Introduction: Multiple sclerosis (MS) is a chronic, inflammatory, (auto) immune disease of the central nervous system (CNS). Cognitive disorders are found in over 50% of patients. Aim: The aim of the study was to determine the distribution of cognitive disorders in people with MS. Methods: The prospective study included 135 respondents with MS and 50 healthy respondents. The respondents were divided into three groups: the first group consisted of 85 respondents where the disease lasted longer than one year, the second group consisted of 50 respondents with newly diagnosed MS, the third group consisted of 50 healthy respondents. Clinical assessment instruments were: Extended Disability Score in Multiple Sclerosis Patients, Mini Mental Status, Battery of Tests to Assess Cognitive Functions: Wechsler Intelligence Scale, Revised Beta Test, Raven Colored Progressive Matrices, Wechsler Memory Scale, Rey Audio Verbal Learning Test -Osterriecht’s complex character test, verbal fluency test. Results: Cognitive disorders were present in 40-60% of respondents with MS. Visuospatial, visuoconstructive and visuoperceptive functions are worse in the first group. Mnestic functions (learning process, short-term and long-term memory, recollection, verbal-logical memory) were most affected in both groups of respondents, ranging from 30-60%. Poorer cognitive domains are in the first groups of respondents. Immediate working process memory (current learning), memory, attention, short-term and logical memory is worse in the examinees of the first group. At the beginning of the disease, 16% had verbal fluency difficulties, and as the disease progresses, the difficulties become more pronounced. Conclusion: Cognitive disorders are heterogeneous, they can be noticed in the early stages of the disease. They refer to impairments of working memory, executive functions and attention, while global intellectual efficiency is later reduced.

Dear Editor-in-Chief Marius M. Scarlat, We have read with great attention the article “Medications in COVID-19 patients: summarizing the current literature from an orthopaedic perspective”, written by Shi Heng Sharon Tan and colleagues (Authors) in the forthcoming August issue of International Orthopaedics [1]. We welcome the opportunity to make a short comment as well. This very interesting article evaluates current literature regarding common medications prescribed in orthopaedic surgery and their potential implications in COVID-19 patients. The Authors emphasized that vitamins are commonly prescribed in various orthopaedic conditions. We want to highlight that older people are in increased risk for mortality due to pandemic of COVID-19, but also for different vascular accidents after hip and/or other bone fractures. Also, hyperhomocysteinemia is common in elderly people and often associated increased risk for fractures and cardiovascular diseases, too. Interestingly, values of vitamin B9 (folic acid) and B12 are in negative correlation with levels of homocysteine [2]. Unfortunately, hyperhomocysteinemia appeared to be predictive of all-cause mortality, independent of frailty, an agerelated clinical state characterized by a global impairment of physiological functions and involving multiple organ systems [3]. In one of the very rare studies, high number of pulmonary embolism was noted in COVID-19 pneumonia patients (20.6%), despite the fact that 90% of them were receiving prophylactic antithrombotic treatment due to the current guidelines [4]. Furthermore, according to PubMed survey, there was no reliable data due to concomitance of COVID19, hyperhomocysteinemia and osteoporosis/fractures. So, what to do when we have older COVID-19 patient with high risks for different cardiovascular diseases, including pulmonary thromboembolism, as well as bone fracture? There is an urgent need to different opinions and recommendations, when proper data are absent due to enormous speed of COVID-19 disaster. Clinicians need to adapt to the challenges posed by this crisis and consider ways to continue serving the most vulnerable amongst us, those with chronic disease with their own substantive morbidity and mortality [5]. In light of this, we suggest that level of homocysteine and B9/B12 vitamin should be measured at clinical follow-up in all patients with COVID-19, immediately after hospitalization. If persistent, hyperhomocysteinemic proosteoporotic/ procoagulability state should be promptly decreased in acute phase of COVID-19, on the base of Latin phrase primum non nocere. Our studies from Bosnia and Herzegovina showed that the intake of B9 vitamin, sometimes with B12 vitamin as well, was efficient in creating normalized homocysteine levels in older patients with ischemic stroke and Parkinson’s disease [6, 7]. Fortunately, risk of side effects is minimal if the daily dose of B9 vitamin is 1–5 mg [8]. In addition, B2/B3/B6 vitamins are, as Authors wrote, enhancers of the immune system and might be efficient as soldiers from second echelon in battling with COVID-19. Lastly, we emphasize that further studies will elucidate hidden but also harmful potential of hyperhomocysteinemia on bone fractures/vascular accidents in COVID-19 patients as well as beneficial add-on effects of B9/B12 vitamin on their osteoporotic/vascular complications. * Suljo Kunić suljo.kunic@hotmail.com

