior arrest seizure if behavior arrest is the prominent feature of the entire seizure.

Clinicians are encouraged to add descriptions of other signs and symptoms, but these additions do not alter the seizure type (eg, focal emotional seizure with tonic right arm activity and hyperventilation). Seizures may be unclassified due to inadequate information or inability to place them in other categories, Dr. Fisher said.

Implications of Seizure Type

Seizure type may suggest a particular treatment, prognosis, restriction of an activity like driving, or an underlying disease process. The ILAE task force initially was interested in developing an entirely new seizure classification based anatomy, brain networks, or pathophysiology. “But we quickly realized that we just did not know enough about the underlying science,” Dr. Fisher said. Instead, they updated the existing, primarily observational classification.

The ILAE plans to publish the classification in an upcoming isssue of Epilepsia. A mapping table will allow neurologists to match old and new seizure terms.

—Jake Remaly

Adding hypothermia therapy to standard care for convulsive status epilepticus is not neuroprotective, according to a report published online Dec. 22 in the New England Journal of Medicine.

Small-animal studies recently reported that therapeutic hypothermia had antiepileptic and neuroprotective properties. Researchers performed an open-label, randomized controlled trial to examine whether the treatment would improve neurologic outcomes in 268 consecutive adults treated at 11 ICUs in France for convulsive status epilepticus during a 4-year period. The average patient age was 57 years, and approximately half the study participants had a history of epilepsy. All required mechanical ventilation.

A total of 130 patients were assigned to receive standard care, and 138 were assigned to hypothermia in which their core body temperature was rapidly lowered to 32-34 degrees C and maintained at that level for 24 hours. Hypothermia was induced using ice-cold IV fluids and was maintained by applying ice packs to the groin and neck and surrounding the patient in a cold-air tunnel, said Stephane Legriel, MD, of the Medical-Surgical ICU, Centre Hospitalier de Versailles-Site André Mignot, France, and his associates.

The primary outcome measure – the absence of functional impairment 90 days after admission, defined as a score of 5 on the Glasgow Outcome Scale – occurred in 49% of the hypothermia group and 43% of the control group, indicating that the addition of hypothermia was not neuroprotective. In addition, ICU mortality, in-hospital mortality, and 90-day mortality were not significantly different between the two study groups. More patients in the hypothermia group (51%) than in the standard-care group (45%) developed pneumonia that was attributed to aspiration, the investigators reported (N Engl J Med. 2016;375:2457-67).

“The results of this trial do not support a beneficial effect of therapeutic hypothermia as compared with standard care alone in patients with convulsive status epilepticus receiving mechanical ventilation,” Dr. Legriel and his associates wrote.

This study was supported by the French Ministry of Health and received no industry support or involvement. Dr. Legriel reported having no relevant financial disclosures; two of his associates reported ties to Alexion, Astellas, Bard, and Gilead.

Adding hypothermia therapy to standard care for convulsive status epilepticus is not neuroprotective, according to a report published online Dec. 22 in the New England Journal of Medicine.

Small-animal studies recently reported that therapeutic hypothermia had antiepileptic and neuroprotective properties. Researchers performed an open-label, randomized controlled trial to examine whether the treatment would improve neurologic outcomes in 268 consecutive adults treated at 11 ICUs in France for convulsive status epilepticus during a 4-year period. The average patient age was 57 years, and approximately half the study participants had a history of epilepsy. All required mechanical ventilation.

A total of 130 patients were assigned to receive standard care, and 138 were assigned to hypothermia in which their core body temperature was rapidly lowered to 32-34 degrees C and maintained at that level for 24 hours. Hypothermia was induced using ice-cold IV fluids and was maintained by applying ice packs to the groin and neck and surrounding the patient in a cold-air tunnel, said Stephane Legriel, MD, of the Medical-Surgical ICU, Centre Hospitalier de Versailles-Site André Mignot, France, and his associates.

The primary outcome measure – the absence of functional impairment 90 days after admission, defined as a score of 5 on the Glasgow Outcome Scale – occurred in 49% of the hypothermia group and 43% of the control group, indicating that the addition of hypothermia was not neuroprotective. In addition, ICU mortality, in-hospital mortality, and 90-day mortality were not significantly different between the two study groups. More patients in the hypothermia group (51%) than in the standard-care group (45%) developed pneumonia that was attributed to aspiration, the investigators reported (N Engl J Med. 2016;375:2457-67).

“The results of this trial do not support a beneficial effect of therapeutic hypothermia as compared with standard care alone in patients with convulsive status epilepticus receiving mechanical ventilation,” Dr. Legriel and his associates wrote.

This study was supported by the French Ministry of Health and received no industry support or involvement. Dr. Legriel reported having no relevant financial disclosures; two of his associates reported ties to Alexion, Astellas, Bard, and Gilead.

Adding hypothermia therapy to standard care for convulsive status epilepticus is not neuroprotective, according to a report published online Dec. 22 in the New England Journal of Medicine.

Small-animal studies recently reported that therapeutic hypothermia had antiepileptic and neuroprotective properties. Researchers performed an open-label, randomized controlled trial to examine whether the treatment would improve neurologic outcomes in 268 consecutive adults treated at 11 ICUs in France for convulsive status epilepticus during a 4-year period. The average patient age was 57 years, and approximately half the study participants had a history of epilepsy. All required mechanical ventilation.

A total of 130 patients were assigned to receive standard care, and 138 were assigned to hypothermia in which their core body temperature was rapidly lowered to 32-34 degrees C and maintained at that level for 24 hours. Hypothermia was induced using ice-cold IV fluids and was maintained by applying ice packs to the groin and neck and surrounding the patient in a cold-air tunnel, said Stephane Legriel, MD, of the Medical-Surgical ICU, Centre Hospitalier de Versailles-Site André Mignot, France, and his associates.

The primary outcome measure – the absence of functional impairment 90 days after admission, defined as a score of 5 on the Glasgow Outcome Scale – occurred in 49% of the hypothermia group and 43% of the control group, indicating that the addition of hypothermia was not neuroprotective. In addition, ICU mortality, in-hospital mortality, and 90-day mortality were not significantly different between the two study groups. More patients in the hypothermia group (51%) than in the standard-care group (45%) developed pneumonia that was attributed to aspiration, the investigators reported (N Engl J Med. 2016;375:2457-67).

“The results of this trial do not support a beneficial effect of therapeutic hypothermia as compared with standard care alone in patients with convulsive status epilepticus receiving mechanical ventilation,” Dr. Legriel and his associates wrote.

This study was supported by the French Ministry of Health and received no industry support or involvement. Dr. Legriel reported having no relevant financial disclosures; two of his associates reported ties to Alexion, Astellas, Bard, and Gilead.

