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1.  Association of Dental Care with Adherence to HEDIS Measures 
The Permanente Journal  2016;20(1):33-40.
The dental setting represents an unrealized opportunity to increase adherence to preventive services and improve health outcomes.
To compare adherence to a subset of Healthcare Effectiveness Data and Information Set (HEDIS) measures among a population that received dental care with a population that did not receive dental care.
Using a retrospective cohort design, we identified 5216 adults who received regular dental care and 5216 persons who did not. The groups were matched on propensity scores, were followed for 3 years, and retained medical and dental benefits. Receipt of dental care was defined as 1 or more dental visits in each 12-month period.
Main Outcome Measures:
Outcome measures were assessed in a subpopulation that qualified for 1 of 5 HEDIS denominator groups (dental = 4184 patients; nondental = 3871 patients). They included 3 preventive measures (cervical, colorectal, and breast cancer screening), 4 chronic disease management services (hemoglobin A1c and low-density lipoprotein cholesterol testing, and nephropathy and retinopathy screening among the diabetes mellitus [DM] population), and 4 health outcome measures (poor glycemic control, low-density lipoprotein cholesterol control, blood pressure control in the DM population, and blood pressure control in the hypertensive population).
Dental care was associated with higher adherence to all three cancer screening measures, one of four disease management services (higher retinopathy screening), and three of four health outcomes (better glycemic control in the DM population and better blood pressure control in the DM and hypertensive populations).
Dental care was associated with improved adherence to 7 of 11 HEDIS measures.
PMCID: PMC4732792  PMID: 26580145
2.  Diagnostic utility of aquaporin-4 in the analysis of active demyelinating lesions 
Neurology  2015;84(2):148-158.
To assess, in a surgical biopsy cohort of active demyelinating lesions, the diagnostic utility of aquaporin-4 (AQP4) immunohistochemistry in identifying neuromyelitis optica (NMO) or NMO spectrum disorder (NMOSD) and describe pathologic features that should prompt AQP4 immunohistochemical analysis and AQP4–immunoglobulin G (IgG) serologic testing.
This was a neuropathologic cohort study of 20 surgical biopsies (19 patients; 11 cord/9 brain), performed because of diagnostic uncertainty, interpreted as active demyelinating disease and containing 2 or more of the following additional features: tissue vacuolation, granulocytic infiltrates, or astrocyte injury.
AQP4 immunoreactivity was lost in 18 biopsies and increased in 2. Immunopathologic features of the AQP4 loss cohort were myelin vacuolation (18), dystrophic astrocytes and granulocytes (17), vascular hyalinization (16), macrophages containing glial fibrillary acid protein (GFAP)–positive debris (14), and Creutzfeldt-Peters cells (0). All 14 cases with available serum tested positive for AQP4-IgG after biopsy. Diagnosis at last follow-up was NMO/NMOSD (15) and longitudinally extensive transverse myelitis (1 each relapsing and single). Immunopathologic features of the AQP4 increased cohort were macrophages containing GFAP-positive debris and granulocytes (2), myelin vacuolation (1), dystrophic astrocytes (1), Creutzfeldt-Peters cells (1), and vascular hyalinization (1). Diagnosis at last follow-up was multiple sclerosis (MS) and both tested AQP4-IgG seronegative after biopsy.
AQP4 immunohistochemistry with subsequent AQP4-IgG testing has diagnostic utility in identifying cases of NMO/NMOSD. This study highlights the importance of considering NMOSD in the differential diagnosis of tumefactive brain or spinal cord lesions. AQP4-IgG testing may avert biopsy and avoid ineffective therapies if these patients are erroneously treated for MS.
PMCID: PMC4336081  PMID: 25503621
3.  Short myelitis lesions in aquaporin-4-IgG-positive neuromyelitis optica spectrum 
JAMA neurology  2015;72(1):81-87.
Short transverse myelitis (STM, <3 vertebral segments) is considered non-characteristic of neuromyelitis optica spectrum disorders (NMOSD). Poor recognition of the potential for STM to occur in NMOSD may lead to increased disability from delay in diagnosis and appropriate treatment.
To determine the frequency of short lesions at the initial myelitis manifestation of NMOSD, and to compare the demographic, clinical and radiological characteristics of aquaporin-4-IgG (AQP4-IgG) seropositive and seronegative STM.
