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Electroencephalogram (EEG) based Brain-computer interface (BCI) is a viable technology. It can enable people with temporal voice impairment to communicate to the world directly from their brain. The electrical signals generated by the human brain during sub-vocalized speech are captured, analyzed, and interpreted as speech using BCI. This review offers an introduction and overview of different modalities in EEG-based BCI applications for silent speech, imagined speech, and inner speech recognition. It briefly presents various techniques and methods from pre-processing techniques to feature classification involved in the development of EEG-based BCI applications for silent speech recognition.

Worldwide stroke care was affected by COVID 19 pandemic and the majority of the literature was on ischemic stroke. Intracerebral hemorrhage (ICH) accounts for about one-fourth of strokes worldwide and has got high mortality and morbidity. We aimed to study the effect of the Pandemic on ICH outcomes and flow metrics during the first wave compared to the pre-pandemic period and how that experience was made used in managing ICH during the second wave. Ours was a single-center observational study, where consecutive patients with non-COVID spontaneous ICH aged more than 18 years who presented within 24 hours of last seen normal were included in the study. We selected the months of June, July, and August in 2021 as the second wave of the pandemic, the same months in 2020 as the first wave of the pandemic, and the same months in 2019 as the pre-pandemic period. We compared the 3-month functional outcomes, in hospital mortality and workflow metrics during the three time periods. We found poor three-month functional outcomes and higher hospital mortality during the first wave of the COVID 19 pandemic, which improved during the second wave. In-hospital time metrics measured by the door to CT time which was delayed during the first wave improved to a level better than the pre-pandemic period during the second wave. ICH volume was more during the first and second waves compared to the pre-pandemic period. Other observations of our study were younger age during the second wave and higher baseline systolic BP at admission during both pandemic waves. Our study showed that functional outcomes and flow metrics in ICH care improved during the second wave of the pandemic through crucial re-organization of hospital stroke workflows. We are sharing this experience because we may have to do further rearrangements in future as the upcoming times are challenging due to new variants emerging.

Objectives: This study was conducted to obtain data on the cognitive effects of lacosamide in Indian population. Methodology: An open labelled prospective observational study in 22 patients who suffered from focal epilepsy. Results: All the pre and post lacosamide cognition scores showed statistically significant positive correlation in this study. Average initial seizure frequency per month was 3.56 (SD 2.58) and median frequency 2.5 seizures per month. Range being 1-8 per month. At the final follow-up at 6months, 87.5% of the study subjects had no seizures. In the remaining12.5% of patients, reduction in seizure frequency was observed. The difference in frequency is statistically significant (Wilcoxon Signed Ranks TestP

Stroke affects the quality of life through its devastating effects on physical, psychological, social, and economic domains. Patient-reported outcome measures help to capture the patient's perspective to changes in the quality of life. The available stroke-specific outcome measures of stroke do not comprehensively measure all the domains.We describe the development and validation of the Stroke Impact Assessment Questionnaire (SIAQ) an interviewer-administered new instrument developed using patient-centered approaches to assess the long-term problems of stroke survivors.We used a sequential exploratory mixed methods approach (QUAL → QUAN) to develop the SIAQ. The design involves an initial qualitative phase aimed at generating the item pool and a subsequent second phase aimed at testing of items using quantitative techniques (Psychometric evaluation).SIAQ, a thirty-item tool, under the eight domains (sensory, motor, social, economic, emotional, behavioral, cognitive, and communication) emerged from Principal Component Analysis. The factor loadings ranged from 0.421 to 0.880. The intraclass coefficient in test-retest reliability r is 0.958 (95% CI 0.9249-0.9799) and in interobserver reliability is 0.9473 (95% CI 0.9125 - 0.9733). The internal consistency Cronbach's alpha for the final 30 item tool was 0.88.SIAQ is a culturally appropriate psychometrically robust questionnaire assessing the long-term outcome of stroke. However, SIAQ is applicable only in stroke survivors for up to 65 years.

Background and ObjectivesTo determine whether cognitive reserve attenuates the association of vascular brain injury with cognition.MethodsCross-sectional data were analyzed from 2 harmonized studies: the Canadian Alliance for Healthy Hearts and Healthy Minds (CAHHM) and the Prospective Urban and Rural Epidemiology (PURE) study. Markers of cognitive reserve were education, involvement in social activities, marital status, height, and leisure physical activity, which were combined into a composite score. Vascular brain injury was defined as nonlacunar brain infarcts or high white matter hyperintensity (WMH) burden on MRI. Cognition was assessed using the Montreal Cognitive Assessment Tool (MoCA) and the Digit Symbol Substitution Test (DSST).ResultsThere were 10,916 participants age 35–81. Mean age was 58.8 years (range 35–81) and 55.8% were female. Education, moderate leisure physical activity, being in a marital partnership, being taller, and participating in social groups were each independently associated with higher cognition, as was the composite cognitive reserve score. Vascular brain injury was associated with lower cognition (β –0.35 [95% confidence interval [CI] –0.53 to −0.17] for MoCA and β −2.19 [95% CI −3.22 to −1.15] for DSST) but the association was not modified by the composite cognitive reserve variable (interactionp= 0.59 for MoCA andp= 0.72 for DSST).ConclusionsBoth vascular brain injury and markers of cognitive reserve are associated with cognition. However, the effects were independent such that the adverse effects of covert vascular brain injury were not attenuated by higher cognitive reserve. To improve cognitive brain health, interventions to both prevent cerebrovascular disease and promote positive lifestyles are needed.

