Pub Date : 2024-05-01DOI: 10.1136/bmjno-2023-000580
Matthew Szmidel, Henry Ma, Thanh Phan
The concept of 'pyramidal weakness' denotes that neurological examination findings can be localised to the central nervous system (CNS), and implying a specific pattern of motor weakness involving upper limb extensors and lower limb flexors. However, other weakness patterns have been observed in CNS lesions. We aim to investigate the pattern of weakness observed in CNS lesions and explore the use of the phrase 'pyramidal weakness' over time. We searched Medline, PubMed, and Google Scholar up to January 1st, 2022, using keywords such as ‘distal weakness,’ ‘upper limb flexion,’ ‘lower limb extension,’ ‘pyramidal weakness,’ and related terms. The inclusion criteria were papers relating to brain or spinal cord lesions and terms inferring their presence or the description of a motor weakness pattern. We identified 117 studies since 1889, of which 29.9% of publications described weakness in upper limb extensors and lower limb flexors, and 26.5% reported distal weakness. We found an early reference to 'pyramidal weakness' in 1922 in the context of unilateral weakness in encephalitis with no description of the upper limb extensor and lower limb flexor pattern. Since 1988, 'pyramidal weakness' has become associated with weakness in upper limb extensors and lower limb flexors. The phrase 'pyramidal weakness', used in its current format, has been more frequent since the 1980s. Distal weakness and upper limb extensor and lower limb flexor weakness have been associated with CNS lesions.
{"title":"Use of the phrase ‘pyramidal weakness’ within the past 100 years","authors":"Matthew Szmidel, Henry Ma, Thanh Phan","doi":"10.1136/bmjno-2023-000580","DOIUrl":"https://doi.org/10.1136/bmjno-2023-000580","url":null,"abstract":"The concept of 'pyramidal weakness' denotes that neurological examination findings can be localised to the central nervous system (CNS), and implying a specific pattern of motor weakness involving upper limb extensors and lower limb flexors. However, other weakness patterns have been observed in CNS lesions. We aim to investigate the pattern of weakness observed in CNS lesions and explore the use of the phrase 'pyramidal weakness' over time. We searched Medline, PubMed, and Google Scholar up to January 1st, 2022, using keywords such as ‘distal weakness,’ ‘upper limb flexion,’ ‘lower limb extension,’ ‘pyramidal weakness,’ and related terms. The inclusion criteria were papers relating to brain or spinal cord lesions and terms inferring their presence or the description of a motor weakness pattern. We identified 117 studies since 1889, of which 29.9% of publications described weakness in upper limb extensors and lower limb flexors, and 26.5% reported distal weakness. We found an early reference to 'pyramidal weakness' in 1922 in the context of unilateral weakness in encephalitis with no description of the upper limb extensor and lower limb flexor pattern. Since 1988, 'pyramidal weakness' has become associated with weakness in upper limb extensors and lower limb flexors. The phrase 'pyramidal weakness', used in its current format, has been more frequent since the 1980s. Distal weakness and upper limb extensor and lower limb flexor weakness have been associated with CNS lesions.","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"51 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141167796","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1136/bmjno-2023-000598
Rebecca M Smith, Caroline Burgess, Jenna Beattie, Abby Newdick, Vassilios Tahtis, Bithi Sahu, John F Golding, Jonathan Marsden, Barry M Seemungal
Background Benign paroxysmal positional vertigo (BPPV) affects approximately half of acute, moderate-severe traumatic brain injury (TBI) patients. To date, there have been no rigorous studies of BPPV assessment or treatment in this cohort. We aimed to determine the safety, practicability, and efficacy of therapist-led BPPV management in acute TBI and the feasibility of a larger effectiveness trial. Methods This was a multi-centre, three-arm, parallel-groups, randomised, feasibility trial. Recruitment was via convenience sampling. The main inclusion criteria were age over 18 years and a confirmed, non-penetrating, acute TBI. BPPV-positive patients were randomly allocated to one of three interventions (repositioning manoeuvres, Brandt–Daroff exercises or advice) using minimisation criteria. Outcome assessors were blinded to the intervention. Results Of 2014 patients screened for inclusion, 180 were assessed for BPPV. Of those assessed, 34% (62/180) had BPPV, and 58 patients received an intervention. Therapist-led interventions were delivered safely and accurately according to intervention monitoring criteria. Resolution of BPPV was observed in 35/58 (60%) patients. The resolution rate was highest following repositioning manoeuvres (78%), followed by the advice (53%) and Brandt–Daroff interventions (42%). 10 patients experienced recurrence. This was observed more frequently in those with skull fractures and bilateral or mixed BPPV. Conclusions Overall, the results provide strong evidence for the feasibility of a future trial. Therapist-led management of BPPV in acute TBI was safe and practicable. Repositioning manoeuvres seemingly yielded a superior treatment effect. However, given the high recurrence rate of post-traumatic BPPV, the optimal time to treat according to patients’ specific recurrence risk requires further investigation. Trial registration [ISRCTN91943864][1], . Data are available upon reasonable request. Data available on reasonable request. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN91943864
{"title":"Treating benign paroxysmal positional vertigo in acute traumatic brain injury: a prospective, randomised clinical trial assessing safety, feasibility, and efficacy","authors":"Rebecca M Smith, Caroline Burgess, Jenna Beattie, Abby Newdick, Vassilios Tahtis, Bithi Sahu, John F Golding, Jonathan Marsden, Barry M Seemungal","doi":"10.1136/bmjno-2023-000598","DOIUrl":"https://doi.org/10.1136/bmjno-2023-000598","url":null,"abstract":"Background Benign paroxysmal positional vertigo (BPPV) affects approximately half of acute, moderate-severe traumatic brain injury (TBI) patients. To date, there have been no rigorous studies of BPPV assessment or treatment in this cohort. We aimed to determine the safety, practicability, and efficacy of therapist-led BPPV management in acute TBI and the feasibility of a larger effectiveness trial. Methods This was a multi-centre, three-arm, parallel-groups, randomised, feasibility trial. Recruitment was via convenience sampling. The main inclusion criteria were age over 18 years and a confirmed, non-penetrating, acute TBI. BPPV-positive patients were randomly allocated to one of three interventions (repositioning manoeuvres, Brandt–Daroff exercises or advice) using minimisation criteria. Outcome assessors were blinded to the intervention. Results Of 2014 patients screened for inclusion, 180 were assessed for BPPV. Of those assessed, 34% (62/180) had BPPV, and 58 patients received an intervention. Therapist-led interventions were delivered safely and accurately according to intervention monitoring criteria. Resolution of BPPV was observed in 35/58 (60%) patients. The resolution rate was highest following repositioning manoeuvres (78%), followed by the advice (53%) and Brandt–Daroff interventions (42%). 