Design, Setting, Participants
We reviewed the records and images of Mayo Clinic AQP4-IgG positive NMOSD patients identified from 1996-2014. Inclusion criteria were: 1) first TM episode; 2) MRI performed ≤90 days from symptom onset; 3) Spinal cord T2-hyperintense lesion <3 vertebral segments; 4) AQP4-IgG seropositivity; 5) final diagnosis NMO or NMOSD. Patients with an initial longitudinally extensive transverse myelitis (LETM) were excluded (n=151). Patients with STM, seronegative for AQP4-IgG, among an Olmsted County population-based cohort of inflammatory demyelinating disorders of the central nervous system were used as a control group.
Main Outcomes and Measures
Delay to diagnosis in months, clinical and radiological characteristics and disability measured by ambulatory status.
Twenty-five AQP4-IgG seropositive patients with an initial STM were included, representing 14% of initial myelitis episodes among NMOSD patients. The STM episode was: the first manifestation of NMOSD in 10 patients (40%); preceded by optic neuritis in 13 patients (52%); and preceded by a nausea and vomiting episode in 2 (8%). In comparison to the excluded NMOSD patients with an initial LETM, delay to diagnosis/treatment was greater when initial lesions were short (p=0.016). In AQP4-IgG positive STM cases subsequent myelitis episodes were longitudinally extensive in 92%. Attributes more common in aquaporin-4-IgG-positive STM patients than in 27 population-based aquaporin-4-IgG-negative STM patients (p<0.05) included: non-Caucasian ethnicity; tonic spasms; co-existing autoimmunity; MRI (central cord lesions, T1 hypointensity; brain inconsistent with multiple sclerosis) and CSF (oligoclonal bands lacking).
Conclusions and Relevance
STM is not uncommon in NMOSD and when present delays diagnosis/treatment. Clinical and radiological characteristics identified in this study may help select STM patients at highest risk for an NMOSD. STM does not exclude consideration of aquaporin-4-IgG testing nor NMOSD diagnosis.
PMCID: PMC4552048  PMID: 25384099
magnetic resonance imaging; transverse myelitis; Devic’s disease
4.  Updated estimate of AQP4-IgG serostatus and disability outcome in neuromyelitis optica 
Neurology  2013;81(14):1197-1204.
To 1) determine, using contemporary recombinant antigen–based assays, the aquaporin-4 (AQP4)–immunoglobulin G (IgG) detection rate in sequential sera of patients assigned a clinical diagnosis of neuromyelitis optica (NMO) but initially scored negative by tissue-based indirect immunofluorescence (IIF) assay; and 2) evaluate the impact of serostatus on phenotype and outcome.
From Mayo Clinic records (2005–2011), we identified 163 patients with NMO; 110 (67%) were seropositive by IIF and 53 (33%) were scored seronegative. Available stored sera from 49 “seronegative” patients were tested by ELISA, AQP4-transfected cell-based assay, and in-house fluorescence-activated cell sorting assay. Clinical characteristics were compared based on final serostatus.
Thirty of the 49 IIF-negative patients (61%) were reclassified as seropositive, yielding an overall AQP4-IgG seropositivity rate of 88% (i.e., 12% seronegative). The fluorescence-activated cell sorting assay improved the detection rate to 87%, cell-based assay to 84%, and ELISA to 79%. The sex ratio (female to male) was 1:1 for seronegatives and 9:1 for seropositives (p < 0.0001). Simultaneous optic neuritis and transverse myelitis as onset attack type (i.e., within 30 days of each other) occurred in 32% of seronegatives and in 3.6% of seropositives (p < 0.0001). Relapse rate, disability outcome, and other clinical characteristics did not differ significantly.
Serological tests using recombinant AQP4 antigen are significantly more sensitive than tissue-based IIF for detecting AQP4-IgG. Testing should precede immunotherapy; if negative, later-drawn specimens should be tested. AQP4-IgG–seronegative NMO is less frequent than previously reported and is clinically similar to AQP4-IgG–seropositive NMO.
PMCID: PMC3795610  PMID: 23997151
5.  Parkinsonian features in hereditary diffuse leukoencephalopathy with spheroids (HDLS) and CSF1R mutations 
Parkinsonism & related disorders  2013;19(10):869-877.
Atypical Parkinsonism associated with white matter pathology has been described in cerebrovascular diseases, mitochondrial cytopathies, osmotic demyelinating disorders, leukoencephalopathies including leukodystrophies, and others. Hereditary diffuse leukoencephalopathy with spheroids (HDLS) is an autosomal dominant disorder with symptomatic onset in midlife and death within a few years after symptom onset. Neuroimaging reveals cerebral white matter lesions that are pathologically characterized by non-inflammatory myelin loss, reactive astrocytosis, and axonal spheroids. Most cases are caused by mutations in the colony-stimulating factor 1 receptor (CSF1R) gene.