BACKGROUND Disturbance of brain iron homeostasis have been linked to acute neuronal injury following cerebral ischemia. Increased body iron stores measured as serum ferritin is an acute-phase reactant involved in cellular defence against oxidative stress and it constitutes the main intracellular iron storage protein. In a healthy population, iron excess may not be a major concern; however, in persons with high oxidative stress and dyslipidaemia, iron excess may place them at greater risk. Hence this study is undertaken to find out the role of iron in acute ischemic stroke and to estimate the iron stores, measured as serum ferritin in acute ischemic stroke patients. METHODS A minimum of 180 consecutive patients above 40 years in the acute phase of ischemic stroke within 72 hours of first episode admitted to the neurology department was selected for the study. Data collection was based on Interview method by detailed questionnaire and laboratory investigations. Quantitative determination of serum ferritin was done by immunoenzymatic colorimetric method using ELISA technique. Association of risk factors like age, gender, place of residence, history of hypertension, dyslipidaemia and diabetes between cases with elevated ferritin and normal values were analysed. RESULTS In the present study incidence of stroke was more common among patients with the age group of more than 50 years and among the 180 cases, 75 % showed elevated serum ferritin levels. Association of risk factors between cases with elevated ferritin and cases with normal ferritin were studied and it shown that history of hypertension, dyslipidaemia and diabetes were statistically significant. Multiple logistic regression showed history of hypertension and dyslipidaemia that were independent predictors of elevated ferritin levels among stroke patients. CONCLUSIONS Serum Ferritin was increased in acute ischemic stroke patients. There was significant association of factors like history of hypertension, dyslipidaemia and diabetes with elevated ferritin levels. KEYWORDS Stroke, Ferritin, Oxidative Stress, Free Radicals

Tuberculous (TB) meningitis (TBM), accounting for 70-80% of cases of neurotuberculosis, is one of the most severe forms of extrapulmonary tuberculosis. Two-thirds of new TB cases come from eight countries. Polymorphisms in toll-interleukin-1 receptor domain and in leukotriene A4 hydrolase (LTA4H) gene, affect the risk of inflammation in TBM. The common site of tuberculoma in children is cerebellum, and they may rarely develop tuberculous encephalopathy which has a high mortality. Young females with a high cerebrospinal fluid (CSF) protein have an increased predisposition to develop optochiasmatic arachnoiditis. Spinal TB meningitis may mimic transverse myelitis or Guillain-Barre syndrome. An extra-neural focus of TB should be sought clinically and radiologically as it may indicate safer and more accessible sites for diagnostic samplings. Cartridge-based nucleic acid amplification test (CBNAAT), also known as Genexpert test, is a polymerase chain reaction (PCR)-based method for detection of TB which also detects rifampicin resistance as it targets the rpob gene of mycobacteria. Line probe assays, based on PCR and reverse hybridization methods, identify mutations associated with drug resistance within a week. TBM being a paucibacillary disease, often evades a definite diagnosis and empirical treatment for a minimum of 9 months is warranted based on clinical judgement. All TBM patients should receive adjunctive corticosteroids, even those with HIV infection. Drug resistance is strongly associated with previous treatment and bedaquiline as well as delamanid have received approvals for multidrug resistant (MDR) TB. The key principle of managing MDR TB is never to add a single drug to a failing regimen. Correct combination and duration of most effective second line drugs in MDR TB require further modifications. Early shunting should be considered in those with hydrocephalus failing medical management. The single most important determinant of outcome is the stage of TBM at which treatment has been started.

Background: Diagnostic errors in neurological diagnosis are a source of preventable harm. Software tools like Differential Diagnosis (DDx) apps in neurology that hold the potential to mitigate this harm are conspicuously lacking.Materials and Methods: A multicenter cross-sectional observational study was designed to compare the diagnostic accuracy of a Neurology DDx App (Neurology Dx) with neurology residents by using vascular neurology clinical vignettes. The study was conducted at 7 leading neurology institutes in India. Study participants comprised of 100 neurology residents from the participating institutes.Measurements: Detecting diagnostic accuracy of residents and App measured as a proportion of correctly identified high likely gold standard DDx was prespecified as the main outcome. Proportions of correctly identified first high likely, first 3 high likely, first 5 high likely, and combined moderate plus high likely gold standard differentials by residents and App were secondary outcomes.Results: 1,000 vignettes were attempted by residents. Frequency of gold standard, high likely differentials correctly identified by residents was 27% compared to 72% by App (absolute difference 45%, 95% CI 35.7-52.8). When high and moderate likely differentials were combined, residents scored 17% compared to 57% by App (absolute difference 40%, 95% CI 33.8-50.0). Residents correctly identified first high likely gold standard differential as their first high likely differential in 34% compared to 18% by App (absolute difference 16%, 95% CI 1.2-25.4).Conclusion: App with predefined knowledge base can complement clinical reasoning of neurology residents. Portability and functionality of such Apps may further strengthen this symbiosis between humans and algorithms (CTRI/2017/06/008838).

The Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) producing strokes is a less explored entity. Our hospital, a stroke-ready one, had an opportunity to manage mucormycosis when it was identified as the nodal center for mucormycosis management. We are sharing our experiences and mistakes in managing the cerebrovascular manifestations of ROCM.We conducted a prospective observational study during the second wave of the COVID-19 pandemic from 1st May 2021 to 30th September 2021, where consecutive patients aged more than 18 years with microbiologically confirmed cases of ROCM were included. Clinical details (timing of stroke onset after ROCM symptoms, GCS, NIHSS), imaging findings (ASPECTS, the territory of stroke, the pattern of infarct, hemorrhagic transformation, cavernous sinus thrombosis), angiogram findings, management details (IV thrombolysis), and outcomes (mRS at discharge and duration of hospital stay) were documented. We also compared the demographics, clinical features (NIHSS), radiological findings, treatment details, duration of hospital stay, and functional outcome at the discharge of the ROCM stroke patients with stroke patients without ROCM.Stroke developed in 42% of patients with ROCM, predominantly anterior circulation border zone ischemic infarcts. Strokes occurred after a median of five days from the onset of ROCM symptoms. The most common vessel involved was the ophthalmic artery, followed by the cavernous ICA. We could not thrombolyse ROCM stroke patients. ROCM patients who developed stroke compared with patients without stroke had a more infiltrative fungal infection and higher inflammatory markers. Mucormycosis associated stroke patients had higher in-hospital mortality and poor functional outcomes.Due to delayed recognition of stroke symptoms, none received reperfusion strategies, leading to poor functional outcomes. For early stroke detection, ROCM cases need frequent monitoring and education of patients and their relatives about the ALS acronym (loss of ambulation, limb weakness, and loss of speech).

In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India.This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases.Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India.

Background : During the first wave of the pandemic, stroke care suffered globally and there were reduced stroke admissions and delays in time metrics. Stroke care was reorganized during the second wave learning from the experience of previous wave. This study shares our experience in stroke time metrics during the second wave of pandemic compared to the first wave. Methods : We did a single-center prospective study, where consecutive acute ischemic stroke patients within 24 hours of the onset of symptoms and aged more than 18 years, who presented to Stroke Unit, Department of Neurology, Government Medical College, Thiruvananthapuram from June 1st to 31st August, 2020 and June 1st to 31st August in 2021 were included. In-hospital time metrics (door to CT time and door to Needle time) were compared during the two time periods. We also compared functional outcomes at discharge and in-hospital mortality during the two periods. Functional outcome at discharge was assessed by modified Rankin scale (mRS). Results : From June to August 2021 (second wave of the COVID 19 pandemic), compared to the same months during the first wave (2020), our study demonstrated better in-hospital time metrics (door to CT time and door to needle time). We also found lower admission systolic blood pressure and higher baseline CT early ischemic changes during the second wave. There was no difference in functional outcome at discharge and in-hospital mortality. Intravenous thrombolysis rates also remained the same during the two periods. Conclusion : Our study has confirmed that time metrics in stroke care can be improved through system rearrangement even during the pandemic. Acute stroke treatments are time-dependent and hospital administrators must stick to the maxim “Time is Brain” while restructuring stroke workflows during future challenges.

Introduction: Carpal tunnel syndrome is the most common entrapment neuropathy and is caused by median nerve compression at the wrist as it passes through carpal tunnel. Aim: To detect cross sectional area (CSA) of median nerve at the level of distal palmar crease and ratio of cross sectional area at level of proximal carpal tunnel to area 5 cm proximal to carpal tunnel using ultrasound. Materials and Methods: Consecutive patients of age between 18 and 70 years, who presented with paraesthesia of hands (aggravated by holding or keeping hand elevated or with history of nocturnal worsening) and electrophysiological confirmed as mild to moderate idiopathic cases of carpal tunnel syndrome were included in the study. Baseline nerve conduction study was done as per standard protocol for carpal tunnel syndrome. Nerve ultrasound was done with high frequency linear-array transducer (7-14 Hz). Results: 50 wrists in 30 Patients with CTS were studied. Females were more involved with a male: female ratio of 1:5. Mean age was 56.8 years (range 25–82 years). Majority of the cases were bilateral (67%). Dominant hand was involved more (80%) than non-dominant one. Most common symptoms were numbness (100%) and paraesthesia on holding (90.91%). On nerve ultrasound, all patients had CSA of median nerve at proximal carpal tunnel more than 10 square millimetre .The wrist fore-arm CSA ratio was more than 1 in all cases. Majority of the hands were having a cross sectional area 10-11.9 square millimetre and more than 16 square millimetre. We found correlation between CSA at distal palmar crease and median sensory conduction studies. Conclusion: Our study affirms previous studies in demonstrating the usefulness of ultrasonography in diagnosing CTS. Median nerve Cross-sectional area can be used for clinical screening of Carpal tunnel syndrome patients. Keyword: Carpal tunnel syndrome, Cross sectional area, Wrist-ultrasound.

Background A novel Mobile Medical Application (App) App was created on iOS platform (Neurology Dx®) to deduce Differential Diagnoses (DDx) from a set of user selected Symptoms, Signs, Imaging data and Lab findings. The DDx generated by the App was compared for diagnostic accuracy with differentials reasoned by participating neurology residents when presented with same clinical vignettes. Methods Hundred neurology residents in seven leading Neurology centers across India participated in this study. A panel of experts created 60 clinical vignettes of varying levels of difficulty related to Cognitive neurology. Each neurology resident was instructed to formulate DDx from a set of 15 cognitive neurology vignettes. Experts in Cognitive Neurology made the gold standard DDx answers to all 60 clinical vignettes. The differentials generated by the App and neurology residents were then compared with the Gold standard. Results Sixty clinical vignettes were tested on 100 neurology residents (15 vignettes each) and also on the App (60 vignettes). The frequency of gold standard high likely answers accurately documented by the residents was 25% compared with 65% by the App (95% CI 33.1–46.3), P < 0.0001. Residents correctly identified the first high likely gold standard answer as their first high likely answer in 35% (95% CI 30.7–36.6) compared with 62% (95% CI 14.1–38.5), P < 0.0001. Conclusion An App with adequate knowledge-base and appropriate algorithm can augment and complement human diagnostic reasoning in drawing a comprehensive list of DDx in the field of Cognitive Neurology (CTRI/2017/06/008838).