ABSTRACT Objective To evaluate memory in patients with drug-resistant epilepsy. Methods Following an examination, 50 patients were diagnosed in accordance with the 2005 proposal of the International League Against Epilepsy and the definition of drug-resistant epilepsy from 2010. The neuropsychological examination used the Wechsler Memory Scale. It assessed seven structural types of memory: general knowledge, orientation, mental control, logical memory, number memory, associative memory, and visual reproduction. The values were compared with 50 subjects without epilepsy. Results Patients with epilepsy had statistically significantly lower values in five of seven structural units of memory. The average value of overall memory efficacy in subjects with epilepsy was 96.5 ± 19.6, while in subjects without epilepsy it was 118 ± 15.6 (p = 0.0002). Memory impairments are greater in those taking polytherapy (p = 0.0429). The overall memory efficiency correlated significantly negatively with seizure frequency (p = 0.0015) and insignificantly negative with the duration of epilepsy (p = 0.1935). Conclusion Patients with drug-resistant epilepsy have lower memory efficiency. Memory impairments are greater in those taking polytherapy, as with those with more frequent seizures. The duration of epilepsy has no significant effect on overall memory performance.

The aim of this study was to evaluate anosognosia in acute stroke phase in order to type of stroke (ischemia, hemorrhage) and stroke localization as well as post-stroke patients recovery. Subjects and methods: In this prospective analysis were included 191 patients (96 males and 95 females) with first-ever stroke who were treated at the Department of neurology of the University Clinical Center in Tuzla. All patients were tested to anosognosia presence in acute stroke phase according to the modified Bisiach scale (7), while the level of disability was assessed using the Rankin scale (8) and level of functioning in daily activities using the Barthel index (9). Re-testing was done in week five post-stroke. Results: The average age of patients was 66.41 (mean age 10.21). Ischemic stroke had 168 patients (88%) while 23 (12%) the hemorrhagic one. The lesions localized to the right hemisphere were in 111 (58.11%) patients as well as in 80 (41.89%) patients with lesions localized to the left hemisphere. Anosognosia with no statistical significance was verified in 28% of patients in acute stroke phase, more often caused by lesions to the right hemisphere. Otherwise, significantly more frequent anosognosia was present in patients with hemorrhagic stroke mostly caused by massive lesions localized to the right hemisphere. Conclusion: Presence of anosognosia in patients with stroke vitally influenced patient’s functional status in re-testing phase just as well as in the acute stroke phase.

Introduction: The depression is a common mental disorder, especially after a stroke, which further aggravates the recovery. Aim: To analyze depression within 48 hours and fifteen days after ischemic stroke in relation to gender and location (brain hemisphere and brain circulation). Methods: We analyzed 40 patients (65.3±10.3 years), half of them were women. Mean age of women was 66.35±7.31 years and men 64.2±12.68 years (p= 0.5). Ischemic stroke was verified by computed tomography. Levels of depression were measured with self-estimated Zung’s scale. On the tests, score of 50 and higher verified depression. Criteria made by Domasio were used to determine location of the IS. Results: Mean value on depression scale in acute phase of ischemic stroke was 46.85 ± 8.6 and in subacute phase 43.4 ± 8 (p =0.06). In 19 (47.5%) patients (55% of women, 40% of men; p=0.3) depression was found during the first and in 10 (25%) patients (35% of women, 15 % of men; p=0.06) during the second evaluation (p<0.019). Mean value on depression in acute phase of illness in women was 49.1 ± 7.38, as well as in men 44.6 ± 9.22 (p=0.088) and in subacute phase in women 45.25 ± 8.04, as well as in men 41.5 ± 7.75 (p=0.16). Concerning location of ischemic stroke, there were no significant differences in levels of depression. Conclusion: Number of patients with post-stroke depression is significantly lower in subacute phase of ischemic stroke. Although the number of depressive women and their depression scores are higher, gender differences are not statistically significant. There is no correlation between post-stroke depression and location of lesion in acute and subacute phase of illness.

Introduction: Small number of studies have evaluated the mortality and the degree of functional disability of post-stroke delirium, and our aim was to determine that. Patients and Methods: Comprehensive neuropsychological assessments were performed within the first week of stroke onset, at hospital discharge, and followed-up for 3, 6 and 12 months after stroke. We used diagnostic tools such as Glasgow Coma Scale, Delirium Rating Scale, National Institutes of Health Stroke Scale and Mini-Mental State. Results: Delirious patients had a significantly higher mortality (p = 0.0005). As opposed to the type of stroke mortality was higher after ischemic (p = 0.0005). The patients without delirium had significantly better cumulative survival during the first year after stroke (p = 0.0005). Delirious patients aged ≥65 years had a significantly lower cumulative survival during the first year after stroke (p = 0.0005). In relation to the type of stroke delirious patients with ischemic had a significantly lower cumulative survival during the first year after stroke (p = 0.0005). Delirious patients had a greater degree of functional impairment at discharge (p = 0.01), three (p = 0.01), six months (p = 0.01) and one year (p = 0.01) after stroke. Conclusion: Delirious patients have a significantly higher mortality, lower cumulative survival and a greater degree of functional disability in the first year after stroke.