In August 2014, we first heard of increased pediatric cases of severe respiratory tract disease, many requiring management in the ICU, and of acute flaccid myelitis/paralysis (AFM) of unknown etiology from many states across the United States. Concurrently with this outbreak in the United States, similar clinical cases were reported in Canada and Europe. Subsequently, enterovirus D68 was confirmed in some, but not all, of the paralyzed children. Although new to many of us, enterovirus D68 was already known as an atypical enterovirus sharing many of its structural and chemical properties with rhinovirus. For example, it most often was reported from respiratory samples and less common from stool samples. It also had been associated with clusters of respiratory disease since 2000 and a 2008 case of fatal AFM.

• Wash your hands often with soap and water for 20 seconds.
• Avoid touching your eyes, nose and mouth with unwashed hands.
• Avoid close contact such as kissing, hugging, and sharing cups with people who are ill.
• Cover your coughs and sneezes with a tissue or shirt sleeve, not your hands.
• Clean and disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone is sick.
• Stay home when you are ill.

In 2014, it was speculated that the epidemic might have been a one-time event. It now appears more likely that enterovirus D68 activity has been increasing since 2000, and that children and immunocompromised hosts will be at greatest risk because of a lack of neutralizing antibody. Ongoing enterovirus surveillance will be critical to understand the potential for severe respiratory disease as will the development of new and effective antivirals. A vaccine for enterovirus 71 recently demonstrated efficacy against hand, foot, and mouth disease in children and may provide insights into the development of vaccines against enterovirus D68.

References

Lancet Infect Dis. 2016 May;16(5):e64-75

Emerg Infect Dis. 2017 Jan;23(1):140-3.

J Med Virol. 2016 May;88(5):739-45

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at [email protected].

In August 2014, we first heard of increased pediatric cases of severe respiratory tract disease, many requiring management in the ICU, and of acute flaccid myelitis/paralysis (AFM) of unknown etiology from many states across the United States. Concurrently with this outbreak in the United States, similar clinical cases were reported in Canada and Europe. Subsequently, enterovirus D68 was confirmed in some, but not all, of the paralyzed children. Although new to many of us, enterovirus D68 was already known as an atypical enterovirus sharing many of its structural and chemical properties with rhinovirus. For example, it most often was reported from respiratory samples and less common from stool samples. It also had been associated with clusters of respiratory disease since 2000 and a 2008 case of fatal AFM.

• Wash your hands often with soap and water for 20 seconds.
• Avoid touching your eyes, nose and mouth with unwashed hands.
• Avoid close contact such as kissing, hugging, and sharing cups with people who are ill.
• Cover your coughs and sneezes with a tissue or shirt sleeve, not your hands.
• Clean and disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone is sick.
• Stay home when you are ill.

In 2014, it was speculated that the epidemic might have been a one-time event. It now appears more likely that enterovirus D68 activity has been increasing since 2000, and that children and immunocompromised hosts will be at greatest risk because of a lack of neutralizing antibody. Ongoing enterovirus surveillance will be critical to understand the potential for severe respiratory disease as will the development of new and effective antivirals. A vaccine for enterovirus 71 recently demonstrated efficacy against hand, foot, and mouth disease in children and may provide insights into the development of vaccines against enterovirus D68.

References

Lancet Infect Dis. 2016 May;16(5):e64-75

Emerg Infect Dis. 2017 Jan;23(1):140-3.

J Med Virol. 2016 May;88(5):739-45

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at [email protected].

In August 2014, we first heard of increased pediatric cases of severe respiratory tract disease, many requiring management in the ICU, and of acute flaccid myelitis/paralysis (AFM) of unknown etiology from many states across the United States. Concurrently with this outbreak in the United States, similar clinical cases were reported in Canada and Europe. Subsequently, enterovirus D68 was confirmed in some, but not all, of the paralyzed children. Although new to many of us, enterovirus D68 was already known as an atypical enterovirus sharing many of its structural and chemical properties with rhinovirus. For example, it most often was reported from respiratory samples and less common from stool samples. It also had been associated with clusters of respiratory disease since 2000 and a 2008 case of fatal AFM.

• Wash your hands often with soap and water for 20 seconds.
• Avoid touching your eyes, nose and mouth with unwashed hands.
• Avoid close contact such as kissing, hugging, and sharing cups with people who are ill.
• Cover your coughs and sneezes with a tissue or shirt sleeve, not your hands.
• Clean and disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone is sick.
• Stay home when you are ill.

In 2014, it was speculated that the epidemic might have been a one-time event. It now appears more likely that enterovirus D68 activity has been increasing since 2000, and that children and immunocompromised hosts will be at greatest risk because of a lack of neutralizing antibody. Ongoing enterovirus surveillance will be critical to understand the potential for severe respiratory disease as will the development of new and effective antivirals. A vaccine for enterovirus 71 recently demonstrated efficacy against hand, foot, and mouth disease in children and may provide insights into the development of vaccines against enterovirus D68.

References

Lancet Infect Dis. 2016 May;16(5):e64-75

Emerg Infect Dis. 2017 Jan;23(1):140-3.

J Med Virol. 2016 May;88(5):739-45

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at [email protected].

ORLANDO – Infliximab and tacrolimus each demonstrate efficacy for treatment of moderate to severe active ulcerative colitis in published studies. However, it remains unknown if one agent offers greater efficacy than the other in this patient population, so researchers in Japan conducted a meta-analysis to find out more.

Lead investigator Shinichi Kawano, MD, at Kyushu University, Fukuoka, Japan, and his colleagues searched PubMed for relevant studies up until August 2016. They conducted a systematic review and identified 79 potential studies of tumor necrosis factor blocker infliximab (Remicade, Janssen) and the calcineurin inhibitor tacrolimus (various brands) in this patient population. They ruled out the vast majority, 75 studies, for not directly comparing therapeutic efficacy. They also excluded one additional study for insufficient data on their five outcomes of interest: rates of clinical remission, clinical response, freedom from colectomy, adverse events, and serious adverse events. They focused on three 2016 retrospective studies with a total of 244 patients, and added 13 of their own patients, 5 taking infliximab and 8 taking tacrolimus, to their dataset.

selvanegra/Thinkstock

ORLANDO – Infliximab and tacrolimus each demonstrate efficacy for treatment of moderate to severe active ulcerative colitis in published studies. However, it remains unknown if one agent offers greater efficacy than the other in this patient population, so researchers in Japan conducted a meta-analysis to find out more.

Lead investigator Shinichi Kawano, MD, at Kyushu University, Fukuoka, Japan, and his colleagues searched PubMed for relevant studies up until August 2016. They conducted a systematic review and identified 79 potential studies of tumor necrosis factor blocker infliximab (Remicade, Janssen) and the calcineurin inhibitor tacrolimus (various brands) in this patient population. They ruled out the vast majority, 75 studies, for not directly comparing therapeutic efficacy. They also excluded one additional study for insufficient data on their five outcomes of interest: rates of clinical remission, clinical response, freedom from colectomy, adverse events, and serious adverse events. They focused on three 2016 retrospective studies with a total of 244 patients, and added 13 of their own patients, 5 taking infliximab and 8 taking tacrolimus, to their dataset.

selvanegra/Thinkstock

ORLANDO – Infliximab and tacrolimus each demonstrate efficacy for treatment of moderate to severe active ulcerative colitis in published studies. However, it remains unknown if one agent offers greater efficacy than the other in this patient population, so researchers in Japan conducted a meta-analysis to find out more.

