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Encephalopathy and encephalitis are major and devastating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus-associated central nervous system complications. Hypoxic/metabolic changes produced by intense inflammatory response against the virus triggers cytokine storm and subsequently acute respiratory distress syndrome and multiple organ failure. Hypoxic/metabolic changes result in encephalopathy. The presence of comorbidities predisposes to hypoxic/metabolic changes responsible for encephalopathy. Altered consciousness, ranging from mild confusion, delirium, to deep coma, is hallmark clinical features. Cortical and subcortical T2/FLAIR signal changes are common neuroimaging abnormalities. In a few isolated case reports of SARS-CoV-2 encephalitis, the virus has been demonstrated in cerebrospinal fluid. The presence of anosmia and ageusia can help in differentiation from other encephalopathies. We analyzed published reports on coronavirus disease 2019-associated encephalopathy. Encephalopathy is common in older patients, the majority are more than 50 years of age. The patients having encephalopathy/encephalitis are either severely or critically ill. Many patients were already on mechanical ventilation. Lung abnormalities are noted in almost all of the patients, presenting with encephalopathy. Encephalopathy is always preceded by commoner clinical features, like, fever, cough, dyspnoea, and headache. In majority, patients are already in the intensive care unit, when encephalopathy develops., (© 2020 Wiley Periodicals LLC.)

COVID-19 is associated with rarer extra-parenchymal manifestations, namely pneumothorax (PTX) and pneumomediastinum (PM) leading to complications and increased mortality. The study aims to describe the prevalence, risk factors for mortality, radiological characteristics and outcome of PTX/PM in patients admitted with COVID-19. This was a retrospective, single-centre, observational study in patients with confirmed COVID-19 presenting with non-iatrogenic PTX/PM from April 2020 to May 2021. Details pertaining to demographics, presentation, radiological characteristics, management and outcome were collected. Cases were classified into spontaneous and barotraumatic PTX/PM and a between-group comparison was performed using Chi-square and t-test. A total of 45 cases (mean age: 53.2 years, 82% males) out of 8,294 confirmed COVID-19 patients developed PTX/PM, the calculated incidence being 0.54%. 29 cases had spontaneous PTX/PM and the remaining 17 cases were attributed to barotrauma. The most common comorbidities were diabetes-mellitus (65.3%) and hypertension (42.3%). The majority of the cases had large PTX (62.1%) with tension in 8 cases (27.5%). There were predominant right-sided pneumothoraces and five were diagnosed with bronchopleural fistula. 37.7% of cases had associated subcutaneous emphysema. The median duration of PTX/PM from symptom onset was delayed at 22.5 and 17.6 days respectively. The mean CT severity score (CTSS) was 20.5 (± 4.9) with fibrosis (53.8%), bronchiectatic changes (50%) and cystic-cavitary changes (23%). There was no statistically significant difference between the spontaneous and barotrauma cohort. 71% of cases died and the majority belonged to the barotrauma cohort. It is imperative to consider the possibility of PTX/PM in patients having COVID-19, especially in those with deterioration in the disease course, both in spontaneously breathing and mechanically ventilated patients. These patients may also have a high incidence of death, reflecting the gravity of COVID-19.

Background: Ongoing pandemic because of COVID-19 has spread across countries, with varied clinical features and severity. Awareness of clinical course among asymptomatic and symptomatology in symptomatic cases is essential for patients' management as well as optimal utilization of health services (in resource limited settings) based on clinical status and risk factors. This study aimed to describe the clinical characteristics and outcomes of patients admitted with COVID-19 illness in the initial phase of the pandemic in India., Methods: It was an observational study. Patients aged 18 years or more, with confirmed SARS-CoV-2 infection, asymptomatic or mildly ill, were included. Patients with moderate-severe disease at admission or incomplete clinical symptomatology records were excluded. Data regarding demography, comorbidities, clinical features and course, treatment, results of SARS-CoV-2 RT-PCR, chest radiographs, and laboratory parameters were obtained retrospectively from hospital records. The outcome was noted in terms of course, patients discharged, still admitted (at the time of the study), or death., Results: Out of 231 cases, most were males (78.3%) with a mean age of 39.8 years. Comorbidities were present in 21.2% of patients, diabetes mellitus and hypertension being the most common. The most common symptoms were dry cough (81, 35%), fever (64, 27.7%), sore throat (36, 15.6%); asymptomatic infection noted in 108 (46.8%) patients. The presence of comorbidities was an independent predictor of symptomatic disease (OR-2.66; 95%CI 1.08-6.53, P = 0·03). None of the patients progressed to moderate-severe COVID-19, and there were no deaths., Conclusions: A large proportion of patients remained asymptomatic whereas those with comorbidities were more likely to be symptomatic. Most with mild disease had a stable disease course, barring few complication in those with comorbidities. The pandemic continues to grow as large number of asymptomatic cases may go undiagnosed., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Family Medicine and Primary Care.)