Background and Purpose: Occurrence of stroke has been reported among patients with COVID-19. The present study compares clinical features and outcomes of stroke patients with and without COVID-19. Methods: The COVID-19 Stroke Study Group (CSSG) is a multicentric study in 18 sites across India to observe and compare the clinical characteristics of patients with stroke admitted during the current pandemic period and a similar epoch in 2019. The present study reports patients of stroke with and without COVID-19 (CoVS and non-CoVS, respectively) seen between February 2020 and July 2020. Demographic, clinical, treatment, and outcome details of patients were collected. Results: The mean age and gender were comparable between the two groups. CoVS patients had higher stroke severity and extent of cerebral involvement on imaging. In-hospital complications and death were higher among CoVS patients (53.06% vs. 17.51%; P < 0.001) and (42.31% vs. 7.6%; P < 0.001), respectively. At 3 months, higher mortality was observed among CoVS patients (67.65% vs. 13.43%; P < 0.001) and good outcome (modified Rankin score [mRS]: 0–2) was seen more often in non-CoVS patients (68.86% vs. 33.33%; P < 0.001). The presence of COVID-19 and baseline stroke severity were independent predictors of mortality. Conclusions: CoVS is associated with higher severity, poor outcome, and increased mortality. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and baseline stroke severity are independent predictors of mortality.

Digital, OBJECTIVE We aimed to compare cardiovascular (CV) events, all-cause mortality, and CV mortality rates among adults with and without diabetes in countries with differing levels of income. RESEARCH DESIGN AND METHODS The Prospective Urban Rural Epidemiology (PURE) study enrolled 143,567 adults aged 35–70 years from 4 high-income countries (HIC), 12 middle-income countries (MIC), and 5 low-income countries (LIC). The mean follow-up was 9.0 6 3.0 years. RESULTS Among those with diabetes, CVD rates (LIC 10.3, MIC 9.2, HIC 8.3 per 1,000 personyears, P < 0.001), all-cause mortality (LIC 13.8, MIC 7.2, HIC 4.2 per 1,000 personyears, P < 0.001), and CV mortality (LIC 5.7, MIC 2.2, HIC 1.0 per 1,000 person-years, P < 0.001) were considerably higher in LIC compared with MIC and HIC. Within LIC, mortality was higher in those in the lowest tertile of wealth index (low 14.7%, middle 10.8%, and high 6.5%). In contrast to HIC and MIC, the increased CV mortality in those with diabetes in LIC remained unchanged even after adjustment for behavioral risk factors and treatments (hazard ratio [95% CI] 1.89 [1.58–2.27] to 1.78 [1.36–2.34]). CONCLUSIONS CVD rates, all-cause mortality, and CV mortality were markedly higher among those with diabetes in LIC compared with MIC and HIC with mortality risk remaining unchanged even after adjustment for risk factors and treatments. There is an urgent need to improve access to care to those with diabetes in LIC to reduce the excess mortality rates, particularly among those in the poorer strata of society., Ciencias Médicas y de la Salud

Objectives: We aimed to compare cardiovascular (CV) events, all-cause and CV mortality rates, among adults with and without diabetes in countries with differing levels of income. Research design and methods: Prospective Urban Rural Epidemiological (PURE) enrolled 143,567 adults aged 35 to 70 years from 4 high income countries (HIC), 12 middle income countries (MIC) and 5 low income countries (LIC). The mean follow-up was 9.0±3.0 years. Results: Among those with diabetes, CVD rates (LIC 10.3, MIC 9.2, HIC 8.3 per 1000 person years, p Conclusions: CVD rates, all-cause and CV mortality were markedly higher among those with diabetes in LIC compared to MIC and HIC with mortality risk remaining unchanged even after adjustment for risk factors and treatments. There is an urgent need to improve access to care to those with diabetes in LIC to reduce the excess mortality rates, particularly among those in the poorer strata of society.

In this study, we have investigated whether fractal dimension is a useful non linear feature for distinguishing electroencephalogram (EEG) of cases with encephalopathy from that of normal healthy EEGs. Both Higuchi’s fractal dimension and Katz’s fractal dimension were computed and were statistically analyzed between the normal and disease groups. Both parameters showed significant difference between the normal and encephalopathy groups, though Higuchi’s fractal dimension showed better discriminating ability. Support Vector Machine (SVM) classifier was also applied for the automated diagnosis of encephalopathy based on EEG. It has been found that SVM classifier performed better when Higuchi’s fractal dimension was utilized as feature set than using both Higuchi’s and Katz’s FD together.