Lead investigator Shinichi Kawano, MD, at Kyushu University, Fukuoka, Japan, and his colleagues searched PubMed for relevant studies up until August 2016. They conducted a systematic review and identified 79 potential studies of tumor necrosis factor blocker infliximab (Remicade, Janssen) and the calcineurin inhibitor tacrolimus (various brands) in this patient population. They ruled out the vast majority, 75 studies, for not directly comparing therapeutic efficacy. They also excluded one additional study for insufficient data on their five outcomes of interest: rates of clinical remission, clinical response, freedom from colectomy, adverse events, and serious adverse events. They focused on three 2016 retrospective studies with a total of 244 patients, and added 13 of their own patients, 5 taking infliximab and 8 taking tacrolimus, to their dataset.

selvanegra/Thinkstock

A test used to detect Zika virus is producing a larger-than-expected number of false-positive results, according to a safety alert issued by the Food and Drug Administration.

The ZIKV Detect IgM Capture ELISA test is the first commercially available Zika serological IgM test – it was approved by the FDA in August 2016 and is used by several commercial laboratories. The test reports only presumptive positive results and a sample has to be sent to the Centers for Disease Control and Prevention for confirmation. Final results can take up to a month to be delivered. In most instances, the preliminary test results have matched the confirmed sample results.

[email protected]

A test used to detect Zika virus is producing a larger-than-expected number of false-positive results, according to a safety alert issued by the Food and Drug Administration.

The ZIKV Detect IgM Capture ELISA test is the first commercially available Zika serological IgM test – it was approved by the FDA in August 2016 and is used by several commercial laboratories. The test reports only presumptive positive results and a sample has to be sent to the Centers for Disease Control and Prevention for confirmation. Final results can take up to a month to be delivered. In most instances, the preliminary test results have matched the confirmed sample results.

[email protected]

A test used to detect Zika virus is producing a larger-than-expected number of false-positive results, according to a safety alert issued by the Food and Drug Administration.

The ZIKV Detect IgM Capture ELISA test is the first commercially available Zika serological IgM test – it was approved by the FDA in August 2016 and is used by several commercial laboratories. The test reports only presumptive positive results and a sample has to be sent to the Centers for Disease Control and Prevention for confirmation. Final results can take up to a month to be delivered. In most instances, the preliminary test results have matched the confirmed sample results.

[email protected]

Studies Provide More Insight Into Zika Effects

Three studies reported on the effects of the Zika virus outbreak in Brazil. The first study examined CT findings of the CNS in 16 newborn babies with congenital Zika virus infection confirmed by tests in CSF. The researchers identified a pattern of CT brain findings in the babies, including decreased brain volume, simplified gyral pattern, calcifications, ventricular dilatation, and prominent occipital bone.

"We live in Pernambuco, a state in northeastern Brazil, which had the highest number of patients with microcephaly during the Zika outbreak in our country," said Natacha Calheiros de Lima Petribu, MD, of the Department of Radiology at Barão de Lucena Hospital. "Our study proves that Zika virus infection can cause congenital brain damage in babies with and without microcephaly."  

Another study analyzed the imaging results of three target groups affected by Zika: adults who developed acute neurologic syndrome, newborns with vertical infection with neurologic disorders, and pregnant women with rash outbreaks suggestive of Zika. Many of the adults had symptoms of Guillain-Barré syndrome. A few showed inflammation of the brain and spinal cord (ie, Bickerstaff's encephalitis) or brainstem and spinal cord lesions. Common MRI findings included enhancement of certain spinal and facial nerves. In the newborns, MRI showed orbital injuries and anatomical changes in brain tissue.  

"It was alarming to find so many cases of neurologic syndromes in adults, some very serious, related to Zika virus infection," said study author Emerson de Melo Casagrande, MD, of the Department of Radiology at Antonio Pedro University Hospital--Federal Fluminense University. "We have also noticed a difference between these syndromes, even though the trigger was the same."

In a third study, ultrasound and fetal MRI were performed on pregnant patients with Zika virus infection at different gestational ages. Once the babies were born, they underwent ultrasound, CT, and MRI. The researchers then created 3-D virtual and physical models of the skulls. More than half of the babies had microcephaly, brain calcifications, and loss of brain tissue volume, along with other structural changes.

"The emergence of Zika virus in the Americas has coincided with increased reports of babies born with microcephaly," said study author Heron Werner Jr, MD, PhD, of the Department of Radiology at Clínica de Diagnóstico por Imagem. "An early diagnosis may help in treating these babies after birth. Moreover, the knowledge of abnormalities present in the CNS may give hints about the pathophysiology of the disease."

Head Impacts Lead to Brain Changes in High School Football Players

Brain imaging exams performed on high school football players after a single season reveal changes in the gray and white matter that correlated with exposure to head impacts, according to researchers.

"It is important to understand the potential changes occurring in the brain related to youth contact sports," said Elizabeth Moody Davenport, PhD, a postdoctoral researcher at UT Southwestern Medical Center in Dallas. "We know that some professional football players suffer from a serious condition called chronic traumatic encephalopathy or CTE. We are attempting to find out when and how that process starts, so that we can keep sports a healthy activity for millions of children and adolescents."

The study included 24 players from a high school football team in North Carolina, each of whom wore a helmet outfitted with the Head Impact Telemetry System (HITS) during all practices and games. The helmets are lined with six accelerometers that measure the magnitude, location, and direction of a hit. Data from the helmets can be uploaded to a computer for analysis.  

"We saw changes in these young players' brains on both structural and functional imaging after a single season of football," said Dr. Davenport.  

In the study, each player underwent pre- and post-season imaging, including a specialized MRI scan, from which diffusion tensor imaging and diffusion kurtosis imaging data were extracted to measure the brain's white matter integrity, and a magnetoencephalography (MEG) scan, which records and analyzes the magnetic fields produced by brain waves. Diffusion imaging can measure the structural white matter changes in the brain, and MEG assesses changes in function.

"MEG can be used to measure delta waves in the brain, which are a type of distress signal," said Dr. Davenport. "Delta waves represent slow wave activity that increases after brain injuries. The delta waves we saw came from the surface of the brain, while diffusion imaging is a measure of the white matter deeper in the brain."  

The research team calculated the change in imaging metrics between the pre- and post-season imaging exams. They measured abnormalities observed on diffusion imaging and abnormally increased delta-wave activity on MEG. The imaging results were then combined with player-specific impact data from the HITS. None of the 24 players were diagnosed with a concussion during the study.