We studied neuropathologically verified HDLS patients with CSF1R mutations to assess Parkinsonian features. Ten families were evaluated with 16 affected individuals. During the course of the illness, all patients had at least some degree of bradykinesia. Fifteen patients had postural instability, and seven had rigidity. Two patients initially presented with Parkinsonian gait and asymmetrical bradykinesia. These two patients and two others exhibited bradykinesia, rigidity, postural instability, and tremor (two with resting) early in the course of the illness. Levodopa/carbidopa therapy in these four patients provided no benefit, and the remaining 12 patients were not treated. The mean age of onset for all patients was about 45 years (range, 18-71) and the mean disease duration was approximately six years (range, 3-11).
We also reviewed HDLS patients published prior to the CSF1R discovery for the presence of Parkinsonian features. Out of 50 patients, 37 had gait impairments, 8 rigidity, 7 bradykinesia, and 5 resting tremor. Our report emphasizes the presence of atypical Parkinsonism in HDLS due to CSF1R mutations.
PMCID: PMC3977389  PMID: 23787135
HDLS; CSF1R mutation; Parkinsonism; Autosomal dominant; White matter disorders
6.  Aquaporin 4 IgG Serostatus and Outcome in Recurrent Longitudinally Extensive Transverse Myelitis 
JAMA neurology  2014;71(1):48-54.
Studies focused on recurrent longitudinally extensive transverse myelitis (rLETM) are lacking.
To determine the aquaporin 4 (AQP4) IgG detection rate using recombinant human APQ4-based assays in sequential serum specimens collected from patients with rLETM categorized as negative by first-generation tissue-based indirect immunofluorescence (IIF) assay and to define the clinical characteristics and motor disability outcomes in AQP4-IgG–positive rLETM.
A search of the Mayo Clinic computerized central diagnostic index (October 1, 2005, through November 30, 2011), cross-linked with the Neuroimmunology Laboratory database, identified 48 patients with rLETM, of whom 36 (75%) were positive and 12 (25%) negative for neuromyelitis optica (NMO) IgG (per IIF of serial serum specimens). Stored serum specimens from “seronegative” patients were retested with recombinant human AQP4-based assays, including enzyme-linked immunosorbent, transfected cell-based, and fluorescence-activated cell-sorting assays. Control patients included 140 AQP4-IgG–positive patients with NMO, of whom a subgroup of 20 initially presented with 2 attacks of transverse myelitis (rLETM-onset NMO).
AQP4-IgG serostatus, clinical characteristics, and Expanded Disability Status Scale score.
Six patients with negative IIF results were reclassified as AQP4-IgG positive, yielding an overall AQP4-IgG seropositivity rate of 89%. Fluorescence-activated cell-sorting, cell-based, and enzyme-linked immunosorbent assays improved the detection rate to 89%, 85%, and 81%, respectively. The female to male ratio was 2:3 for AQP4-IgG–negative rLETM and 5:1 for AQP4-IgG–positive patients. The AQP4-IgG–positive patients with rLETM or rLETM-onset NMO were similar in age at onset, sex ratio, attack severity, relapse rate, and motor disability. From Kaplan-Meier analyses, 36% of AQP4-IgG–positive patients with rLETM are anticipated to need a cane to walk within 5 years after onset. For patients with rLETM-onset NMO, the median time from onset to first optic neuritis attack (54 months) was similar to the median disease duration for AQP4-IgG–positive patients with rLETM (59 months). The median number of attacks was 3 for AQP4-IgG–positive patients with rLETM (range, 2-22), and the first optic neuritis attack for those with rLETM-onset NMO followed a median of 3 myelitis attacks (range, 2-19). Immunosuppressant therapy reduced the relapse rate in both AQP4-IgG–positive and AQP4-IgG–negative patients with rLETM.
Recombinant antigen–based assays significantly increase AQP4-IgG detection in patients with rLETM, and AQP4-IgG–negative adults with rLETM are rare. Evolution to NMO can be anticipated in AQP4-IgG–positive patients. Early initiation of immunotherapy may result in a more favorable motor outcome.
PMCID: PMC3934000  PMID: 24248262
7.  Effects of Age and Sex on Aquaporin-4 Autoimmunity 
Archives of neurology  2012;69(8):1039-1043.
To determine the sex and age distribution of aquaporin-4 (AQP4) autoimmunity using data derived from clinical service laboratory testing of 56 464 patient samples.
Observational analysis.