Background: Nearly one-third of patients don't achieve seizure control with existing antiepileptic drugs. Brivaracetam (BRV) is a new member of the racetam class of drug, designed to selectively target SV2A, with binding affinity 15- to 30-fold greater than that of levetiracetam., Objective: This pooled analysis reports efficacy and tolerability data of adjunct BRV (50, 100, and 200 mg/day) compared with placebo in Indian patients with uncontrolled focal epilepsy., Methods: Data of 104 patients (aged 16-80 years) from 2 studies (N01252 and N01358) were pooled for this analysis. The studies comprised an 8-week prospective baseline period, and a 12-week treatment period. The study endpoints included median percent reduction from baseline in focal seizure frequency/28-days, ≥50% responder rate, and seizure freedom (all seizure types). The safety analysis included treatment-emergent adverse events (TEAEs)., Results: The efficacy population comprised 101 patients. In the Indian sub-group population, median percent reduction from baseline in focal seizure frequency/28-days was greater in the BRV dose groups: 39.7% (p = 0.00868), 46.8% (p = 0.00180) and 48.2% (p = 0.05224), for BRV 50, 100, 200 mg/day, respectively, compared with 20.6% for placebo. Responder rates (≥50%) were 38.1%, 45.7%, and 45.5% for BRV 50, 100, and 200 mg/day, respectively, compared with 11.7% for placebo. Complete seizure freedom was reported by 4.8% (1/21) and 2.9% (1/35) of patients on BRV50 and 100 mg/day, respectively, and none out of the 11 and 34 patients on BRV200 mg/day and placebo, respectively. In the safety population (n = 104), most commonly reported TEAEs (reported by ≥5% of patients taking brivaracetam) were headache and cough; most TEAEs were mild or moderate in intensity., Conclusion: This pooled analysis has provided evidence that adjunct brivaracetam, was effective and well-tolerated in Indian patients with uncontrolled focal epilepsy., Competing Interests: None

Competing Interests: None

Competing Interests: None

Background: Several studies have shown many risk factors associated with disease onset, but the sialic acid association with oxidative stress biomarkers may a key factor in the pathogenesis of Alzheimer's disease (AD). We aim to find out the most specific biomarker from the peripheral blood samples in moderate to severe Alzheimer's patients., Methods: This study examined the level of sialic acid associated with oxidative stress biomarkers and total antioxidant capacity level (TAC) in the plasma samples. Different parameters of Oxidative stress and Total antioxidant capacity by the immunoassay method have been examined in AD patients as compared to controls. The Catalase (CAT), Superoxide dismutase (SOD), Lipid peroxidation (LPO), Glutathione peroxidase (GPx), Total Glutathione (GSH), and Protein carbonyl group levels were estimated in this study., Results: Increased level of sialic acid is found associated with a higher level of reactive oxygen species parameters in the patients. The antioxidant parameter levels have been found significantly lower in AD, while Protein carbonyl group and lipid peroxidation were increased in cases as compared to controls with the area under the curve (AUC) 0.816, p < 0.0001 and 0.754, p < 0.0001. The Protein carbonyl group, Total antioxidant capacity (TAC), and Sigma-Aldrich TAC levels were higher in females as compared to males in AD patients., Conclusion: During AD pathology, sialic acid, protein carbonyl, and lipid peroxidation were found as the more sensitive marker that may be used as a diagnostic and prognostic biomarker., (Copyright © 2020 Elsevier Inc. All rights reserved.)

COVID-19 is caused by the coronavirus SARS-CoV-2 that has an affinity for neural tissue. There are reports of encephalitis, encephalopathy, cranial neuropathy, Guillain-Barrè syndrome, and myositis/rhabdomyolysis in patients with COVID-19. In this review, we focused on the neuromuscular manifestations of SARS-CoV-2 infection. We analyzed all published reports on SARS-CoV-2-related peripheral nerve, neuromuscular junction, muscle, and cranial nerve disorders. Olfactory and gustatory dysfunction is now accepted as an early manifestation of COVID-19 infection. Inflammation, edema, and axonal damage of olfactory bulb have been shown in autopsy of patients who died of COVID-19. Olfactory pathway is suggested as a portal of entry of SARS-CoV-2 in the brain. Similar to involvement of olfactory bulb, isolated oculomotor, trochlear and facial nerve has been described. Increasing reports Guillain-Barrè syndrome secondary to COVID-19 are being published. Unlike typical GBS, most of COVID-19-related GBS were elderly, had concomitant pneumonia or ARDS, more prevalent demyelinating neuropathy, and relatively poor outcome. Myalgia is described among the common symptoms of COVID-19 after fever, cough, and sore throat. Duration of myalgia may be related to the severity of COVID-19 disease. Few patients had muscle weakness and elevated creatine kinase along with elevated levels of acute-phase reactants. All these patients with myositis/rhabdomyolysis had severe respiratory complications related to COVID-19. A handful of patients with myasthenia gravis showed exacerbation of their disease after acquiring COVID-19 disease. Most of these patients recovered with either intravenous immunoglobulins or steroids.