Players with greater head impact exposure had the greatest change in diffusion imaging and MEG metrics. "Change in diffusion imaging metrics correlated most to linear acceleration, similar to the impact of a car crash," said Dr. Davenport. "MEG changes correlated most to rotational impact, similar to a boxer's punch. These results demonstrate that you need both imaging metrics to assess impact exposure, because they correlate with different biomechanical processes."

Similar studies are being conducted this fall, and a consortium has been formed to continue the brain imaging research in youth contact sports across the country, said Dr. Davenport. "Without a larger population that is closely followed in a longitudinal study, it is difficult to know the long-term effects of these changes," she said. "We do not know if the brain's developmental trajectory is altered, or if the off-season time allows for the brain to return to normal."

Depression in Soldiers Linked to Brain Disruption From Injury

Using multiple brain imaging techniques, researchers have found that a disruption of the circuitry in the brain's cognitive-emotional pathways may provide a physical foundation for depression symptoms in some service members who have had mild traumatic brain injury (mTBI) in combat. "We can link these connectivity changes in the brain to poor top-down emotional processing and greater maladaptive rumination, or worrying, in symptomatic depressed soldiers after mTBI," said Ping-Hong Yeh, PhD, scientist and physicist at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland.

According to the Defense and Veterans Brain Injury Center, 352,619 service members worldwide have been diagnosed with TBI since 2000, the majority of these cases being mTBI. In addition, psychiatric disorders, such as anxiety and major depressive disorders, are becoming common in military personnel with brain injuries.

"With the increased survival of soldiers due to improvements in body armor and advanced medical care, there has been an increase in the number of soldiers surviving major trauma. Consequently, a large number of soldiers are returning from war with mTBI," said Dr. Yeh. "Mood disorders are common in military-related mTBI patients. This is an ongoing problem facing a large number of warriors in current areas of conflict, and it is likely to be a persistent problem for the foreseeable future."

For the study, researchers used diffusion-weighted imaging (DWI) and resting-state functional MRI (fMRI) to examine 130 active male service members diagnosed with mTBI and a control group of 52 men without mTBI. Depression symptoms were rated based on the Beck Depression Inventory (BDI), a 21-item, self-reporting assessment that measures characteristic attitudes and symptoms of depression. Patients with a BDI score greater than 20 are considered to have moderate to severe depression symptoms.

BDI scores showed that 75 of the patients with mTBI had moderate to severe depression symptoms. Imaging results showed that white matter tracts—the circuits that connect brain regions critical for cognitive and emotional control—were disrupted in the patients with moderate to severe depression symptoms. Researchers also saw changes in the gray matter cognitive-emotional networks in these patients.

"We found consistencies in the locations of disrupted neurocircuitry, as revealed by DWI and resting-state fMRI, that are unique to the clinical symptoms of mTBI patients," said Dr. Yeh. "We have related the brain structural and functional changes in cognitive-emotional networks to depressive symptoms in mTBI patients."  

This research can possibly lead to treatment strategies in the future, he added. "Though the results of this study were not applied directly to patient care, the neuroimaging changes we found might be incorporated into treatment plans for personalized medicine in the future."  

Short-Term Sleep Deprivation Affects Heart Function

Getting too little sleep takes a toll on your heart, researchers reported. People who work in fire and emergency medical services, medical residencies, and other high-stress jobs are often called upon to work 24-hour shifts with little opportunity for sleep. While it is known that extreme fatigue can affect many physical, cognitive, and emotional processes, this is the first study to examine how working a 24-hour shift specifically affects cardiac function.

"For the first time, we have shown that short-term sleep deprivation in the context of 24-hour shifts can lead to a significant increase in cardiac contractility, blood pressure, and heart rate," said study author Daniel Kuetting, MD, of the Department of Diagnostic and Interventional Radiology at the University of Bonn in Germany.  

For the study, Dr. Kuetting and colleagues recruited 20 healthy radiologists (19 men) with a mean age of 31.6. Each of the study participants underwent cardiovascular magnetic resonance (CMR) imaging with strain analysis before and after a 24-hour shift with an average of three hours of sleep.

"Cardiac function in the context of sleep deprivation has not previously been investigated with CMR strain analysis, the most sensitive parameter of cardiac contractility," said Dr. Kuetting. The researchers also collected blood and urine samples from the participants and measured blood pressure and heart rate.  

Following short-term sleep deprivation, the participants showed significant increases in mean peak systolic strain (-23.4 vs -21.9), systolic (118.5 mmHg vs 112.8 mmHg) and diastolic (69.2 mmHg vs 62.9 mmHg) blood pressure and heart rate (68.9 bpm vs 63.0 bpm). In addition, the participants had significant increases in levels of thyroid stimulating hormone (TSH), thyroid hormones FT3 and FT4, and cortisol.  

Although the researchers were able to perform follow-up examinations of half of the participants after regular sleep, further study in a larger cohort is needed to determine possible long-term effects of sleep loss, said Dr. Kuetting.

"The study was designed to investigate real-life work-related sleep deprivation," said Dr. Kuetting. "While the participants were not permitted to consume caffeine or food and beverages containing theobromine, such as chocolate, nuts, or tea, we did not take into account factors like individual stress level or environmental stimuli."

As people continue to work longer hours or work at more than one job to make ends meet, it is critical to investigate the detrimental effects of too much work and not enough sleep. The results of this pilot study are transferable to other professions in which long periods of uninterrupted labor are common, said Dr. Kuetting. "These findings may help us better understand how workload and shift duration affect public health."  

Aerobic Exercise Preserves Brain Volume and Improves Cognitive Function

Using a new MRI technique, researchers have found that adults with mild cognitive impairment (MCI) who exercised four times per week during a six-month period experienced an increase in brain volume in specific areas of the brain, but adults who participated in aerobic exercise experienced greater gains than those who just stretched.  

"Even over a short period of time, we saw aerobic exercise lead to a remarkable change in the brain," said Laura D. Baker, PhD, Associate Professor of Gerontology and Geriatric Medicine at Wake Forest School of Medicine (WFSM) in Winston-Salem, North Carolina.

The study included 35 adults with MCI participating in a randomized, controlled trial of exercise intervention. The participants were separated into two groups. Sixteen adults (average age, 63) engaged in aerobic activity, including treadmill, stationary bike, or elliptical training, four times per week for six months. A control group of 19 adults (average age, 67) participated in stretching exercises with the same frequency. High-resolution brain MR images were acquired from all participants before and after the six-month activity period. The MRI results were compared using conventional and biomechanical metrics to measure the change in brain volume and shape.  

"We used high-resolution MR images to measure anatomical changes within areas of the brain to obtain volumetric data and directional information," said Jeongchul Kim, PhD, a coinvestigator at WFSM.  