10 patients experienced recurrence. This was observed more frequently in those with skull fractures and bilateral or mixed BPPV. Conclusions Overall, the results provide strong evidence for the feasibility of a future trial. Therapist-led management of BPPV in acute TBI was safe and practicable. Repositioning manoeuvres seemingly yielded a superior treatment effect. However, given the high recurrence rate of post-traumatic BPPV, the optimal time to treat according to patients’ specific recurrence risk requires further investigation. Trial registration [ISRCTN91943864][1], <https://doi.org/10.1186/ISRCTN91943864>. Data are available upon reasonable request. Data available on reasonable request. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN91943864","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"94 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141167858","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.1136/bmjno-2023-000616
Seyran Naghdi, Martin Underwood, Anna Brown, Manjit Matharu, Callum Duncan, Natasha Davies, Aiva Aksentyte, Hema Mistry
Background Migraine is the second most common prevalent disorder worldwide and is a top cause of disability with a substantial economic burden. Many preventive migraine medications have notable side effects that affect different body organs. Method We systematically searched for published randomised controlled trials (RCTs) using terms for migraine/headache and preventive medications. Using eligibility criteria, two reviewers independently assessed the articles. Cochrane risk-of-bias tool was applied to assess the quality of the studies. Data were classified by system organ class (SOC). Results Thirty-two RCTs with 21 780 participants met the eligibility criteria for the incidence of adverse events (AEs). Additionally, 33 RCTs with 22 615 participants were included to synthesise the incidence of serious AEs (SAEs). The percentage of attributed AEs and SAEs to each SOC for 10 preventive drugs with different dosing regimens was calculated. Amitriptyline and topiramate had a higher incidence of nervous system disorders; Topiramate was also associated with a higher incidence of psychiatric disorders. All drugs showed a certain incidence of infections and infestations, with Onabotulinumtoxin A (BTA) having the lowest rate. BTA had a higher incidence of musculoskeletal disorders than the other drugs. Calcitonin gene-related peptide (CGRP) monoclonal antibodies (MAbs) such as fremanezumab and galcanezumab were linked to more general disorders and administration site conditions than other drugs. Conclusion Notably, the observed harm to SOCs varies among these preventive drugs. We suggest conducting head-to-head RCTs to evaluate the safety profile of oral medications, BTA, and CGRP MAbs in episodic and/or chronic migraine populations. PROSPERO registration number CRD42021265993. All data relevant to the study are included in the article or uploaded as supplementary information.
{"title":"Adverse and serious adverse events incidence of pharmacological interventions for managing chronic and episodic migraine in adults: a systematic review","authors":"Seyran Naghdi, Martin Underwood, Anna Brown, Manjit Matharu, Callum Duncan, Natasha Davies, Aiva Aksentyte, Hema Mistry","doi":"10.1136/bmjno-2023-000616","DOIUrl":"https://doi.org/10.1136/bmjno-2023-000616","url":null,"abstract":"Background Migraine is the second most common prevalent disorder worldwide and is a top cause of disability with a substantial economic burden. Many preventive migraine medications have notable side effects that affect different body organs. Method We systematically searched for published randomised controlled trials (RCTs) using terms for migraine/headache and preventive medications. Using eligibility criteria, two reviewers independently assessed the articles. Cochrane risk-of-bias tool was applied to assess the quality of the studies. Data were classified by system organ class (SOC). Results Thirty-two RCTs with 21 780 participants met the eligibility criteria for the incidence of adverse events (AEs). Additionally, 33 RCTs with 22 615 participants were included to synthesise the incidence of serious AEs (SAEs). The percentage of attributed AEs and SAEs to each SOC for 10 preventive drugs with different dosing regimens was calculated. Amitriptyline and topiramate had a higher incidence of nervous system disorders; Topiramate was also associated with a higher incidence of psychiatric disorders. All drugs showed a certain incidence of infections and infestations, with Onabotulinumtoxin A (BTA) having the lowest rate. BTA had a higher incidence of musculoskeletal disorders than the other drugs. Calcitonin gene-related peptide (CGRP) monoclonal antibodies (MAbs) such as fremanezumab and galcanezumab were linked to more general disorders and administration site conditions than other drugs. Conclusion Notably, the observed harm to SOCs varies among these preventive drugs. We suggest conducting head-to-head RCTs to evaluate the safety profile of oral medications, BTA, and CGRP MAbs in episodic and/or chronic migraine populations. PROSPERO registration number CRD42021265993. All data relevant to the study are included in the article or uploaded as supplementary information.","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"211 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140630887","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.1136/bmjno-2024-000706
Chin-Hen Chang, Timithy Mark McClellan, Kevin David Lopez, Thomas Wasser, Somkiat Hemtasilpa
Introduction Nerve conduction study (NCS) and electromyography (EMG) are electrodiagnostic studies that are highly tolerated by patients despite their nature of causing pain and discomfort. However, few studies have focused on the true tolerability of these procedures in patients. This study aimed to determine the true tolerance rate of NCS and EMG in patient populations and the factors that might be associated with them. Methods Participants scheduled for electrodiagnostic studies were prospectively recruited between March 2023 and September 2023. After completion of the study, the physicians completed a questionnaire on each patient’s tolerance of the studies. Results Of the 103 patients enrolled in the study, 98 were able to tolerate both tests, and 5 patients were intolerant to 1 or both tests. The overall tolerance rate of NCS and EMG was 95.1% (0.951, 95% CI 0.897 to 0.981). Age, sex, ethnicity, the type of NCS performed and the type of EMG performed were not associated with NCS or EMG intolerance. Conclusion Most patients tolerated the NCS and EMG; however, a small percentage of patients were intolerant. Clinicians should recognise the intolerance of certain patients when introducing and performing electrodiagnostic tests. Data are available upon reasonable request.
