OBJECTIVE

To evaluate the association of late-life depression with mild cognitive impairment (MCI) and dementia in a multiethnic community cohort. DESIGN AND SETTING A cohort study was conducted in Northern Manhattan, New York, New York. PARTICIPANTS A total of 2160 community-dwelling Medicare recipients aged 65 years or older were included in the study.

METHODS

Depression was assessed using the 10-item version of the Center for Epidemiological Studies Depression scale (CES-D) and defined by a CES-D score of 4 or more. We used logistic regression for cross-sectional association analyses and proportional hazards regression for longitudinal analyses. MAIN OUTCOME MEASURES Mild cognitive impairment dementia, and progression from MCI to dementia were the main outcome measures. We also used subcategories of MCI (amnestic and nonamnestic), and dementia (probable Alzheimer disease and vascular dementia, including possible Alzheimer disease with stroke).

RESULTS

Baseline depression was associated with prevalent MCI (odds ratio, 1.4; 95% CI, 1.1-1.9) and dementia (2.2; 1.6-3.1). Baseline depression was associated with an increased risk of incident dementia (hazard ratio [HR], 1.7; 95% CI, 1.2-2.3) but not with incident MCI (0.9; 0.7-1.2). Persons with MCI and coexisting depression at baseline had a higher risk of progression to dementia (HR, 2.0; 95% CI, 1.2-3.4), especially vascular dementia (4.3; 1.1-17.0), but not Alzheimer disease (1.9; 1.0-3.6).

CONCLUSION

The association of depression with prevalent MCI and with progression from MCI to dementia, but not with incident MCI, suggests that depression accompanies cognitive impairment but does not precede it.

BACKGROUND

Neuromyelitis optica (NMO) is an autoimmune disease of the central nervous system in which aberrant antibody responses to the astrocytic water channel aquaporin 4 have been described. Experimental evidence is emerging that NMO is partly driven by the proinflammatory cytokine interleukin 6 (IL-6), which propagates the survival of disease-specific B cell subclasses, and deviates CD4+ T helper cell differentiation toward IL-17-producing T helper 17 cells. Tocilizumab is a recombinant humanized monoclonal antibody against the IL-6 receptor approved for treatment of rheumatoid arthritis.

OBJECTIVES

To study clinical and paraclinical effects of tocilizumab in a patient with NMO. DESIGN Case report. SETTING Academic neurology department. PATIENT A patient with highly active aquaporin 4-seropositive NMO who failed numerous immunosuppressive interventions, including high-dose corticosteroids, mitoxantrone, plasma exchange (PE), rituximab (anti-CD20), and alemtuzumab (anti-CD52), before receiving tocilizumab. MAIN OUTCOME MEASURES Clinical disability, magnetic resonance imaging, cytokines and transcription factors levels in the cerebrospinal fluid, and peripheral blood mononuclear cells.

RESULTS

A patient who continued to accumulate neurological disability and magnetic resonance imaging activity while receiving numerous immunoactive therapies stabilized, and eventually improved clinically and on magnetic resonance metrics after treatment initiation with tocilizumab. Treatment and clinical response correlated with a significant reduction of IL-6 levels in the CSF as well as a diminished expression of signal transducer and activator of transcription 3.

CONCLUSIONS

Tocilizumab might be effective in NMO, here in a patient not responding to leukocyte depletion. Our findings further support data that implicate IL-6 as a critical molecule in the immunopathogenesis of NMO, and a critical role for T cells in the pathogenesis of this disorder.

OBJECTIVE

To investigate the expression of CD161 (KLRB1) and CCR6 on human γδ T cells in blood and cerebrospinal fluid (CSF) of patients with a clinically isolated syndrome (CIS) and multiple sclerosis (MS) in relapse. DESIGN Flow cytometry analysis of CD161 and CCR6 expression and intracellular cytokine staining for interleukin 17 and interferon-γ on human γδ T cells in blood and CSF samples. SETTING Department of Neurology, Klinikum rechts der Isar, Technische Universität München, a tertiary referral center. PATIENTS Twenty-six patients with CIS/MS in active relapse, 10 patients with other autoimmune disorders, 12 patients with neuroinfectious diseases, and 15 patients with noninflammatory neurological diseases. MAIN OUTCOME MEASURES Frequencies of CD161high and CCR6+ γδ T cells in blood and CSF samples of patients with CIS/MS in relapse and control patients.

RESULTS

γδ T cells were increased in both blood and CSF of patients with CIS/MS in relapse as compared with controls with noninflammatory disease. The fraction of CD161high CCR6+ γδ T cells was significantly higher in the CSF of patients with CIS/MS in relapse than of those with systemic autoimmune disorders or controls with noninflammatory disease. The CD161high CCR6+ double-positive γδ T-cell population was further enriched in the CSF in relation to blood in patients with CIS/MS in relapse but not in patients with infectious disease or the other control groups. The CD161high CCR6+ γδ T-cell population was characterized by its capacity to produce interleukin 17.

CONCLUSION

Interleukin 17-producing CD161high CCR6+ γδ T cells might contribute to the compartmentalized inflammatory process in the central nervous system of patients with MS.

OBJECTIVE

To assess the reliability of new magnetic resonance imaging (MRI) lesion counts by clinicians in a multiple sclerosis specialty clinic. DESIGN An observational study. SETTING A multiple sclerosis specialty clinic. PATIENTS Eighty-five patients with multiple sclerosis participating in a National Institutes of Health-supported longitudinal study were included. INTERVENTION Each patient had a brain MRI scan at entry and 6 months later using a standardized protocol. MAIN OUTCOME MEASURES The number of new T2 lesions, newly enlarging T2 lesions, and gadolinium-enhancing lesions were measured on the 6-month MRI using a computer-based image analysis program for the original study. For this study, images were reanalyzed by an expert neuroradiologist and 3 clinician raters. The neuroradiologist evaluated the original image pairs; the clinicians evaluated image pairs that were modified to simulate clinical practice. New lesion counts were compared across raters, as was classification of patients as MRI active or inactive.

RESULTS

Agreement on lesion counts was highest for gadolinium-enhancing lesions, intermediate for new T2 lesions, and poor for enlarging T2 lesions. In 18% to 25% of the cases, MRI activity was classified differently by the clinician raters compared with the neuroradiologist or computer program. Variability among the clinical raters for estimates of new T2 lesions was affected most strongly by the image modifications that simulated low image quality and different head position.

CONCLUSIONS

Between-rater variability in new T2 lesion counts may be reduced by improved standardization of image acquisitions, but this approach may not be practical in most clinical environments. Ultimately, more reliable, robust, and accessible image analysis methods are needed for accurate multiple sclerosis disease-modifying drug monitoring and decision making in the routine clinic setting.