The analysis revealed that for both the aerobic and stretching groups, brain volume increased in most gray matter regions, including the temporal lobe, which supports short-term memory.  

"Compared to the stretching group, the aerobic activity group had greater preservation of total brain volume, increased local gray matter volume, and increased directional stretch of brain tissue," said Dr. Kim.  

Among participants of the stretching group, the analysis revealed a local contraction, or atrophy, within the white matter connecting fibers. Such directional deformation, or shape change, is partially related to volume loss, but not always, according to Dr. Kim.

"Directional changes in the brain without local volume changes could be a novel biomarker for neurologic disease," he said. "It may be a more sensitive marker for the tiny changes that occur in a specific brain region before volumetric changes are detectable on MRI."  

Both MRI measures are important to the treatment of MCI and Alzheimer's disease, which require the careful tracking of changes in the brain while patients engage in interventions, including diet and exercise, to slow the progression of the disease.  

Study participants were tested to determine the effect of exercise intervention on cognitive performance. Participants in the aerobic exercise group showed statistically significant improvement in executive function after six months, whereas the stretching group did not improve.  

"Any type of exercise can be beneficial," said Dr. Kim. "If possible, aerobic activity may create potential benefits for higher cognitive functioning."    

Studies Provide More Insight Into Zika Effects

Three studies reported on the effects of the Zika virus outbreak in Brazil. The first study examined CT findings of the CNS in 16 newborn babies with congenital Zika virus infection confirmed by tests in CSF. The researchers identified a pattern of CT brain findings in the babies, including decreased brain volume, simplified gyral pattern, calcifications, ventricular dilatation, and prominent occipital bone.

"We live in Pernambuco, a state in northeastern Brazil, which had the highest number of patients with microcephaly during the Zika outbreak in our country," said Natacha Calheiros de Lima Petribu, MD, of the Department of Radiology at Barão de Lucena Hospital. "Our study proves that Zika virus infection can cause congenital brain damage in babies with and without microcephaly."  

Another study analyzed the imaging results of three target groups affected by Zika: adults who developed acute neurologic syndrome, newborns with vertical infection with neurologic disorders, and pregnant women with rash outbreaks suggestive of Zika. Many of the adults had symptoms of Guillain-Barré syndrome. A few showed inflammation of the brain and spinal cord (ie, Bickerstaff's encephalitis) or brainstem and spinal cord lesions. Common MRI findings included enhancement of certain spinal and facial nerves. In the newborns, MRI showed orbital injuries and anatomical changes in brain tissue.  

"It was alarming to find so many cases of neurologic syndromes in adults, some very serious, related to Zika virus infection," said study author Emerson de Melo Casagrande, MD, of the Department of Radiology at Antonio Pedro University Hospital--Federal Fluminense University. "We have also noticed a difference between these syndromes, even though the trigger was the same."

In a third study, ultrasound and fetal MRI were performed on pregnant patients with Zika virus infection at different gestational ages. Once the babies were born, they underwent ultrasound, CT, and MRI. The researchers then created 3-D virtual and physical models of the skulls. More than half of the babies had microcephaly, brain calcifications, and loss of brain tissue volume, along with other structural changes.

"The emergence of Zika virus in the Americas has coincided with increased reports of babies born with microcephaly," said study author Heron Werner Jr, MD, PhD, of the Department of Radiology at Clínica de Diagnóstico por Imagem. "An early diagnosis may help in treating these babies after birth. Moreover, the knowledge of abnormalities present in the CNS may give hints about the pathophysiology of the disease."

Head Impacts Lead to Brain Changes in High School Football Players

Brain imaging exams performed on high school football players after a single season reveal changes in the gray and white matter that correlated with exposure to head impacts, according to researchers.

"It is important to understand the potential changes occurring in the brain related to youth contact sports," said Elizabeth Moody Davenport, PhD, a postdoctoral researcher at UT Southwestern Medical Center in Dallas. "We know that some professional football players suffer from a serious condition called chronic traumatic encephalopathy or CTE. We are attempting to find out when and how that process starts, so that we can keep sports a healthy activity for millions of children and adolescents."

The study included 24 players from a high school football team in North Carolina, each of whom wore a helmet outfitted with the Head Impact Telemetry System (HITS) during all practices and games. The helmets are lined with six accelerometers that measure the magnitude, location, and direction of a hit. Data from the helmets can be uploaded to a computer for analysis.  

"We saw changes in these young players' brains on both structural and functional imaging after a single season of football," said Dr. Davenport.  

In the study, each player underwent pre- and post-season imaging, including a specialized MRI scan, from which diffusion tensor imaging and diffusion kurtosis imaging data were extracted to measure the brain's white matter integrity, and a magnetoencephalography (MEG) scan, which records and analyzes the magnetic fields produced by brain waves. Diffusion imaging can measure the structural white matter changes in the brain, and MEG assesses changes in function.

"MEG can be used to measure delta waves in the brain, which are a type of distress signal," said Dr. Davenport. "Delta waves represent slow wave activity that increases after brain injuries. The delta waves we saw came from the surface of the brain, while diffusion imaging is a measure of the white matter deeper in the brain."  

The research team calculated the change in imaging metrics between the pre- and post-season imaging exams. They measured abnormalities observed on diffusion imaging and abnormally increased delta-wave activity on MEG. The imaging results were then combined with player-specific impact data from the HITS. None of the 24 players were diagnosed with a concussion during the study.

Players with greater head impact exposure had the greatest change in diffusion imaging and MEG metrics. "Change in diffusion imaging metrics correlated most to linear acceleration, similar to the impact of a car crash," said Dr. Davenport. "MEG changes correlated most to rotational impact, similar to a boxer's punch. These results demonstrate that you need both imaging metrics to assess impact exposure, because they correlate with different biomechanical processes."

Similar studies are being conducted this fall, and a consortium has been formed to continue the brain imaging research in youth contact sports across the country, said Dr. Davenport. "Without a larger population that is closely followed in a longitudinal study, it is difficult to know the long-term effects of these changes," she said. "We do not know if the brain's developmental trajectory is altered, or if the off-season time allows for the brain to return to normal."

Depression in Soldiers Linked to Brain Disruption From Injury

Using multiple brain imaging techniques, researchers have found that a disruption of the circuitry in the brain's cognitive-emotional pathways may provide a physical foundation for depression symptoms in some service members who have had mild traumatic brain injury (mTBI) in combat. "We can link these connectivity changes in the brain to poor top-down emotional processing and greater maladaptive rumination, or worrying, in symptomatic depressed soldiers after mTBI," said Ping-Hong Yeh, PhD, scientist and physicist at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland.

According to the Defense and Veterans Brain Injury Center, 352,619 service members worldwide have been diagnosed with TBI since 2000, the majority of these cases being mTBI. In addition, psychiatric disorders, such as anxiety and major depressive disorders, are becoming common in military personnel with brain injuries.