In this study, an empirical mode decomposition (EMD) technique has been applied for EEG signals to identify a neurological disease state qualified as encephalopathy. The EMD technique is an efficient method for decomposing nonstationary and nonlinear signals, which makes it suitable for biosignal processing. This technique generates various components of the signal called intrinsic mode functions (IMFs) whose features are examined for the diagnosis of the disease. We found significant differences between the healthy and patient groups for both statistical and nonlinear parameters of IMFs of the recorded EEGs, which makes those suitable for the diagnosis of encephalopathy. Statistical values, namely minimum, maximum, mean, and standard deviation, and nonlinear parameters, namely approximate entropy and sample entropy of the IMFs, were calculated. Both these features were fed to a Support Vector Machine (SVM) classifier, and their performance parameters were evaluated. It is concluded that statistical parameters, as well as nonlinear parameters of the EEG IMFs, are prospective potential features for automated diagnosis of encephalopathy.

The unprecedented challenges during the COVID pandemic and the subsequent lockdown had resulted in a delay in treatment metrics for acute stroke. There is a rising concern that COVID-19 co-infection can adversely affect stroke outcome. We aim to investigate the impact of COVID-19 in the management of stroke patients. We also compared the differences in stroke manifestations, etiological pattern, treatment course, and outcome of acute stroke patients in COVID-19 confirmed cases.A single-center retrospective study was done at the Stroke Unit, Government Medical College, Thiruvananthapuram. Consecutive patients of acute stroke confirmed by imaging, presenting within 24 hours of the onset of symptoms in May to July 2020 and May to July 2019, were included. The primary data variables included baseline demographics, risk factors, admission NIHSS, stroke timings, thrombolysis rate, TOAST etiology, mRS at discharge, and in-hospital mortality.Strokes with higher NIHSS, arrival blood sugar and blood pressure, and delays in door-to-CT and door-to-needle time were more during the pandemic. Intravenous thrombolysis was less and mortality was higher in COVID-19 strokes during the pandemic. COVID-19-positive stroke patients had more hemorrhagic strokes, more severe strokes with low CT ASPECTS, more hemorrhagic transformation, high in-hospital mortality, and poor functional outcome at discharge and 3 months.Our study was a hypothesis-generating study with a limited number of patients. This study has reconfirmed the higher severity of the stroke, with a higher mRS score and mortality during the pandemic, especially among COVID-19-positive stroke patients.

Electroencephalogram (EEG) signals portray hidden neuronal interactions in the brain and indicate brain dynamics. These signals are dynamic, complex, chaotic and nonlinear, the nature of which is represented with features - fractal dimensions, entropies and chaotic features. This study aims at examining the discriminative power of individual features and their combination in the diagnosis of a neuro-pathological condition called encephalopathy. Feature combination is accomplished with the help of feature selection using Gini impurity score that improves discriminative power and keeps redundancy minimal. Further, three widely used non-parametric classifiers which are known to be effective with wavelet features on EEG signals — Support Vector Machine, Random Forest, Multilayer Perceptron — are employed for disease classification. The models created by the combination of aforementioned stages are analysed and evaluated with performance scores, leading to an optimal model for automated diagnostic applications.

Fibromyalgia is an intense musculoskeletal pain causing sleep, fatigue, and mood problems. Sleep studies have suggested that 70%-80% of fibromyalgia patients complain of non-restorative sleep. The abnormalities in sleep have been implicated as both a cause and effect of the disease. In this paper, the electroencephalogram (EEG) signals of sleep stages 2 and 3 are used to classify the normal and fibromyalgia classes automatically. We have used various nonlinear parameters, namely sample entropy (SampEn), fractal dimension (FD), higher order spectra (HOS), largest Lyapunov exponent (LLE), Kolmogorov complexity (KC), Hurst exponent (HE), energy, and power in various frequency bands from the EEG signals. Then these features are subjected to Student's t-test to select the clinically significant features, and are classified using the support vector machine (SVM) classifier. Our proposed method can classify normal and fibromyalgia subjects using the stage 2 sleep EEG signals with an accuracy of 96.15%, sensitivity and specificity of 96.88% and 95.65%, respectively. Performance of the developed system can be improved further by adding more subjects in each class, and can be employed for clinical use.

BACKGROUND Magnesium has been implicated as a key molecule in several mechanisms of migraine pathogenesis. Central neuronal hyperexcitability is suggested to be the pivotal physiological disturbance predisposing to migraine. In this study, the role of serum magnesium in defining the physiologic threshold for migraine and modulating the various mechanisms of migraine genesis was searched for. MATERIALS AND METHODS The study enrolled adult migraine patients of age 18 to 40 years (41 females and 29 males) with and without aura and healthy controls of the same age group. Serum magnesium levels measured in the interictal period (between attacks) in cases were compared with the results from controls. Serum calcium levels were also measured and compared in both groups. Design- Case-control study. RESULTS Serum magnesium was found to be significantly low among cases with migraine compared to controls. Serum magnesium levels showed inverse correlation with frequency of migraine attacks, implying the role of a decreased serum magnesium level in defining the susceptibility to migraine. Results also showed an association between serum magnesium and calcium levels. Serum calcium was found to be low when serum magnesium was low. CONCLUSION Magnesium has a fundamental role in establishing the threshold for migraine headaches.

In this study, we have reinvestigated the chaotic features and sub-band energies of EEG and its ability for aiding neurologists in detecting epileptic seizures. The study was done on the EEG of ictal and interictal phases of epileptic patients and of normal subjects. The EEG was decomposed using discrete wavelet transform to obtain various sub-bands and the chaotic features like correlation dimension and largest Lyapunov exponent were extracted. The analysis results clearly show that the correlation dimension and largest Lyapunov exponent have their lowest value during seizure activity, higher for interictal and even higher values for normal EEG. These values strongly suggest that interictal phase EEG of an epileptic patient is less complex and more predictable compared to normal EEG. Chaotic features extracted are potential parameters for automated diagnosis of epilepsy. Support vector machine (SVM) classifier was implemented based on both sub-band energies and chaotic features extracted from EEG. Classification performance parameters of SVM classifier based on sub-band decomposed energies and chaotic features were calculated.