{"title":"Tolerability of electrodiagnostic studies in patients: a prospective study","authors":"Chin-Hen Chang, Timithy Mark McClellan, Kevin David Lopez, Thomas Wasser, Somkiat Hemtasilpa","doi":"10.1136/bmjno-2024-000706","DOIUrl":"https://doi.org/10.1136/bmjno-2024-000706","url":null,"abstract":"Introduction Nerve conduction study (NCS) and electromyography (EMG) are electrodiagnostic studies that are highly tolerated by patients despite their nature of causing pain and discomfort. However, few studies have focused on the true tolerability of these procedures in patients. This study aimed to determine the true tolerance rate of NCS and EMG in patient populations and the factors that might be associated with them. Methods Participants scheduled for electrodiagnostic studies were prospectively recruited between March 2023 and September 2023. After completion of the study, the physicians completed a questionnaire on each patient’s tolerance of the studies. Results Of the 103 patients enrolled in the study, 98 were able to tolerate both tests, and 5 patients were intolerant to 1 or both tests. The overall tolerance rate of NCS and EMG was 95.1% (0.951, 95% CI 0.897 to 0.981). Age, sex, ethnicity, the type of NCS performed and the type of EMG performed were not associated with NCS or EMG intolerance. Conclusion Most patients tolerated the NCS and EMG; however, a small percentage of patients were intolerant. Clinicians should recognise the intolerance of certain patients when introducing and performing electrodiagnostic tests. Data are available upon reasonable request.","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"85 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140831293","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.1136/bmjno-2024-000667
Louise Rath, Wei Zhen Yeh, Angie Roldan, Robb Wesselingh, Michael Zhong, Tracie Tan, Nabil Seery, Francesca Bridge, YiChao Foong, Olga Skibina, Cassie Nesbitt, Helmut Butzkueven, Mastura Monif, Anneke van der Walt
Background In Australia, tixagevimab/cilgavimab 150 mg/150 mg was a government-funded pre-exposure prophylaxis for COVID-19 people with multiple sclerosis (pwMS) and other neuroimmunological conditions (pwNIc) treated with anti-CD20 antibodies or sphingosine-1-phosphate receptor modulators were eligible. Objective To analyse the roll-out, uptake and real-world efficacy of tixagevimab/cilgavimab in the prevention and severity of COVID-19. To assess compliance with uptake depending on the location of delivery. Methods We undertook a single-centre study. 440 pwMS and pwNIc were eligible. Logistic regression was used to assess predictors of COVID-19 during follow-up and to assess predictors of uptake among those who consented. Results Of the eligible pwMS and pwNIc in our service, 52.7% (233/440) requested a consultation and were included in this study. Consultation resulted in 71.7% of people (167/233) receiving the treatment. Of these, 94.0% (157/167) had received three or more COVID-19 vaccines. Among those who received a single dose of tixagevimab/cilgavimab, 19.16% (32/167) tested positive for COVID-19 during the observational window. The majority of these were on ocrelizumab (68.8% (22/32)). None of those with COVID-19 required hospitalisation or supplemental oxygen. There was no difference in odds of COVID-19 during the observation period between those who received and did not receive tixagevimab/cilgavimab (adjusted OR, aOR 2.16 (95% CI 0.82 to 6.85), p=0.43). Uptake of tixagevimab/cilgavimab was highest when offered at the hospital infusion centre (aOR 3.09 (95% CI 1.08 to 9.94) relative to referral to the local pharmacy, p=0.04). Conclusion Tixagevimab/cilgavimab administration did not protect against subsequent COVID-19 in our cohort. Compliance with uptake was influenced by administration location. Data are available on reasonable request.