Mayo Clinic Neuroimmunology Laboratory.
Between October 1, 2005, and January 4, 2011, 56 464 patients were tested for AQP4-IgG; 2960 (5.2%) patients were seropositive.
Main Outcome Measure
Seropositivity for AQP4-IgG.
Patients seropositive for AQP4-IgG were older than seronegative patients (mean [SD] age, 46 [16] vs 42 [15] years, respectively; P<.001). More females than males were tested (37 662 vs 16 810, respectively; P<.001). Among 2743 seropositive patients, 146 (5.3%) were pediatric (aged ≤18 years) and 333 (12.1%) were elderly (aged ≥65 years). The sex distribution of seropositive patients was 2465 females and 306 males (absolute female:male ratio, 8.1:1; P<.001). After adjusting for the number of females tested, an excess of females persisted (adjusted female:male ratio, 3.6:1). Female predominance for AQP4-IgG was more striking in adults (absolute female:male ratio, 8.4:1; adjusted female:male ratio, 3.5:1) than in pediatric patients (absolute female: male ratio, 4.3:1; adjusted female:male ratio, 2.9:1) (P<.001). Elderly women were more likely to be seropositive than individuals in other age categories (13.1% vs 6.0%, respectively; P<.001). The proportion of AQP4-IgG–seropositive individuals (detection rate), defined by decade of age, increased exponentially in women after age 50 years.
Seropositivity for AQP4-IgG occurs predominantly in females, particularly in individuals older than 18 years. Among seropositive patients, 1 in 6 is in the extremes of age. The detection rate of AQP4-IgG increased in women after age 50 years.
PMCID: PMC3746965  PMID: 22507888
8.  MRI characteristics and scoring in HDLS due to CSF1R gene mutations 
Neurology  2012;79(6):566-574.
To describe the brain MRI characteristics of hereditary diffuse leukoencephalopathy with spheroids (HDLS) with known mutations in the colony-stimulating factor 1 receptor gene (CSF1R) on chromosome 5.
We reviewed 20 brain MRI scans of 15 patients with autopsy- or biopsy-verified HDLS and CSF1R mutations. We assessed sagittal T1-, axial T1-, T2-, proton density-weighted and axial fluid-attenuated inversion recovery images for distribution of white matter lesions (WMLs), gray matter involvement, and atrophy. We calculated a severity score based on a point system (0−57) for each MRI scan.
Of the patients, 93% (14 of 15) demonstrated localized WMLs with deep and subcortical involvement, whereas one patient revealed generalized WMLs. All WMLs were bilateral but asymmetric and predominantly frontal. Fourteen patients had a rapidly progressive clinical course with an initial MRI mean total severity score of 16.7 points (range 10−33.5). Gray matter pathology and brainstem atrophy were absent, and the corticospinal tracts were involved late in the disease course. There was no enhancement, and there was minimal cerebellar pathology.
Recognition of the typical MRI patterns of HDLS and the use of an MRI severity score might help during the diagnostic evaluation to characterize the natural history and to monitor potential future treatments. Indicators of rapid disease progression were symptomatic disease onset before 45 years, female sex, WMLs extending beyond the frontal regions, a MRI severity score greater than 15 points, and mutation type of deletion.
PMCID: PMC3413763  PMID: 22843259
9.  Mutations in the colony stimulating factor 1 receptor (CSF1R) cause hereditary diffuse leukoencephalopathy with spheroids 
Nature genetics  2011;44(2):200-205.
Hereditary diffuse leukoencephalopathy with spheroids (HDLS) is an autosomal dominantly inherited central nervous system white matter disease with variable clinical presentations including personality and behavioral changes, dementia, depression, parkinsonism, seizures, and others1,2. We combined genome-wide linkage analysis with exome sequencing and identified 14 different mutations affecting the tyrosine kinase domain of the colony stimulating factor receptor 1 (encoded by CSF1R) in 14 families affected by HDLS. In one kindred, the de novo occurrence of the mutation was confirmed. Follow-up sequencing analyses identified an additional CSF1R mutation in a patient clinically diagnosed with corticobasal syndrome (CBS). In vitro, CSF-1 stimulation resulted in the rapid autophosphorylation of selected tyrosine-residues in the kinase domain of wild-type but not mutant CSF1R, suggesting that HDLS may result from a partial loss of CSF1R function. Since CSF1R is a critical mediator of microglial proliferation and differentiation in the brain, our findings suggest an important role for microglial dysfunction in HDLS pathogenesis.
PMCID: PMC3267847  PMID: 22197934

Results 1-9 (9)