Purpose: Drawing differential diagnoses to a Neuro-ophthalmology clinical scenario is a difficult task for a neurology trainee. The authors conducted a study to determine if a mobile application specialized in suggesting differential diagnoses from clinical scenarios can complement clinical reasoning of a neurologist in training. Methods: A cross-sectional multicenter study was conducted to compare the accuracy of neurology residents versus a mobile medical app (Neurology Dx) in drawing a comprehensive list of differential diagnoses from Neuro-ophthalmology clinical vignettes. The differentials generated by residents and the App were compared with the Gold standard differential diagnoses adjudicated by experts. The prespecified primary outcome was the proportion of correctly identified high likely gold standard differential diagnosis by residents and App. Results: Neurology residents (n = 100) attempted 1500 Neuro-ophthalmology clinical vignettes. Frequency of correctly identified high likely differential diagnosis by residents was 19.42% versus 53.71% by the App (P < 0.0001). The first listed differential diagnosis by the residents matched with that of the first differential diagnosis adjudicated by experts (gold standard differential diagnosis) with a frequency of 26.5% versus 28.3% by the App, whereas the combined output of residents and App scored a frequency of 41.2% in identifying the first gold standard differential correctly. The residents correctly identified the first three and first five gold standard differential diagnosis with a frequency of 17.83% and 19.2%, respectively, as against 22.26% and 30.39% (P < 0.0001) by the App. Conclusion: A ruled based app in Neuro-ophthalmology has the potential to complement a neurology resident in drawing a comprehensive list of differential diagnoses.

In patients with Parkinson's disease (PD), the occurrence of motor and non-motor symptoms increases with disease progression. The range of neuropsychiatric symptoms (NPS) vary among individuals and can be burdensome for caregivers. Only a few studies have identified the contributing factors of NPS and caregiver burden in India.We aimed to study the clinical profile, disability, and predictive factors of NPS in PD patients and associated caregiver's burden.This was a cross-sectional observational study carried out in PD patients and their respective caregivers attending a movement disorder clinic in a tertiary care teaching hospital in Kerala. A total of 104 patients diagnosed with idiopathic PD receiving levodopa therapy and who had a primary caregiver were enrolled in the study. Structured questionnaires were administered to both patients and caregivers to collect data. Data analysis was done using an independent t-test, linear, and multiple regression analysis.Among 104 patients recruited for the study, 61.5% of patients had shown at least one NPS and 40.44% showed multiple NPS. Results from the study showed that depression is the primary NPS occurring in IPD patients (55.8%) followed by irritability, anxiety, and apathy. On linear regression models, the prime determinant of NPS was the Everyday Abilities Scale for India (EASI). For caregiver burden, the main determinants were the presence of NPS, duration of caregiving, EASI, and RBDSQ score.NPS in PD are highly associated with and are determinants of caregiver burden. Detailed assessment and specific interventions aimed at NPS could alleviate caregiver burden.

A reduced mortality rate is a good indication of a nation’s efficient health sector. For reducing the mortality rate a critical patient should be transferred to a well-equipped hospital at the earliest. In road accident cases the importance of Golden Hour needs no explanation. For effectively implementing this goal, the movement of ambulances on our roads should be made hustle free, Autonomous Ambulance Management System with Real-Time Patient Monitoring using IoT is an answer to this million dollar question – how to reduce the handover time. The proposed system will identify the nearest hospital, the shortest route, sends vital parameters to the hospital in advance and moreover controls the traffic signal to ensure smooth passage of the ambulance. An efficient and effective way to help achieve the goal of saving a life.

Introduction: Oxidative stress by producing lipid peroxidation products like oxidised Low Density Lipoprotein (LDL) acts as independent risk factor in ischemic stroke. When lipid peroxidation overwhelms antioxidative defense mechanism; it results in enhanced formation of oxidized LDL which promotes atherosclerosis. Human serum Paraoxanase (PON 1) which is an ester hydrolase synthesized in the liver prevents the oxidative modification of LDL. Aim: To investigate the level of oxidized LDL as oxidative stress marker and paraoxonase activity as an antioxidant enzyme in ischemic stroke patients and also the relation between Oxidized-Low Density Lipoprotein (Ox-LDL) level and Computed Tomography (CT) findings in ischemic stroke patients. Materials and Methods: The subjects in this study comprised of 40 ischemic stroke patients and 40 age and gender matched controls. Fasting plasma glucose, serum paraoxanase activity, plasma oxidised LDL level, fasting lipid profile were determined. Data was analysed using Statistical Package for Social Sciences (SPSS) version 16.0. Results: Ischemic stroke patients had significantly lower paraoxanase activity (2.26 µg/ml), total cholesterol (>200 mg%) and fasting plasma glucose levels (>126 mg%). Conclusion: Oxidised LDL level >2.26 µg/ml, paraoxanase activity 126 mg% were independent risk factors for stroke. Significantly higher levels of oxidized LDL were seen in patients with infarct in anterior circulation. This study implies that raised oxidized LDL level and low serum paraoxanase activity are independent risk factors of ischemic stroke in patients with no other risk factors.