{"title":"Real-world efficacy, roll-out and uptake of intramuscular tixagevimab/cilgavimab as COVID-19 pre-exposure prophylaxis in people with multiple sclerosis and neuroimmunological conditions during the COVID-19 pandemic","authors":"Louise Rath, Wei Zhen Yeh, Angie Roldan, Robb Wesselingh, Michael Zhong, Tracie Tan, Nabil Seery, Francesca Bridge, YiChao Foong, Olga Skibina, Cassie Nesbitt, Helmut Butzkueven, Mastura Monif, Anneke van der Walt","doi":"10.1136/bmjno-2024-000667","DOIUrl":"https://doi.org/10.1136/bmjno-2024-000667","url":null,"abstract":"Background In Australia, tixagevimab/cilgavimab 150 mg/150 mg was a government-funded pre-exposure prophylaxis for COVID-19 people with multiple sclerosis (pwMS) and other neuroimmunological conditions (pwNIc) treated with anti-CD20 antibodies or sphingosine-1-phosphate receptor modulators were eligible. Objective To analyse the roll-out, uptake and real-world efficacy of tixagevimab/cilgavimab in the prevention and severity of COVID-19. To assess compliance with uptake depending on the location of delivery. Methods We undertook a single-centre study. 440 pwMS and pwNIc were eligible. Logistic regression was used to assess predictors of COVID-19 during follow-up and to assess predictors of uptake among those who consented. Results Of the eligible pwMS and pwNIc in our service, 52.7% (233/440) requested a consultation and were included in this study. Consultation resulted in 71.7% of people (167/233) receiving the treatment. Of these, 94.0% (157/167) had received three or more COVID-19 vaccines. Among those who received a single dose of tixagevimab/cilgavimab, 19.16% (32/167) tested positive for COVID-19 during the observational window. The majority of these were on ocrelizumab (68.8% (22/32)). None of those with COVID-19 required hospitalisation or supplemental oxygen. There was no difference in odds of COVID-19 during the observation period between those who received and did not receive tixagevimab/cilgavimab (adjusted OR, aOR 2.16 (95% CI 0.82 to 6.85), p=0.43). Uptake of tixagevimab/cilgavimab was highest when offered at the hospital infusion centre (aOR 3.09 (95% CI 1.08 to 9.94) relative to referral to the local pharmacy, p=0.04). Conclusion Tixagevimab/cilgavimab administration did not protect against subsequent COVID-19 in our cohort. Compliance with uptake was influenced by administration location. Data are available on reasonable request.","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"2017 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140831314","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.1136/bmjno-2023-000558
Alishba Kamran, Neha Saleem Paryani, Noor Fatima Suri, Javeria Khan, Fahad Amir, Marium Mehmood, Sehan Siraj Lashkerwala, Javeria Hayat, Shayan Marsia
Background and purpose We conducted a systematic review and meta-analysis to assess the incidence of acute kidney injury (AKI) in patients undergoing CT angiography (CTA) and CT perfusion (CTP) for acute ischaemic stroke (AIS). Concerns over contrast-induced nephropathy (CIN) often lead medical centres to mandate pre-imaging serum creatinine level assessments, causing unnecessary delays. We aim to confirm further the practice of conducting CTA/CTP without first testing creatinine. Methods We searched PubMed, Cochrane Central and Scopus from inception until March 2023 for studies reporting on AKI in patients with AIS receiving CTA/CTP. Outcomes of interest were (1) the odds of AKI in patients receiving CTA/CTP versus non-contrast CT and (2) the overall incidence of AKI and haemodialysis in patients with AIS undergoing CTA/CTP. Results Results were pooled using a random effects model. 13 studies were included (5 cohort and 8 single-arm studies) with 5104 patients in total, out of which 4347 patients received CTA/CTP and 757 patients received no contrast. In case–control studies, 4.8% (OR=0.66, 95% CI 0.35 to 1.22, Z=1.32, p=0.19) of patients who received CTA/CTP developed AKI, compared with 7.7% of patients in the control group. Temporary haemodialysis was required for two patients in the analysed studies. Conclusions Non-randomised evidence suggests that CTA/CTP is not associated with a statistically significant increase in the risk of AKI in patients with stroke. Further well-designed prospective studies are required to explore potential risk factors of CIN in specific patient populations such as diabetes mellitus and chronic kidney disease. All data relevant to the study are included in the article or uploaded as supplementary information.