In the recent years there has been increasing trend towards the practice of on-table extubation after pediatric cardiac surgery among practitioner in European and non-European countries. In this article we share our experience with on-table extubation among children after cardiac surgery in the developing world supported with the currently available literature., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background/objective: Diffusion weighted imaging (DWI) lesions have been well described in patients with acute spontaneous intracerebral hemorrhage (sICH). However, there are limited data on the influence of these lesions on sICH functional outcomes. We conducted a prospective observational cohort study with blinded imaging and outcomes assessment to determine the influence of DWI lesions on long-term outcomes in patients with acute sICH. We hypothesized that DWI lesions are associated with worse modified Rankin Scale (mRS) at 3 months after hospital discharge., Methods: Consecutive sICH patients meeting study criteria were consented for an magnetic resonance imaging (MRI) scan of the brain and evaluated for remote DWI lesions by neuroradiologists blinded to the patients' hospital course. Blinded mRS outcomes were obtained at 3 months. Logistic regression was used to determine significant factors (p < 0.05) associated with worse functional outcomes defined as an mRS of 4-6. The generalized estimating equation (GEE) approach was used to investigate the effect of DWI lesions on dichotomized mRS (0-3 vs 4-6) longitudinally., Results: DWI lesions were found in 60 of 121 patients (49.6%). The presence of a DWI lesion was associated with increased odds for an mRS of 4-6 at 3 months (OR 5.987, 95% CI 1.409-25.435, p = 0.015) in logistic regression. Using the GEE model, patients with a DWI lesion were less likely to recover over time between 14 days/discharge and 3 months (p = 0.005)., Conclusions: DWI lesions are common in primary sICH, occurring in almost half of our cohort. Our data suggest that DWI lesions are associated with worse mRS at 3 months in good grade sICH and are predictive of impaired recovery after hospital discharge. Further research into the pathophysiologic mechanisms underlying DWI lesions may lead to novel treatment options that may improve outcomes associated with this devastating disease.

The common causes of mediastinal widening are lymphadenopathy, pericardial effusion, paravertebral abscess, and aortic aneurysm. We present a patient with spinal tuberculosis, paravertebral abscess, and plural effusion that led to mediastinal widening. In this patient, Chest X-ray was deceptive., Competing Interests: None

Competing Interests: None

Objective: Airway obstruction after postoperative extubation is a dreaded but uncommon complication in patients undergoing circumferential cervical spine surgery (CCSS). The cuff leak test (CLT) has been utilized to assess air leak around the endotracheal tube which may reflect airway swelling. In this prospective observational study, we analyze the temporal evolution of CLT and perioperative factors that may influence it., Methods: Twenty patients undergoing single-stage CCSS were managed according to our extubation protocol. Patients were maintained intubated overnight following surgery. They were extubated if a CLT > 200 mL and both intensive care unit (ICU) and Neurosurgery teams agreed that it was safe. Patients extubated in the first postoperative day (8 of 20) comprised the early group, and the remaining patients (12 of 20) the delayed group. Patient and operative data were analyzed as a single group and comparing both groups., Results: The main indication for surgery was cervical deformity. Median number of levels fused was 5 anteriorly (range, 1-6) and 6 (range, 1-13) posteriorly. Patients were kept intubated for an average of 73.6 hours (range, 26-222 hours) and stayed in the ICU for 119.1 hours (range, 36-360 hours). There were 4 failed extubations and 3 patients (15%) required a tracheostomy. Patient profiles between both groups were very similar across most patient variables but differed significantly regarding infraglottic luminal area (p < 0.05). Patients with larger preoperative cuff leak values tended to have a shorter intubation period (p = 0.053)., Conclusion: This study objectively demonstrates the difficulties in airway management following CCSS and provides useful insight for preoperative planning and counseling. Local anatomic factors influence airway outcome more than operative factors. The study format does not allow for testing of interventions but we suggest that patients with favorable anatomy (larger infraglottic luminal area) may benefit from a less strict airway management protocol.