"With the increased survival of soldiers due to improvements in body armor and advanced medical care, there has been an increase in the number of soldiers surviving major trauma. Consequently, a large number of soldiers are returning from war with mTBI," said Dr. Yeh. "Mood disorders are common in military-related mTBI patients. This is an ongoing problem facing a large number of warriors in current areas of conflict, and it is likely to be a persistent problem for the foreseeable future."

For the study, researchers used diffusion-weighted imaging (DWI) and resting-state functional MRI (fMRI) to examine 130 active male service members diagnosed with mTBI and a control group of 52 men without mTBI. Depression symptoms were rated based on the Beck Depression Inventory (BDI), a 21-item, self-reporting assessment that measures characteristic attitudes and symptoms of depression. Patients with a BDI score greater than 20 are considered to have moderate to severe depression symptoms.

BDI scores showed that 75 of the patients with mTBI had moderate to severe depression symptoms. Imaging results showed that white matter tracts—the circuits that connect brain regions critical for cognitive and emotional control—were disrupted in the patients with moderate to severe depression symptoms. Researchers also saw changes in the gray matter cognitive-emotional networks in these patients.

"We found consistencies in the locations of disrupted neurocircuitry, as revealed by DWI and resting-state fMRI, that are unique to the clinical symptoms of mTBI patients," said Dr. Yeh. "We have related the brain structural and functional changes in cognitive-emotional networks to depressive symptoms in mTBI patients."  

This research can possibly lead to treatment strategies in the future, he added. "Though the results of this study were not applied directly to patient care, the neuroimaging changes we found might be incorporated into treatment plans for personalized medicine in the future."  

Short-Term Sleep Deprivation Affects Heart Function

Getting too little sleep takes a toll on your heart, researchers reported. People who work in fire and emergency medical services, medical residencies, and other high-stress jobs are often called upon to work 24-hour shifts with little opportunity for sleep. While it is known that extreme fatigue can affect many physical, cognitive, and emotional processes, this is the first study to examine how working a 24-hour shift specifically affects cardiac function.

"For the first time, we have shown that short-term sleep deprivation in the context of 24-hour shifts can lead to a significant increase in cardiac contractility, blood pressure, and heart rate," said study author Daniel Kuetting, MD, of the Department of Diagnostic and Interventional Radiology at the University of Bonn in Germany.  

For the study, Dr. Kuetting and colleagues recruited 20 healthy radiologists (19 men) with a mean age of 31.6. Each of the study participants underwent cardiovascular magnetic resonance (CMR) imaging with strain analysis before and after a 24-hour shift with an average of three hours of sleep.

"Cardiac function in the context of sleep deprivation has not previously been investigated with CMR strain analysis, the most sensitive parameter of cardiac contractility," said Dr. Kuetting. The researchers also collected blood and urine samples from the participants and measured blood pressure and heart rate.  

Following short-term sleep deprivation, the participants showed significant increases in mean peak systolic strain (-23.4 vs -21.9), systolic (118.5 mmHg vs 112.8 mmHg) and diastolic (69.2 mmHg vs 62.9 mmHg) blood pressure and heart rate (68.9 bpm vs 63.0 bpm). In addition, the participants had significant increases in levels of thyroid stimulating hormone (TSH), thyroid hormones FT3 and FT4, and cortisol.  

Although the researchers were able to perform follow-up examinations of half of the participants after regular sleep, further study in a larger cohort is needed to determine possible long-term effects of sleep loss, said Dr. Kuetting.

"The study was designed to investigate real-life work-related sleep deprivation," said Dr. Kuetting. "While the participants were not permitted to consume caffeine or food and beverages containing theobromine, such as chocolate, nuts, or tea, we did not take into account factors like individual stress level or environmental stimuli."

As people continue to work longer hours or work at more than one job to make ends meet, it is critical to investigate the detrimental effects of too much work and not enough sleep. The results of this pilot study are transferable to other professions in which long periods of uninterrupted labor are common, said Dr. Kuetting. "These findings may help us better understand how workload and shift duration affect public health."  

Aerobic Exercise Preserves Brain Volume and Improves Cognitive Function

Using a new MRI technique, researchers have found that adults with mild cognitive impairment (MCI) who exercised four times per week during a six-month period experienced an increase in brain volume in specific areas of the brain, but adults who participated in aerobic exercise experienced greater gains than those who just stretched.  

"Even over a short period of time, we saw aerobic exercise lead to a remarkable change in the brain," said Laura D. Baker, PhD, Associate Professor of Gerontology and Geriatric Medicine at Wake Forest School of Medicine (WFSM) in Winston-Salem, North Carolina.

The study included 35 adults with MCI participating in a randomized, controlled trial of exercise intervention. The participants were separated into two groups. Sixteen adults (average age, 63) engaged in aerobic activity, including treadmill, stationary bike, or elliptical training, four times per week for six months. A control group of 19 adults (average age, 67) participated in stretching exercises with the same frequency. High-resolution brain MR images were acquired from all participants before and after the six-month activity period. The MRI results were compared using conventional and biomechanical metrics to measure the change in brain volume and shape.  

"We used high-resolution MR images to measure anatomical changes within areas of the brain to obtain volumetric data and directional information," said Jeongchul Kim, PhD, a coinvestigator at WFSM.  

The analysis revealed that for both the aerobic and stretching groups, brain volume increased in most gray matter regions, including the temporal lobe, which supports short-term memory.  

"Compared to the stretching group, the aerobic activity group had greater preservation of total brain volume, increased local gray matter volume, and increased directional stretch of brain tissue," said Dr. Kim.  

Among participants of the stretching group, the analysis revealed a local contraction, or atrophy, within the white matter connecting fibers. Such directional deformation, or shape change, is partially related to volume loss, but not always, according to Dr. Kim.

"Directional changes in the brain without local volume changes could be a novel biomarker for neurologic disease," he said. "It may be a more sensitive marker for the tiny changes that occur in a specific brain region before volumetric changes are detectable on MRI."  

Both MRI measures are important to the treatment of MCI and Alzheimer's disease, which require the careful tracking of changes in the brain while patients engage in interventions, including diet and exercise, to slow the progression of the disease.  

Study participants were tested to determine the effect of exercise intervention on cognitive performance. Participants in the aerobic exercise group showed statistically significant improvement in executive function after six months, whereas the stretching group did not improve.  

"Any type of exercise can be beneficial," said Dr. Kim. "If possible, aerobic activity may create potential benefits for higher cognitive functioning."    

Studies Provide More Insight Into Zika Effects

Three studies reported on the effects of the Zika virus outbreak in Brazil. The first study examined CT findings of the CNS in 16 newborn babies with congenital Zika virus infection confirmed by tests in CSF. The researchers identified a pattern of CT brain findings in the babies, including decreased brain volume, simplified gyral pattern, calcifications, ventricular dilatation, and prominent occipital bone.