{"title":"Incidence of acute kidney injury in patients with acute ischaemic stroke undergoing CT angiography (CTA) and CT perfusion (CTP): a systematic review and meta-analysis","authors":"Alishba Kamran, Neha Saleem Paryani, Noor Fatima Suri, Javeria Khan, Fahad Amir, Marium Mehmood, Sehan Siraj Lashkerwala, Javeria Hayat, Shayan Marsia","doi":"10.1136/bmjno-2023-000558","DOIUrl":"https://doi.org/10.1136/bmjno-2023-000558","url":null,"abstract":"Background and purpose We conducted a systematic review and meta-analysis to assess the incidence of acute kidney injury (AKI) in patients undergoing CT angiography (CTA) and CT perfusion (CTP) for acute ischaemic stroke (AIS). Concerns over contrast-induced nephropathy (CIN) often lead medical centres to mandate pre-imaging serum creatinine level assessments, causing unnecessary delays. We aim to confirm further the practice of conducting CTA/CTP without first testing creatinine. Methods We searched PubMed, Cochrane Central and Scopus from inception until March 2023 for studies reporting on AKI in patients with AIS receiving CTA/CTP. Outcomes of interest were (1) the odds of AKI in patients receiving CTA/CTP versus non-contrast CT and (2) the overall incidence of AKI and haemodialysis in patients with AIS undergoing CTA/CTP. Results Results were pooled using a random effects model. 13 studies were included (5 cohort and 8 single-arm studies) with 5104 patients in total, out of which 4347 patients received CTA/CTP and 757 patients received no contrast. In case–control studies, 4.8% (OR=0.66, 95% CI 0.35 to 1.22, Z=1.32, p=0.19) of patients who received CTA/CTP developed AKI, compared with 7.7% of patients in the control group. Temporary haemodialysis was required for two patients in the analysed studies. Conclusions Non-randomised evidence suggests that CTA/CTP is not associated with a statistically significant increase in the risk of AKI in patients with stroke. Further well-designed prospective studies are required to explore potential risk factors of CIN in specific patient populations such as diabetes mellitus and chronic kidney disease. All data relevant to the study are included in the article or uploaded as supplementary information.","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"1 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140800531","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.1136/bmjno-2023-000570
Xueli Zhang, Zhuoting Zhu, Yu Huang, Xianwen Shang, Terence J O'Brien, Patrick Kwan, Jason Ha, Wei Wang, Shunming Liu, Xiayin Zhang, Katerina Kiburg, Yining Bao, Jing Wang, Honghua Yu, Mingguang He, Lei Zhang
Background Alzheimer’s disease (AD) and age-related macular degeneration (AMD) share similar pathological features, suggesting common genetic aetiologies between the two. Investigating gene associations between AD and AMD may provide useful insights into the underlying pathogenesis and inform integrated prevention and treatment for both diseases. Methods A stratified quantile–quantile (QQ) plot was constructed to detect the pleiotropy among AD and AMD based on genome-wide association studies data from 17 008 patients with AD and 30 178 patients with AMD. A Bayesian conditional false discovery rate-based (cFDR) method was used to identify pleiotropic genes. UK Biobank was used to verify the pleiotropy analysis. Biological network and enrichment analysis were conducted to explain the biological reason for pleiotropy phenomena. A diagnostic test based on gene expression data was used to predict biomarkers for AD and AMD based on pleiotropic genes and their regulators. Results Significant pleiotropy was found between AD and AMD (significant leftward shift on QQ plots). APOC1 and APOE were identified as pleiotropic genes for AD–AMD (cFDR <0.01). Network analysis revealed that APOC1 and APOE occupied borderline positions on the gene co-expression networks. Both APOC1 and APOE genes were enriched on the herpes simplex virus 1 infection pathway. Further, machine learning-based diagnostic tests identified that APOC1, APOE (areas under the curve (AUCs) >0.65) and their upstream regulators, especially ZNF131, ADNP2 and HINFP, could be potential biomarkers for both AD and AMD (AUCs >0.8). Conclusion In this study, we confirmed the genetic pleiotropy between AD and AMD and identified APOC1 and APOE as pleiotropic genes. Further, the integration of multiomics data identified ZNF131, ADNP2 and HINFP as novel diagnostic biomarkers for AD and AMD. Data are available in a public, open access repository. GRASP database for GWAS data (); GTEx database for gene expression data (); GEO database for gene expression data (); and UK Biobank for GWAS data ().
背景阿尔茨海默病（AD）和老年性黄斑变性（AMD）具有相似的病理特征，表明两者之间存在共同的遗传病因。研究阿尔茨海默病和老年性黄斑变性之间的基因关联可能有助于深入了解其潜在的发病机制，并为这两种疾病的综合预防和治疗提供依据。方法 基于17 008例AD患者和30 178例AMD患者的全基因组关联研究数据，构建了分层量纲-量纲（QQ）图，以检测AD和AMD之间的多重性。使用基于贝叶斯条件假发现率（cFDR）的方法来识别多向性基因。英国生物库用于验证多效性分析。进行了生物网络和富集分析，以解释多效性现象的生物学原因。使用基于基因表达数据的诊断测试，根据多效基因及其调控因子预测AD和AMD的生物标志物。结果 发现 AD 和 AMD 之间存在显著的多效性（QQ 图上显著左移）。APOC1和APOE被确定为AD-AMD的多效基因（cFDR 0.65），其上游调控因子，尤其是ZNF131、ADNP2和HINFP，可成为AD和AMD的潜在生物标志物（AUC>0.8）。结论 在这项研究中，我们证实了AD和AMD之间的遗传多效性，并确定了APOC1和APOE为多效基因。此外，通过整合多组学数据，我们发现 ZNF131、ADNP2 和 HINFP 是新型的 AD 和 AMD 诊断生物标记物。数据可在公开、开放的资源库中获取。GWAS数据的GRASP数据库（）；基因表达数据的GTEx数据库（）；基因表达数据的GEO数据库（）；GWAS数据的英国生物库（）。
{"title":"Shared genetic aetiology of Alzheimer’s disease and age-related macular degeneration by APOC1 and APOE genes","authors":"Xueli Zhang, Zhuoting Zhu, Yu Huang, Xianwen Shang, Terence J O'Brien, Patrick Kwan, Jason Ha, Wei Wang, Shunming Liu, Xiayin Zhang, Katerina Kiburg, Yining Bao, Jing Wang, Honghua Yu, Mingguang He, Lei Zhang","doi":"10.1136/bmjno-2023-000570","DOIUrl":"https://doi.org/10.1136/bmjno-2023-000570","url":null,"abstract":"Background Alzheimer’s disease (AD) and age-related macular degeneration (AMD) share similar pathological features, suggesting common genetic aetiologies between the two. Investigating gene associations between AD and AMD may provide useful insights into the underlying pathogenesis and inform integrated prevention and treatment for both diseases. Methods A stratified quantile–quantile (QQ) plot was constructed to detect the pleiotropy among AD and AMD based on genome-wide association studies data from 17 008 patients with AD and 30 178 patients with AMD. A Bayesian conditional false discovery rate-based (cFDR) method was used to identify pleiotropic genes. UK Biobank was used to verify the pleiotropy analysis. Biological network and enrichment analysis were conducted to explain the biological reason for pleiotropy phenomena. A diagnostic test based on gene expression data was used to predict biomarkers for