Background: Tuberculous meningitis is commonly associated with a poor outcome. Simple bedside prognostic scores can help immensely in predicting the outcome., Materials and Method: A total of 721 patients, from 5 of our previous studies, were included. With primary outcome measure as death, a prognostic model was derived using binary logistic regression. The model was assessed using discrimination and calibration, and internally validated using the bootstrap method. A bedside prognostic score was derived by rounding of the regression coefficients to the nearest integers., Results: A total of 126 (17.48%) patients died. The final model found that higher age, stage III disease, baseline MBI ≤ 12, papilledema and hydrocephalus were significant predictors of death. The final model showed good discrimination as evident by an AUC = 83.1% (95% confidence interval 79.5%-86.7%, P < .001) and good calibration (Hosmer and Lemeshow test P = .579). The model remained valid after internal validation by boot strapping. A simple bedside score with the acronym MASH-P to denote variables baseline MBI (M), age (A), stage (S), hydrocephalus (H) and papilledema (P), was thus derived. The score can range from 0 to 10. Higher the score, higher is the probability of death; a score of 0 carries a predicted probability of just 1.7% while a score of 10 corresponds to a predicted probability of 65%. An electronic ready reckoner has also been developed to aid prognostication on the go., Conclusion: MASH-P is a simple prognostic scoring model that can be used at bedside and aid in decision making as well as counselling., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The present work illustrates the promising intervention of smart diagnostics devices through artificial intelligence (AI) and mechanobiological approaches in health care practices. The artificial intelligence and mechanobiological approaches in diagnostics widen the scope for point of care techniques for the timely revealing of diseases by understanding the biomechanical properties of the tissue of interest. Smart diagnostic device senses the physical parameters due to change in mechanical, biological, and luidic properties of the cells and to control these changes, supply the necessary drugs immediately using AI techniques. The latest techniques like sweat diagnostics to measure the overall health, Photoplethysmography (PPG) for real-time monitoring of pulse waveform by capturing the reflected signal due to blood pulsation), Micro-electromechanical systems (MEMS) and Nano-electromechanical systems (NEMS) smart devices to detect disease at its early stage, lab-on-chip and organ-on-chip technologies, Ambulatory Circadian Monitoring device (ACM), a wrist-worn device for Parkinson's disease have been discussed. The recent and futuristic smart diagnostics tool/techniques like emotion recognition by applying machine learning algorithms, atomic force microscopy that measures the fibrinogen and erythrocytes binding force, smartphone-based retinal image analyser system, image-based computational modeling for various neurological disorders, cardiovascular diseases, tuberculosis, predicting and preventing of Zika virus, optimal drugs and doses for HIV using AI, etc. have been reviewed. The objective of this review is to examine smart diagnostics devices based on artificial intelligence and mechanobiological approaches, with their medical applications in healthcare. This review determines that smart diagnostics devices have potential applications in healthcare, but more research work will be essential for prospective accomplishments of this technology., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© King Abdulaziz City for Science and Technology 2020.)

Introduction: Tuberculous meningitis (TBM) is the most severe form of tuberculosis. As reported in various studies, stroke is common among patients with TBM, with a prevalence of 17-54%. The present study assessed platelet dysfunction and coagulation abnormality in patients with TBM., Methods: This was a prospective observational study that included 123 consecutive patients with TBM. In addition to clinical and radiological parameters, the complete platelet function and coagulation function were studied. The patients were followed up to 6 months., Results: A significant correlation between platelet abnormality and stroke in patients with TBM was reported in this study. Results of the univariate analysis revealed that haematological parameters such as mean platelet volume (MPV) (p < 0.001), platelet distribution width (PDW)(p < 0.001), platelet-large cell ratio (P-LCR) (p < 0.001), and platelet aggregometry (PAg) (p < 0.001) were significantly associated with infarct. However, other haematological parameters such as bleeding time (p = 0.712), clotting time (p = 0.362), activated partial thromboplastin time (p = 0.094), INR (p = 0.420), protein C (p = 0.988), and protein S (p = 0.579) were not significantly associated with infarct. During follow-up at 3 and 6 months, parameters such as MPV (p < 0.001), PDW (p < 0.001), and P-LCR (p < 0.001) were significantly associated with infarct., Conclusion: The present study concluded that platelet abnormalities in patients with TBM contribute to infarct and are associated with poor clinical outcomes. This study suggested the role of antiplatelet agents in preventing stroke in patients with TBM.