Objective To elucidate the genetic cause of a large 5 generation South Indian family with multiple individuals with predominantly an upper limb postural tremor and posturing in keeping with another form of tremor, namely, dystonic tremor. Methods Whole-genome single nucleotide polymorphism (SNP) microarray analysis was undertaken to look for copy number variants in the affected individuals. Results Whole-genome SNP microarray studies identified a tandem duplicated genomic segment of chromosome 15q24 present in all affected family members. Whole-genome sequencing demonstrated that it comprised a ∼550-kb tandem duplication encompassing the entire LINGO1 gene. Conclusions The identification of a genomic duplication as the likely molecular cause of this condition, resulting in an additional LINGO1 gene copy in affected cases, adds further support for a causal role of this gene in tremor disorders and implicates increased expression levels of LINGO1 as a potential pathogenic mechanism.

Background: Epilepsy with myoclonic absences (EMAs) is a distinct form of childhood epilepsy characterized by a peculiar seizure type that identifies this condition. Purpose: To describe the clinical, electroencephalographic features, treatment strategies and outcome in this first case series of two siblings with normal intelligence presenting with EMAs. Materials and methods: Both siblings underwent video-polygraphic investigations (simultaneous recording of electroencephalogram [EEG] and electromyogram [EMG] from deltoids), high-resolution magnetic resonance imaging (MRI), karyotyping, neuropsychological evaluation and language assessment. Results: Both the children had a mean age of onset of prototype seizures by 3.5 years. Myoclonic absences (MAs) were characterized by rhythmic, bilateral, synchronous, symmetric 3-Hz spike–wave discharges, associated with EMG myoclonic bursts at 3 Hz, superimposed on a progressively increasing tonic muscle contraction. The interictal EEG showed a normal background activity with bursts of generalized spike and waves (SWs) as well as rare focal SWs independently over bilateral temporal and frontal regions. Increase in the seizure frequency from 5 to 100/day was observed due to use of carbamazepine and phenobarbitone which decreased with its withdrawal and introduction of valproate. Though lamotrigine was given as an add on to valproate, it did not benefit them and was therefore replaced by topiramate at 3.5 mg/kg/day which has maintained them on remission at one year follow up. Conclusions: Recognition of this ictal pattern allows identification and differentiation of EMAs from other seizure types. Idiopathic and symptomatic EMAs need to be differentiated from childhood absence epilepsy with myoclonia. MAs are worsened by drugs like carbamazepine while valproate either alone or in combination with topiramate (preferred to lamotrigine) gives excellent outcome.

EEG contains immense information about the brain activity which cannot be understood completely by visual inspection. Powerful signal processing algorithms in EEG analysis can greatly assist the physicians and neurologists to extract such hidden information. It has been found that EEG being a time-varying and non-stationary signal, can be analyzed by non-linear methods. In this paper we tried to evaluate the non linear features like Approximate Entropy, Sample Entropy and Hurst Exponent in epileptic and normal EEG and has obtained clear discrimination between them. These features extracted during interictal phase EEG are potential parameters for exploring the possibility of epilepsy diagnosis from interictal phase EEG. SVM classifier was implemented for the non linear features extracted from EEG. Classification parameters of classifier based on non linear features were calculated.

This study evaluates the impact of a free antiretroviral therapy (ART) programme on the employment status of people living with HIV/AIDS. Patients on ART were interviewed regarding the employment status before and after ten months of enrollment into therapy. We included patients who were started on the free ART program of Kerala state at the Medical College, Thrissur. We documented the demographic details, indication for starting ART, disease status, WHO staging and CD4 count (whenever available) and the job status at the time of enrollment into the study. We collected data about the patient's job status at the end of ten months of ART. We excluded patients below 20 years of age, those who died during the study period and those lost for follow-up before the end of ten months from the analysis. We looked at factors associated with having employment at the end of ten months of ART using logistic regression. At the end of ten months of therapy the employment status improved significantly (p0.01) to 74% (77 patients). We found that 96.4% of those previously employed are at present employed, while 65.8% of those previously unemployed are employed at present. A history of previous employment (p=0.014) was associated with acquisition of employment; sex, duration on ART, stage of disease or age does not significantly influence the present employment status. This study suggests that the provision of free ART by the state can significantly improve the employment status of PLWHA.

Background: Parkinson disease (PD) generally requires therapy for prolonged periods often with multiple drugs; drug-related adverse effects often add to the existing morbidity. Although, such ADRs are common, comprehensive information about their incidence, severity, and ultimate health effects are not available. The objective of the study was to analyze the pattern of occurrence of Adverse Drug Reactions (ADRs) in patients receiving anti-parkinson agents (APA) in a tertiary care hospital. We also aimed to assess the causality, severity and preventability of these ADRs. Methods: This prospective, observational study with 6 month follow up was conducted among consecutive PD patients receiving anti parkinson agents attending the Movement disorder clinic of Neurology department between April 1 st 2011 and September 30 th 2012. Tools used were ADR Reporting form of National Pharmacovigilance centre, WHO causality scale, Hartwig and Siegel scale to assess severity and Schumock and Thornton scale to assess preventability of ADRs. Descriptive statistics was used and the values were expressed in numbers and percentages. Results: ADRs were experienced in 87 patients (82.1%) out of 106 patients and most of these patients were on combination therapy (66%). No gender difference in distribution of ADRs was observed. The most common reactions were sedation, dizziness, dry mouth and fatigue. The drug usage was in the order of pramipexole (58.4%), levodopa+carbidopa (55.7%), trihexyphenidyl (28.3%), entacapone (5.7%) and amantadine (7.5%). Majority of the ADRs were mild level 1 (71.1%). ADR was maximum with entacapone. Majority of ADRs belonged to the causality possible ADR category. All the ADRs came under the definitely or probably preventable category. Conclusions: ADRs with antiparkinsonian drugs is common but mild and preventable.