AD and AMD based on pleiotropic genes and their regulators. Results Significant pleiotropy was found between AD and AMD (significant leftward shift on QQ plots). APOC1 and APOE were identified as pleiotropic genes for AD–AMD (cFDR <0.01). Network analysis revealed that APOC1 and APOE occupied borderline positions on the gene co-expression networks. Both APOC1 and APOE genes were enriched on the herpes simplex virus 1 infection pathway. Further, machine learning-based diagnostic tests identified that APOC1, APOE (areas under the curve (AUCs) >0.65) and their upstream regulators, especially ZNF131, ADNP2 and HINFP, could be potential biomarkers for both AD and AMD (AUCs >0.8). Conclusion In this study, we confirmed the genetic pleiotropy between AD and AMD and identified APOC1 and APOE as pleiotropic genes. Further, the integration of multiomics data identified ZNF131, ADNP2 and HINFP as novel diagnostic biomarkers for AD and AMD. Data are available in a public, open access repository. GRASP database for GWAS data (<https://grasp.nhlbi.nih.gov/FullResults.aspx>); GTEx database for gene expression data (<https://www.gtexportal.org/>); GEO database for gene expression data (<https://www.ncbi.nlm.nih.gov/geo/>); and UK Biobank for GWAS data (<https://www.ukbiobank.ac.uk/>).","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"48 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140560636","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background Essential tremor (ET) is a movement disorder that affects 4%–5% of adults >65 years. For patients with medically refractory ET, neurosurgical interventions such as deep brain stimulation (DBS) and unilateral MR-guided focused ultrasound thalamotomy (MRgFUS) are available. In this retrospective cohort study, we examined the demographics of patients with ET who have received MRgFUS and evaluated trends in DBS usage in the USA after the introduction of MRgFUS in 2016. Methods We used multiple databases to examine the demographics of patients who received DBS and MRgFUS, and trends in DBS. To assess the demographics, we queried the TriNetX database from 2003 to 2022 to identify patients diagnosed with ET and stratify them by DBS or MRgFUS treatment by using Current Procedural Terminology codes. Patient demographics were reported as frequencies and percentages. To examine the trends in DBS for ET, the yearly frequency of DBS procedures done for ET between 2012 and 2019 was extracted from the National Inpatient Sample (NIS) database, and breakpoint analysis was performed. Additionally, the yearly frequency of MRgFUS procedures for ET was obtained from Insightec Exlabate. Results Most of the patients (88.69%) in the cohort extracted from TriNetX database self-identified as white, followed by black or African American (2.40%) and Asian (0.52%). A higher percentage of black patients received MRgFUS treatment than DBS (4.10% vs 1.88%). According to the NIS database, from 2012 to 2020, 13 525 patients received DBS for ET. Conclusion This study provides an overview of the characteristics of patients who undergo DBS or MRgFUS. We found notable differences in sex and race among patients who underwent each treatment type. Additionally, until at least the beginning of 2020, the number of DBS procedures for ET was not negatively affected after the introduction of MRgFUS. Data may be obtained from a third party and are not publicly available. The data that support the findings of this study are available from TriNETx Healthcare Network, National Inpatient Sample and Insightec Exablate. Restrictions apply to the availability of these data, which were used under license for this study.
{"title":"Demographics of focused ultrasound thalamotomy for essential tremor and trends in deep brain stimulation surgery after its introduction in the USA","authors":"Diwas Gautam, Vishal Venkatraman, Joshua Horns, Lexie Zidanyue Yang, Hui-Jie Lee, Panagiotis Kassavetis, Jumana Alshaikh, Paolo Moretti, Ben Shofty, Shervin Rahimpour","doi":"10.1136/bmjno-2023-000582","DOIUrl":"https://doi.org/10.1136/bmjno-2023-000582","url":null,"abstract":"Background Essential tremor (ET) is a movement disorder that affects 4%–5% of adults >65 years. For patients with medically refractory ET, neurosurgical interventions such as deep brain stimulation (DBS) and unilateral MR-guided focused ultrasound thalamotomy (MRgFUS) are available. In this retrospective cohort study, we examined the demographics of patients with ET who have received MRgFUS and evaluated trends in DBS usage in the USA after the introduction of MRgFUS in 2016. Methods We used multiple databases to examine the demographics of patients who received DBS and MRgFUS, and trends in DBS. To assess the demographics, we queried the TriNetX database from 2003 to 2022 to identify patients diagnosed with ET and stratify them by DBS or MRgFUS treatment by using Current Procedural Terminology codes. Patient demographics were reported as frequencies and percentages. To examine the trends in DBS for ET, the yearly frequency of DBS procedures done for ET between 2012 and 2019 was extracted from the National Inpatient Sample (NIS) database, and breakpoint analysis was performed. Additionally, the yearly frequency of MRgFUS procedures for ET was obtained from Insightec Exlabate. Results Most of the patients (88.69%) in the cohort extracted from TriNetX database self-identified as white, followed by black or African American (2.40%) and Asian (0.52%). A higher percentage of black patients received MRgFUS treatment than DBS (4.10% vs 1.88%). According to the NIS database, from 2012 to 2020, 13 525 patients received DBS for ET. Conclusion This study provides an overview of the characteristics of patients who undergo DBS or MRgFUS. We found notable differences in sex and race among patients who underwent each treatment type. Additionally, until at least the beginning of 2020, the number of DBS procedures for ET was not negatively affected after the introduction of MRgFUS. Data may be obtained from a third party and are not publicly available. The data that support the findings of this study are available from TriNETx Healthcare Network, National Inpatient Sample and Insightec Exablate. Restrictions apply to the availability of these data, which were used under license for this study.","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"10 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140560646","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-01DOI: 10.1136/bmjno-2023-000578
Jihoon Kang, Hyunjoo Song, Seong Eun Kim, Jun Yup Kim, Hong-Kyun Park, Yong-Jin Cho, Kyung Bok Lee, Juneyoung Lee, Ji Sung Lee, Ah Rum Choi, Mi Yeon Kang, Philip B Gorelick, Hee-Joon Bae