"We live in Pernambuco, a state in northeastern Brazil, which had the highest number of patients with microcephaly during the Zika outbreak in our country," said Natacha Calheiros de Lima Petribu, MD, of the Department of Radiology at Barão de Lucena Hospital. "Our study proves that Zika virus infection can cause congenital brain damage in babies with and without microcephaly."  

Another study analyzed the imaging results of three target groups affected by Zika: adults who developed acute neurologic syndrome, newborns with vertical infection with neurologic disorders, and pregnant women with rash outbreaks suggestive of Zika. Many of the adults had symptoms of Guillain-Barré syndrome. A few showed inflammation of the brain and spinal cord (ie, Bickerstaff's encephalitis) or brainstem and spinal cord lesions. Common MRI findings included enhancement of certain spinal and facial nerves. In the newborns, MRI showed orbital injuries and anatomical changes in brain tissue.  

"It was alarming to find so many cases of neurologic syndromes in adults, some very serious, related to Zika virus infection," said study author Emerson de Melo Casagrande, MD, of the Department of Radiology at Antonio Pedro University Hospital--Federal Fluminense University. "We have also noticed a difference between these syndromes, even though the trigger was the same."

In a third study, ultrasound and fetal MRI were performed on pregnant patients with Zika virus infection at different gestational ages. Once the babies were born, they underwent ultrasound, CT, and MRI. The researchers then created 3-D virtual and physical models of the skulls. More than half of the babies had microcephaly, brain calcifications, and loss of brain tissue volume, along with other structural changes.

"The emergence of Zika virus in the Americas has coincided with increased reports of babies born with microcephaly," said study author Heron Werner Jr, MD, PhD, of the Department of Radiology at Clínica de Diagnóstico por Imagem. "An early diagnosis may help in treating these babies after birth. Moreover, the knowledge of abnormalities present in the CNS may give hints about the pathophysiology of the disease."

Head Impacts Lead to Brain Changes in High School Football Players

Brain imaging exams performed on high school football players after a single season reveal changes in the gray and white matter that correlated with exposure to head impacts, according to researchers.

"It is important to understand the potential changes occurring in the brain related to youth contact sports," said Elizabeth Moody Davenport, PhD, a postdoctoral researcher at UT Southwestern Medical Center in Dallas. "We know that some professional football players suffer from a serious condition called chronic traumatic encephalopathy or CTE. We are attempting to find out when and how that process starts, so that we can keep sports a healthy activity for millions of children and adolescents."

The study included 24 players from a high school football team in North Carolina, each of whom wore a helmet outfitted with the Head Impact Telemetry System (HITS) during all practices and games. The helmets are lined with six accelerometers that measure the magnitude, location, and direction of a hit. Data from the helmets can be uploaded to a computer for analysis.  

"We saw changes in these young players' brains on both structural and functional imaging after a single season of football," said Dr. Davenport.  

In the study, each player underwent pre- and post-season imaging, including a specialized MRI scan, from which diffusion tensor imaging and diffusion kurtosis imaging data were extracted to measure the brain's white matter integrity, and a magnetoencephalography (MEG) scan, which records and analyzes the magnetic fields produced by brain waves. Diffusion imaging can measure the structural white matter changes in the brain, and MEG assesses changes in function.

"MEG can be used to measure delta waves in the brain, which are a type of distress signal," said Dr. Davenport. "Delta waves represent slow wave activity that increases after brain injuries. The delta waves we saw came from the surface of the brain, while diffusion imaging is a measure of the white matter deeper in the brain."  

The research team calculated the change in imaging metrics between the pre- and post-season imaging exams. They measured abnormalities observed on diffusion imaging and abnormally increased delta-wave activity on MEG. The imaging results were then combined with player-specific impact data from the HITS. None of the 24 players were diagnosed with a concussion during the study.

Players with greater head impact exposure had the greatest change in diffusion imaging and MEG metrics. "Change in diffusion imaging metrics correlated most to linear acceleration, similar to the impact of a car crash," said Dr. Davenport. "MEG changes correlated most to rotational impact, similar to a boxer's punch. These results demonstrate that you need both imaging metrics to assess impact exposure, because they correlate with different biomechanical processes."

Similar studies are being conducted this fall, and a consortium has been formed to continue the brain imaging research in youth contact sports across the country, said Dr. Davenport. "Without a larger population that is closely followed in a longitudinal study, it is difficult to know the long-term effects of these changes," she said. "We do not know if the brain's developmental trajectory is altered, or if the off-season time allows for the brain to return to normal."

Depression in Soldiers Linked to Brain Disruption From Injury

Using multiple brain imaging techniques, researchers have found that a disruption of the circuitry in the brain's cognitive-emotional pathways may provide a physical foundation for depression symptoms in some service members who have had mild traumatic brain injury (mTBI) in combat. "We can link these connectivity changes in the brain to poor top-down emotional processing and greater maladaptive rumination, or worrying, in symptomatic depressed soldiers after mTBI," said Ping-Hong Yeh, PhD, scientist and physicist at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland.

According to the Defense and Veterans Brain Injury Center, 352,619 service members worldwide have been diagnosed with TBI since 2000, the majority of these cases being mTBI. In addition, psychiatric disorders, such as anxiety and major depressive disorders, are becoming common in military personnel with brain injuries.

"With the increased survival of soldiers due to improvements in body armor and advanced medical care, there has been an increase in the number of soldiers surviving major trauma. Consequently, a large number of soldiers are returning from war with mTBI," said Dr. Yeh. "Mood disorders are common in military-related mTBI patients. This is an ongoing problem facing a large number of warriors in current areas of conflict, and it is likely to be a persistent problem for the foreseeable future."

For the study, researchers used diffusion-weighted imaging (DWI) and resting-state functional MRI (fMRI) to examine 130 active male service members diagnosed with mTBI and a control group of 52 men without mTBI. Depression symptoms were rated based on the Beck Depression Inventory (BDI), a 21-item, self-reporting assessment that measures characteristic attitudes and symptoms of depression. Patients with a BDI score greater than 20 are considered to have moderate to severe depression symptoms.

BDI scores showed that 75 of the patients with mTBI had moderate to severe depression symptoms. Imaging results showed that white matter tracts—the circuits that connect brain regions critical for cognitive and emotional control—were disrupted in the patients with moderate to severe depression symptoms. Researchers also saw changes in the gray matter cognitive-emotional networks in these patients.

"We found consistencies in the locations of disrupted neurocircuitry, as revealed by DWI and resting-state fMRI, that are unique to the clinical symptoms of mTBI patients," said Dr. Yeh. "We have related the brain structural and functional changes in cognitive-emotional networks to depressive symptoms in mTBI patients."  

This research can possibly lead to treatment strategies in the future, he added. "Though the results of this study were not applied directly to patient care, the neuroimaging changes we found might be incorporated into treatment plans for personalized medicine in the future."  