Objective: Disseminated tuberculosis is characterized with involvement of two or more non-contiguous sites. In this work we evaluated patients of tuberculous meningitis for possible extra-central nervous system tuberculosis., Method: This prospective observational study was performed at a tertiary care institute in Northern India. We included consecutive HIV-uninfected cases of TBM. Patients were evaluated for extra-central nervous system (CNS) tuberculosis. We focussed on peripheral lymph nodes, chest, abdomen, and spinal involvement. All patients were subjected to MRI brain and spine. Patients were also subjected to CT thorax and abdomen. Enlarged lymph nodes, if present, were biopsied. Ascitic and pleural fluid were subjected to biochemical, cellular analysis as well as cartridge-based nucleic acid amplification test (CBNAAT) for detection of Mycobacterium tuberculosis and rifampicin resistance., Results: We enrolled 110 patients of TBM. After cerebrospinal fluid examination alone, 14 (12.7%) patients had microbiologically-confirmed TBM. After planned work-up for extra CNS tuberculosis, 5 additional cases were microbiologically confirmed. Similarly, before work-up for extra CNS tuberculosis, 29 (26.4%) patients were categorized as probable TBM. The number of probable cases increased to 72 (65.5%) (P<0.001) with identification of tuberculosis elsewhere. Lung (83.6%) was the most involved site. Abdominal tuberculosis was noted in 29 (26.4%) patients. On imaging spine, 17 (15.5%) patients demonstrated presence of spinal tuberculous. Lymph adenopathy recorded in 2 cases. Lymph node biopsy revealed tuberculous granuloma in both the cases. All 7 patients, who died, had disseminated tuberculosis., Conclusion: Extra CNS tuberculous involvement is common in TBM. Search for extra CNS tuberculous enables upgrading diagnostic accuracy., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

For more than the last two decades, there has been research going on to develop advanced energy technologies involving minimum environmental pollution, to replace the conventional fossil energy systems. Solid oxide fuel cells (SOFCs) are one of the most promising, eco-friendly and efficient means for the generation of electricity to meet the future energy requirements. This research work focuses on the parametric sensitivity analysis for natural gas fueled high temperature tubular SOFC. Firstly, for the tubular SOFC, a one-dimensional radially symmetrical model has been developed and solved using the finite-difference method. Then, the effect of the variation of important operational and design parameters on its performance has been analyzed. The parameters typically include composition, inlet fuel temperature, pressure, length of SOFC tube and thicknesses of its components. The composition is expressed as steam to methane ratio and it has been observed that the voltage and power density developed by the SOFC diminishes as the ratio increases. Further, a change in the inlet fuel pressure of the tubular SOFC has no pronounced influence on the voltage and power density developed. On the other hand, with an increase in the inlet fuel temperature, a small improvement in these performance characteristics is exhibited. The axial length of the tubular SOFC does conspicuously influence its performance characteristics but solely at current densities greater than 4000A/m 2 . An increase in the thickness of its components results in a reduction in its voltage and power density developed. The largest decline in these performance characteristics with the increase in thickness is observed for electrolyte followed by cathode and anode respectively., (© 2020 Published by Elsevier Ltd.)

A subset of neuritic form of leprosy, called pure neuritic leprosy (PNL), seen in a minority of leprosy patients, is characterized by peripheral neuropathy without skin lesions and an absence of acid-fast bacilli on skin smears. Patients with PNL are often started on drug therapy without confirmation of diagnosis. We, therefore, did a prospective study of clinically diagnosed PNL patients with correlation of ultrasonographic and biopsy findings. A total of 100 consecutive patients with PNL, diagnosed according to the consensus case definition, were included in the study. All patients underwent nerve conduction study, peripheral nerve ultrasonography, and sural nerve biopsy. Multiple mononeuropathies were present in 75% of cases, mononeuropathy in 18%, and polyneuropathy in the remaining 7%. Compared to clinical examination, ultrasonographic assessment of the peripheral nerves was not only better at the detection of thickening but also helped in characterization of their fascicular architecture, echogenicity, and vascularity. A total of 32 cases were confirmed on nerve biopsy, out of which 75% had demonstrable lepra bacilli. Cranial nerve involvement, presence of trophic ulcers, and bilateral thickening of the great auricular nerve were significantly associated with the positivity of lepra bacilli. A significant improvement in the disability score happened after multidrug therapy. A comprehensive electrophysiologic, ultrasonographic, and histological evaluation may be helpful in establishing a diagnosis of PNL with greater confidence, while ruling out other non-leprosy diagnoses., (© 2020 Peripheral Nerve Society.)