Background The landscape of stroke care has shifted from stand-alone hospitals to cooperative networks among hospitals. Despite the importance of these networks, limited information exists on their characteristics and functional attributes. Methods We extracted patient-level data on acute stroke care and hospital connectivity by integrating national stroke audit data with reimbursement claims data. We then used this information to transform interhospital transfers into a network framework, where hospitals were designated as nodes and transfers as edges. Using the Louvain algorithm, we grouped densely connected hospitals into distinct stroke care communities. The quality and characteristics in given stroke communities were analysed, and their distinct types were derived using network parameters. The clinical implications of this network model were also explored. Results Over 6 months, 19 113 patients with acute ischaemic stroke initially presented to 1009 hospitals, with 3114 (16.3%) transferred to 246 stroke care hospitals. These connected hospitals formed 93 communities, with a median of 9 hospitals treating a median of 201 patients. Derived communities demonstrated a modularity of 0.904, indicating a strong community structure, highly centralised around one or two hubs. Three distinct types of structures were identified: single-hub (n=60), double-hub (n=22) and hubless systems (n=11). The endovascular treatment rate was highest in double-hub systems, followed by single-hub systems, and was almost zero in hubless systems. The hubless communities were characterised by lower patient volumes, fewer hospitals, no hub hospital and no stroke unit. Conclusions This network analysis could quantify the national stroke care system and point out areas where the organisation and functionality of acute stroke care could be improved. Data is available with permission from the Korean Health Insurance Review and Assessment Service (HIRA). As this study used a government-owned database, it requires special permission to use it.
{"title":"Network analysis of stroke systems of care in Korea","authors":"Jihoon Kang, Hyunjoo Song, Seong Eun Kim, Jun Yup Kim, Hong-Kyun Park, Yong-Jin Cho, Kyung Bok Lee, Juneyoung Lee, Ji Sung Lee, Ah Rum Choi, Mi Yeon Kang, Philip B Gorelick, Hee-Joon Bae","doi":"10.1136/bmjno-2023-000578","DOIUrl":"https://doi.org/10.1136/bmjno-2023-000578","url":null,"abstract":"Background The landscape of stroke care has shifted from stand-alone hospitals to cooperative networks among hospitals. Despite the importance of these networks, limited information exists on their characteristics and functional attributes. Methods We extracted patient-level data on acute stroke care and hospital connectivity by integrating national stroke audit data with reimbursement claims data. We then used this information to transform interhospital transfers into a network framework, where hospitals were designated as nodes and transfers as edges. Using the Louvain algorithm, we grouped densely connected hospitals into distinct stroke care communities. The quality and characteristics in given stroke communities were analysed, and their distinct types were derived using network parameters. The clinical implications of this network model were also explored. Results Over 6 months, 19 113 patients with acute ischaemic stroke initially presented to 1009 hospitals, with 3114 (16.3%) transferred to 246 stroke care hospitals. These connected hospitals formed 93 communities, with a median of 9 hospitals treating a median of 201 patients. Derived communities demonstrated a modularity of 0.904, indicating a strong community structure, highly centralised around one or two hubs. Three distinct types of structures were identified: single-hub (n=60), double-hub (n=22) and hubless systems (n=11). The endovascular treatment rate was highest in double-hub systems, followed by single-hub systems, and was almost zero in hubless systems. The hubless communities were characterised by lower patient volumes, fewer hospitals, no hub hospital and no stroke unit. Conclusions This network analysis could quantify the national stroke care system and point out areas where the organisation and functionality of acute stroke care could be improved. Data is available with permission from the Korean Health Insurance Review and Assessment Service (HIRA). As this study used a government-owned database, it requires special permission to use it.","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"48 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140560555","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background The shift towards milder strokes and studies suggesting that stroke symptoms vary by age and sex may challenge the Face-Arm-Speech Time (FAST) coverage. We aimed to study the proportion of stroke cases admitted with FAST symptoms, sex and age differences in FAST presentation and explore any additional advantage of including new item(s) from the National Institute of Health Stroke Scale (NIHSS) to the FAST algorithm. Methods This registry-based study included patients admitted with acute stroke to Sahlgrenska University Hospital (November 2014 to June 2019) with NIHSS items at admission. FAST symptoms were extracted from the NIHSS at admission, and sex and age differences were explored using descriptive statistics. Results Of 5022 patients, 46% were women. Median NIHSS at admission for women was (2 (8–0) and for men 2 (7–0)). In total, 2972 (59%) had at least one FAST symptom, with no sex difference (p=0.22). No sex or age differences were found in FAST coverage when stratifying for stroke severity. 52% suffered mild strokes, whereas 30% had FAST symptoms. The most frequent focal NIHSS items not included in FAST were sensory (29%) and visual field (25%) and adding these or both in modified FAST algorithms led to a slight increase in strokes captured by the algorithms (59%–67%), without providing enhanced prognostic information. Conclusions 60% had at least one FAST symptom at admission, only 30% in mild strokes, with no sex or age difference. Adding new items from the NIHSS to the FAST algorithm led only to a slight increase in strokes captured. Data are available upon reasonable request. Data from registries are subject to the Personal Data Act (Swedish law No SFS 1998:204). Data may be available to researchers upon request, after review of secrecy (contact the author ks.sunnerhagen@neuro.gu.se). According to the Swedish regulation (epn.se/en/start/regulations/), the permission to use data can only be according to application and approval from the ethical board.