Epilepsy, a chronic brain disorder characterized by recurrent unprovoked seizures, affects people of all ages. Epilepsy affects every sphere of the individual's life, cutting across age, gender and social differences. Major areas of education, employment, marriage, child rearing and social functioning are often affected and the overall quality of life is hampered due to the uncertain nature of the illness and its consequences1. The aim of the study is to identify the social problems and self esteem of patients with seizure disorders and to compare the social problems and self esteem of male and female patients with seizure disorders.

The Revised National Tuberculosis Control Programme (RNTCP), the State-run Tuberculosis Control Initiative of the Government of India, recommends intermittent thrice a week Directly Observed Treatment Short course (DOTS) both during intensive phase and continuation phase for a total of nine months for tubercular meningitis. However, most recent guidelines recommend daily regimen.Assessment of the in-hospital mortality in patients with meningeal tuberculosis.We retrospectively analyzed the data of patients (n = 98) admitted with a diagnosis of meningeal tuberculosis from January 1st 2006 to December 31st 2009 in a tertiary care centre in South India. Thwaites index score of four or less was used for diagnosis of meningeal tuberculosis which is a weighted diagnostic index score for dichotomised clinical variables including age, blood white cell count, duration of illness, CSF total white cell count, and CSF neutrophil percentage. We compared in-hospital treatment outcome of patients on thrice weekly intermittent DOTS regimen with daily regimen patients.The inhospital mortality was same (27%) in the two treatment regimens (p 0.944). However, there was less incidence of hepatic dysfunction in the intermittent DOTS regimen, even though it was not statistically significant (p 0.148).In the short-term, both regimens have similar mortality outcomes and no statistically significant difference in hepatic dysfunction during the hospital stay.

The objective of this work was to develop a serum-free medium that supported the growth of secondary Syrian hamster embryo (SHE) cells suitable for use in the morphological transformation assay (MTA). The current assay employs high levels of fetal bovine serum, each lot of which must be selected for its efficacy in the assay. To circumvent the problems associated with the use of serum, two serum-free media (CGM-4 and CGM-9) were developed. The approach used was to replace serum with more defined hormones and growth factors. DME/F12 with low NaHCO3 (pH 6.7) was chosen as a basal nutrient medium since this pH has been reported to give enhanced transformation. Both serum-free media supported the clonal high density growth of normal secondary SHE cells. These media were also found to support the growth of several established SHE cell lines exhibiting successive stages of neoplastic progression. However, significant differential responses of the individual cell lines to CGM-4 and CGM-9 were observed, whereas, in serum-supplemented medium all three lines responded similarly. These results raise the hope that CGM-4 and CGM-9 will be useful for studies of altered autocrine function during transformation and progression as well as for use in the transformation assay itself.

Background The role of variables like duration of diabetes, diabetic control and microvascular complications in the causation of cognitive decline in patients with type 2 diabetes is not well studied. The contribution of hypertension to the cognitive decline in nondemented diabetic patients is unclear. Aims: We wanted to see if cognition in patients with type 2 diabetes is associated with the duration of diabetes, control of diabetes, complications of diabetes, vascular risk factors, or depression. We also looked at association of noncompliance with cognition, and depression. Settings and Design: We recruited ambulant patients with type 2 diabetes who are 55 years or more in age from the weekly diabetic clinic. We excluded patients with past history of stroke. Methods and Material: We selected the time taken for the Trial A test, delayed recall on ten-word list from Consortium to Establish a Registry for Alzheimer's Disease (CERAD), Rowland Universal Dementia Assessment Scale (RUDAS) and Centre for Epidemiologic Studies Depression scale (CES-D) screening instrument to assess these patients. Statistical Analysis Used: We utilized mean, standard deviation, Chi-square test and Pearson's correlation for statistical analysis. We considered P < 0.05 to be significant. Results: RUDAS scores inversely correlated (r = −0.360) with CES-D scores (P = 0.002). Scores of the screening instrument for depression, the CES-D was associated with the duration of diabetes mellitus (P = 0.018), fasting blood glucose (P = 0.029) as well as with 2-hour post prandial blood glucose (P = 0.017). Conclusions: There is correlation between depression and global cognitive score. Depression seems to be associated with duration of diabetes and control of diabetes.

A high prevalence of epilepsy in children is frequently found in developing countries. Though high rates of acquired brain injury may contribute, the possibility that malnutrition may lower seizure threshold has rarely been examined. This review suggests potential biochemical mechanisms that could adversely affect seizure threshold, particularly the effect of malnutrition on inhibitory neurotransmitters and electrolytes. Supporting evidence from animal research and epidemiological findings in children are discussed.

Syndromic forms of cortical maldevelopment continue to be a curiosity. Hypomelanosis of Ito (HI) is the presence of whirled hypochromic skin lesions often associated with nondermatological manifestations. The polymorphism of brain abnormalities associated with HI is well known. We report three cases of Hypomelanosis of Ito, occuring in infants, and associated with cerebral malformation.