Background: Neurological presentation with isolated multiple cranial nerve palsies is common and its diverse causes include infectious, neoplastic, and inflammatory pathologies. The aetiological spectrum may depend upon geographical regions. We undertook this study to explore clinical spectrum and aetiological profile of multiple cranial nerve palsies., Methods: This hospital-based prospective observational study was conducted from August 2015 to August 2017. All the consecutive patients of multiple cranial palsies presenting to the neurology department were included in the studies. Primary objectives were to define anatomical syndromes/cranial nerve combinations and to establish aetiology. Secondary objectives were to study associated factors. The multiple cranial nerve palsy was defined as involvement of two or more non-homologous nerves. Patients of neuromuscular junction disorders, anterior horn cell disorders, myopathies, brain stem syndromes were excluded. All patients underwent structured protocol of clinical evaluation, investigations and few specialized investigations in accordance with clinical suspicion to establish the diagnosis., Results: Fifty-four patients with a mean age of 39.9 ± 14.2 years were included. Commonest cranial nerve involved was the abducens (75.9%) among all nerve combinations. The cavernous sinus syndrome (37%), orbital apex syndrome (22.2%) and jugular foramen syndrome (11.1%) were the most frequent anatomical patterns. Infections (40.7%) were the commonest aetiology followed by neoplastic and idiopathic in four patients., Conclusion: Cavernous sinus syndrome was the commonest anatomical syndrome of multiple cranial nerve palsies and infections were the commonest cause in this study., Competing Interests: None

COVID-19, in most patients, presents with mild flu-like illness. Elderly patients with comorbidities, like hypertension, diabetes, or lung and cardiac disease, are more likely to have severe disease and deaths. Neurological complications are frequently reported in severely or critically ill patients with comorbidities. In COVID-19, both central and peripheral nervous systems can be affected. The SARS-CoV-2 virus causes the disease COVID-19 and has the potential to invade the brain. The SARS-CoV-2 virus enters the brain either via a hematogenous route or olfactory system. Angiotensin-converting enzyme two receptors, present on endothelial cells of cerebral vessels, are a possible viral entry point. The most severe neurological manifestations, altered sensorium (agitation, delirium, and coma), are because of hypoxic and metabolic abnormalities. Characteristic cytokine storm incites severe metabolic changes and multiple organ failure. Profound coagulopathies may manifest with ischemic or hemorrhagic stroke. Rarely, SARS-CoV-2 virus encephalitis or pictures like acute disseminated encephalomyelitis or acute necrotizing encephalopathy have been reported. Nonspecific headache is a commonly experienced neurological symptom. A new type of headache "personal protection equipment-related headache" has been described. Complete or partial anosmia and ageusia are common peripheral nervous system manifestations. Recently, many cases of Guillain-Barré syndrome in COVID-19 patients have been observed, and a postinfectious immune-mediated inflammatory process was held responsible for this. Guillain-Barré syndrome does respond to intravenous immunoglobulin. Myalgia/fatigue is also common, and elevated creatine kinase levels indicate muscle injury. Most of the reports about neurological complications are currently from China. COVID-19 pandemic is spreading to other parts of the world; the spectrum of neurological complications is likely to widen further., Competing Interests: None

A 70-year old female presented with complaints of fever with chills, headache for 15 days and altered sensorium for 7 days. Peripheral blood smear showed ring form of P. falciparum and CT brain revealed bilateral subdural hematoma. Patient received Artesunate based combination therapy and recovered completely without surgical intervention within 8 days of admission., (© Journal of the Association of Physicians of India 2011.)

Background: The management of disseminated cysticercosis is unclear and largely considered hazardous. The role of albendazole remains controversial in such patients., Methods: A tertiary care, University hospital-based prospective intervention study was conducted from December 2015 to December 2017. Patients with disseminated cysticercosis, defined as the presence of multiple viable neurocysticerci (≥ 3) in the brain along with involvement of an additional extra site, were included in the study. Patients with cysticercal encephalitis were excluded. A detailed evaluation, including ophthalmoscopy, ocular B scans, ultrasound abdomen, and X-rays were done. Albendazole was administered at a dose of 15 mg/kg/day in 3 cycles of 28 days each. All patients were also given adjuvant corticosteroids and anti-epileptic drugs. Clinical and radiological follow up was carried out at a difference of 3 months between each treatment cycle. For radiological quantification, lesions were counted at 10 pre-specified levels. Statistical analysis was done to estimate the difference in seizure frequency and lesion load., Results: Twenty-nine patients (21 with > 20 lesions; 8 with ≤ 20 lesions) were given albendazole as per the protocol. There was a significant reduction in the occurrence of seizures (P < 0.001) and headache (P < 0.001). A significant reduction in lesion load from baseline to third follow-up was seen in the estimations done at different levels (P < 0.001). No patient developed serious side-effect warranting cessation of therapy., Conclusion: Cyclical use of albendazole appears efficacious in treating disseminated cysticercosis. The method of quantification described may be used in future studies for objective assessment., Trial Registration: ISRCTN11630542; 28th September 2019; Retrospectively registered.