背景 脑卒中向轻度脑卒中的转变以及有关脑卒中症状因年龄和性别而异的研究可能会对 "面-臂-言语时间"（FAST）的覆盖范围提出挑战。我们的目的是研究具有 FAST 症状的入院脑卒中病例比例、FAST 表现的性别和年龄差异，并探讨将美国国立卫生研究院脑卒中量表 (NIHSS) 的新项目纳入 FAST 算法是否会带来额外优势。方法 这项以登记为基础的研究纳入了 Sahlgrenska 大学医院收治的急性卒中患者（2014 年 11 月至 2019 年 6 月），患者入院时具有 NIHSS 项目。从入院时的 NIHSS 中提取 FAST 症状，并使用描述性统计学方法探讨性别和年龄差异。结果 5022 名患者中，46% 为女性。入院时女性 NIHSS 中位数为 2（8-0），男性为 2（7-0）。共有 2972 名患者（59%）至少有一种 FAST 症状，无性别差异（P=0.22）。根据中风严重程度进行分层后，FAST 的覆盖率没有发现性别或年龄差异。52% 的患者为轻度脑卒中，而 30% 的患者有 FAST 症状。未纳入 FAST 的最常见病灶 NIHSS 项目是感觉（29%）和视野（25%），在改进的 FAST 算法中增加这两项或两项会使算法捕获的脑卒中略有增加（59%-67%），但不会提供更好的预后信息。结论 60% 的患者在入院时至少有一种 FAST 症状，只有 30% 的患者为轻度脑卒中，且无性别或年龄差异。在 FAST 算法中增加 NIHSS 的新项目只会使捕捉到的脑卒中略有增加。数据可在合理要求下提供。登记处的数据受《个人数据法》（瑞典法律编号 SFS 1998:204）管辖。经保密审查后，研究人员可索取数据（请联系作者 ks.sunnerhagen@neuro.gu.se）。根据瑞典法规 (epn.se/en/start/regulations/)，只有在提出申请并获得伦理委员会批准后才能使用数据。
{"title":"The precision by the Face Arm Speech Time (FAST) algorithm in stroke capture, sex and age differences: a stroke registry study","authors":"Guri Hagberg, Haakon Ihle-Hansen, Tamar Abzhandadze, Malin Reinholdsson, Adam Viktorisson, Hege Ihle-Hansen, Katharina Stibrant Sunnerhagen","doi":"10.1136/bmjno-2023-000574","DOIUrl":"https://doi.org/10.1136/bmjno-2023-000574","url":null,"abstract":"Background The shift towards milder strokes and studies suggesting that stroke symptoms vary by age and sex may challenge the Face-Arm-Speech Time (FAST) coverage. We aimed to study the proportion of stroke cases admitted with FAST symptoms, sex and age differences in FAST presentation and explore any additional advantage of including new item(s) from the National Institute of Health Stroke Scale (NIHSS) to the FAST algorithm. Methods This registry-based study included patients admitted with acute stroke to Sahlgrenska University Hospital (November 2014 to June 2019) with NIHSS items at admission. FAST symptoms were extracted from the NIHSS at admission, and sex and age differences were explored using descriptive statistics. Results Of 5022 patients, 46% were women. Median NIHSS at admission for women was (2 (8–0) and for men 2 (7–0)). In total, 2972 (59%) had at least one FAST symptom, with no sex difference (p=0.22). No sex or age differences were found in FAST coverage when stratifying for stroke severity. 52% suffered mild strokes, whereas 30% had FAST symptoms. The most frequent focal NIHSS items not included in FAST were sensory (29%) and visual field (25%) and adding these or both in modified FAST algorithms led to a slight increase in strokes captured by the algorithms (59%–67%), without providing enhanced prognostic information. Conclusions 60% had at least one FAST symptom at admission, only 30% in mild strokes, with no sex or age difference. Adding new items from the NIHSS to the FAST algorithm led only to a slight increase in strokes captured. Data are available upon reasonable request. Data from registries are subject to the Personal Data Act (Swedish law No SFS 1998:204). Data may be available to researchers upon request, after review of secrecy (contact the author ks.sunnerhagen@neuro.gu.se). According to the Swedish regulation (epn.se/en/start/regulations/), the permission to use data can only be according to application and approval from the ethical board.","PeriodicalId":52754,"journal":{"name":"BMJ Neurology Open","volume":"41 1","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140560759","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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