Short-Term Sleep Deprivation Affects Heart Function

Getting too little sleep takes a toll on your heart, researchers reported. People who work in fire and emergency medical services, medical residencies, and other high-stress jobs are often called upon to work 24-hour shifts with little opportunity for sleep. While it is known that extreme fatigue can affect many physical, cognitive, and emotional processes, this is the first study to examine how working a 24-hour shift specifically affects cardiac function.

"For the first time, we have shown that short-term sleep deprivation in the context of 24-hour shifts can lead to a significant increase in cardiac contractility, blood pressure, and heart rate," said study author Daniel Kuetting, MD, of the Department of Diagnostic and Interventional Radiology at the University of Bonn in Germany.  

For the study, Dr. Kuetting and colleagues recruited 20 healthy radiologists (19 men) with a mean age of 31.6. Each of the study participants underwent cardiovascular magnetic resonance (CMR) imaging with strain analysis before and after a 24-hour shift with an average of three hours of sleep.

"Cardiac function in the context of sleep deprivation has not previously been investigated with CMR strain analysis, the most sensitive parameter of cardiac contractility," said Dr. Kuetting. The researchers also collected blood and urine samples from the participants and measured blood pressure and heart rate.  

Following short-term sleep deprivation, the participants showed significant increases in mean peak systolic strain (-23.4 vs -21.9), systolic (118.5 mmHg vs 112.8 mmHg) and diastolic (69.2 mmHg vs 62.9 mmHg) blood pressure and heart rate (68.9 bpm vs 63.0 bpm). In addition, the participants had significant increases in levels of thyroid stimulating hormone (TSH), thyroid hormones FT3 and FT4, and cortisol.  

Although the researchers were able to perform follow-up examinations of half of the participants after regular sleep, further study in a larger cohort is needed to determine possible long-term effects of sleep loss, said Dr. Kuetting.

"The study was designed to investigate real-life work-related sleep deprivation," said Dr. Kuetting. "While the participants were not permitted to consume caffeine or food and beverages containing theobromine, such as chocolate, nuts, or tea, we did not take into account factors like individual stress level or environmental stimuli."

As people continue to work longer hours or work at more than one job to make ends meet, it is critical to investigate the detrimental effects of too much work and not enough sleep. The results of this pilot study are transferable to other professions in which long periods of uninterrupted labor are common, said Dr. Kuetting. "These findings may help us better understand how workload and shift duration affect public health."  

Aerobic Exercise Preserves Brain Volume and Improves Cognitive Function

Using a new MRI technique, researchers have found that adults with mild cognitive impairment (MCI) who exercised four times per week during a six-month period experienced an increase in brain volume in specific areas of the brain, but adults who participated in aerobic exercise experienced greater gains than those who just stretched.  

"Even over a short period of time, we saw aerobic exercise lead to a remarkable change in the brain," said Laura D. Baker, PhD, Associate Professor of Gerontology and Geriatric Medicine at Wake Forest School of Medicine (WFSM) in Winston-Salem, North Carolina.

The study included 35 adults with MCI participating in a randomized, controlled trial of exercise intervention. The participants were separated into two groups. Sixteen adults (average age, 63) engaged in aerobic activity, including treadmill, stationary bike, or elliptical training, four times per week for six months. A control group of 19 adults (average age, 67) participated in stretching exercises with the same frequency. High-resolution brain MR images were acquired from all participants before and after the six-month activity period. The MRI results were compared using conventional and biomechanical metrics to measure the change in brain volume and shape.  

"We used high-resolution MR images to measure anatomical changes within areas of the brain to obtain volumetric data and directional information," said Jeongchul Kim, PhD, a coinvestigator at WFSM.  

The analysis revealed that for both the aerobic and stretching groups, brain volume increased in most gray matter regions, including the temporal lobe, which supports short-term memory.  

"Compared to the stretching group, the aerobic activity group had greater preservation of total brain volume, increased local gray matter volume, and increased directional stretch of brain tissue," said Dr. Kim.  

Among participants of the stretching group, the analysis revealed a local contraction, or atrophy, within the white matter connecting fibers. Such directional deformation, or shape change, is partially related to volume loss, but not always, according to Dr. Kim.

"Directional changes in the brain without local volume changes could be a novel biomarker for neurologic disease," he said. "It may be a more sensitive marker for the tiny changes that occur in a specific brain region before volumetric changes are detectable on MRI."  

Both MRI measures are important to the treatment of MCI and Alzheimer's disease, which require the careful tracking of changes in the brain while patients engage in interventions, including diet and exercise, to slow the progression of the disease.  

Study participants were tested to determine the effect of exercise intervention on cognitive performance. Participants in the aerobic exercise group showed statistically significant improvement in executive function after six months, whereas the stretching group did not improve.  

"Any type of exercise can be beneficial," said Dr. Kim. "If possible, aerobic activity may create potential benefits for higher cognitive functioning."    

Patients with epilepsy who also have periventricular nodular heterotopia (PVNH) are difficult to manage surgically because the relative influence of the nodular tissue and the overlying cortex on the generation of seizures is variable. A review of the relevant medical literature suggests that inter-ictal spiking from nodules often occurs in patients with PVNH, but it is rare for patients to experience seizures arising from the nodular tissue alone. It is more likely to find that the onset of seizures occurs simultaneously with overlying neocortex or mesial temporal structures.    

Thompson SA, Kalamangalam GP, Tandon N. Intracranial evaluation and laser ablation for epilepsy with periventricular nodular heterotopia. Seizure. 2016;41:211-216.

Patients with epilepsy who also have periventricular nodular heterotopia (PVNH) are difficult to manage surgically because the relative influence of the nodular tissue and the overlying cortex on the generation of seizures is variable. A review of the relevant medical literature suggests that inter-ictal spiking from nodules often occurs in patients with PVNH, but it is rare for patients to experience seizures arising from the nodular tissue alone. It is more likely to find that the onset of seizures occurs simultaneously with overlying neocortex or mesial temporal structures.    

Thompson SA, Kalamangalam GP, Tandon N. Intracranial evaluation and laser ablation for epilepsy with periventricular nodular heterotopia. Seizure. 2016;41:211-216.

Patients with epilepsy who also have periventricular nodular heterotopia (PVNH) are difficult to manage surgically because the relative influence of the nodular tissue and the overlying cortex on the generation of seizures is variable. A review of the relevant medical literature suggests that inter-ictal spiking from nodules often occurs in patients with PVNH, but it is rare for patients to experience seizures arising from the nodular tissue alone. It is more likely to find that the onset of seizures occurs simultaneously with overlying neocortex or mesial temporal structures.    

Thompson SA, Kalamangalam GP, Tandon N. Intracranial evaluation and laser ablation for epilepsy with periventricular nodular heterotopia. Seizure. 2016;41:211-216.