In posterior reversible encephalopathy syndrome, brain magnetic resonance imaging (MRI) reveals bilateral occipital, parietal, and subcortical white matter hyperintensities on T2/fluid-attenuated inversion recovery (FLAIR) sequences. After treatment, imaging abnormalities are usually reversible. Eclampsia is the most frequent cause of posterior reversible encephalopathy syndrome in pregnancy. We report a 24-year-old woman, who presented to our clinic 4 weeks after normal vaginal delivery with bilateral vision loss. Loss of vision was first noticed in the 20th week of pregnancy. Even after delivery, her vision did not improve. In the postpartum period, she started having periodic myoclonic jerks. Electroencephalography demonstrated periodic generalized discharges. A brain MRI performed in the 20th week of the antepartum period showed bilateral parieto-occipital cortical white matter T2/FLAIR hyperintensities. A follow-up brain MRI, 5 months later, revealed marked reversal of white matter signal changes. Cerebrospinal fluid examination revealed raised anti-measles antibody titer, confirming the diagnosis of subacute sclerosing panencephalitis. In conclusion, in a patient with subacute sclerosing panencephalitis (SSPE) during the postpartum period, cortical vision loss and parieto-occipital white matter T2/FLAIR hyperintensities can simulate eclampsia. Inadvertent treatment with magnesium sulfate is likely if the diagnosis is missed.

Background: Guillain-Barré syndrome (GBS) is a monophasic disease characterized by acute polyradiculoneuropathy., Aim: This study investigated cardiovascular complications in patients with GBS and their relationship with outcomes., Design and Methods: We included 96 patients, who were diagnosed with GBS according to Brighton case definitions. All enrolled patients were evaluated according to a predetermined algorithm, which included nerve conduction studies, cerebrospinal fluid analysis, electrocardiography, 2D echo, cardiac markers and autonomic function testing., Results: We enrolled a total of 96 patients. The mean age of patients was 35.75 ± 17.66 years. Furthermore, 54.2% of patients developed cardiovascular complications, of which changes in electrocardiography (ECG) findings (50%), hypertension (28.12%), labile hypertension (12.5), tachycardia (26.04), bradycardia (13.54%) and a fluctuating heart rate (HR) (11.46) were common. Other cardiovascular complications seen in GBS patients were increased pro-BNP (26.04%), raised troponin T levels (3.12%), acute coronary syndrome (2.08%), heart failure (2.08%) and abnormal 2D echo findings (8.33%). The results of the univariate analysis revealed that a history of preceding infection, a Medical Research Council sum score, neck muscle weakness, facial nerve involvement, bulbar involvement, respiratory failure, cardiovascular complications, autonomic dysfunction, acute motor sensory axonal neuropathy subtype and baseline Hughes score were significantly (P < 0.005) associated with poor outcomes. However, none of these factors were found to be independently associated with poor outcomes in the multivariate analysis., Conclusion: A considerable number of patients with GBS developed cardiovascular complications and it needs attention., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: Antiretroviral therapy (ART) is considered the most effective way to prevent perinatal transmission of human immunodeficiency virus (HIV). However, there is little knowledge about the effect of ART on the brain of HIV uninfected children born to HIV infected mothers (HUC). The current study evaluated the brain's microstructural integrity, and cognitive function in HUC compared to healthy children born to normal mothers (CHNM) and HIV infected children born to HIV infected mothers (HIC) to investigate the effect of in-utero exposure of ART on cerebral gray and white matter., Materials and Methods: Forty nine HIC, 12 HUC and 18 CHNM underwent neuropsychological (NP) assessment and a brain MRI. Diffusion tensor imaging (DTI) data was used to generate fractional anisotropy (FA) and mean diffusivity (MD) maps. Voxel wise comparison for FA and MD was performed between three groups using an analysis of covariance (ANCOVA) including age and sex as covariates, and correction for multiple comparisons (false discovery rate (FDR), p ​< ​0.05 with minimum extended cluster size, 150 voxels). NP test scores were also compared between three groups using ANOVA with Post Hoc Bonferroni multiple comparison corrections (p ​< ​0.05). Significantly changed FA and MD values in different brain regions in HIC and HUC compared to CHNM were used for correlation analysis with NP test scores using Pearson's correlation., Results: HIC and HUC groups showed significantly decreased NP test scores in various domain compared to CHNM. Significantly lower NP test scores was observed in HIC than those of HUC. HIC showed decreased FA and increased MD in multiple brain sites as compared to both CHNM and HUC. Decreased FA along with both increased and decreased MD in different brain regions was present in HUC compared to CHNM. Both positive and negative correlation of altered FA and MD values from different brain regions in HIC and HUC with NP test scores was observed., Conclusion: The presence of brain tissue changes and neurocognitive function deficit in absence of HIV infection in HUC indicates that ART may have a detrimental impact on the developing brain. The findings of the current study underscore the need for screening of ART exposed children for neurodevelopment and cognitive abnormalities at an early stage and call for access to early interventions, and nutritional and care programs., Competing Interests: All the listed coauthors have no conflict of interest., (© 2020 The Authors.)

Introduction: A neurological consultation is needed in nearly 45% of patients suffering from cancer. The present study was planned to evaluate the clinical, radiological and histopathological spectrum of patients with an underlying malignancy and presenting with a neurological complaint., Materials and Methods: We prospectively evaluated all patients provisionally diagnosed either with a primary or secondary malignancy of the brain on the basis of clinical, radiological and/or histopathological features., Results: A total of 155 patients were enrolled from a total of 4893 admissions done from January 2015 to July 2016. The common presenting symptoms were headache, back pain and paraparesis. Around 26% of patients presented with an altered sensorium, 19.4% with seizures and 21% had at least one cranial nerve involvement. The most common site of involvement was the brain noted in 49.7% of patients. Primary malignancies constituted 78 cases (50.7%) while secondary malignancies included 77 cases (49.3%). Magnetic resonance imaging (MRI) revealed 92 (59.4%) intra-axial lesions and 59 (38.1%) extra-axial lesions, with five cases having both. The most common diagnoses were intra-cerebral metastases and glioblastoma (intra-axial), and vertebral metastases and meningioma (extra-axial). Histopathological confirmation was obtained in 59 patients (38.1%) with 12 primary and 47 secondary lesions. Ten (6.45%) patients had an unknown primary with secondary metastases. The three most common histopathologically confirmed diagnoses were adenocarcinoma lung, plasma cell dyscrasia and adenocarcinoma prostate., Conclusion: Primary neurological consultations with an unknown primary are common hence a high index of suspicion can prevent an inadvertent delay in the diagnosis and appropriate treatment of a malignant lesion. Developing a neuro-oncology register may help us in gaining more insight into such situations., Competing Interests: The authors declare that there are no financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work., (Copyright: © 2019 Journal of Family Medicine and Primary Care.)

Tuberculous meningitis (TBM) is a commonly encountered central nervous system infection. Characteristic clinical, imaging and cerebrospinal fluid parameters help clinicians to make a prompt presumptive diagnosis that enables them to start empirical anti-tuberculosis treatment. There are several close mimic to TBM, such as partially treated pyogenic meningitis, fungal meningitis, sarcoidosis, meningeal metastases and meningeal lymphomatosis. Microbiological confirmation instils a sense of confidence amongst treating physicians. With conventional phenotypic methods (cerebrospinal fluid microscopy and culture), in more than 50 per cent patients, microbiological confirmation is not achieved. Moreover, these methods take a long time before providing conclusive results. Negative result does not rule out Mycobacterium tuberculosis infection of the brain. Genotypic methods, such as IS 6110 polymerase chain reaction and automated Xpert M. tuberculosis/rifampicin (MTB/RIF) assay system improved the TBM diagnostics, as results are rapidly available. Xpert MTB/RIF assay, in addition, detects rifampicin resistance. Xpert MTB/RIF Ultra is advanced technology which has higher (60-70%) sensitivity and is being considered a game-changer in the diagnostics of TBM. A large number of TBM cases remain unconfirmed. The situation of TBM diagnostics will remain grim, if low-cost technologies are not widely available. Till then, physicians continue to rely on their clinical acumen to start empirical anti-tuberculosis treatment., Competing Interests: None

Competing Interests: None

Subacute sclerosing panencephalitis (SSPE) is a slowly progressive brain disorder caused by mutant measles virus. SSPE affects younger age groups. SSPE incidence is proportional to that of measles. High-income countries have seen substantial decline in SSPE incidence following universal vaccination against measles. SSPE virus differs from wild measles virus. Measles virus genome recovered from the autopsied brain tissues demonstrates clustered mutations in virus genome particularly in the M gene. These mutations destroy the structure and functioning of the encoded proteins. Complete infectious virus particle has rarely been recovered from the brain. Human neurons lack required receptor for entry of measles virus inside the neurons. Recent in vitro studies suggest that mutations in F protein confer hyperfusogenic properties to measles virus facilitating transneuronal viral spread. The inflammatory response in the brain leads to extensive tissue damage. Clinically, SSPE is characterized by florid panencephalitis. Clinically, SSPE is characterized by cognitive decline, periodic myoclonus, gait abnormalities, vision loss, and ultimately to a vegetative state. Chorioretinitis is a common ocular abnormality. Electroencephalography (EEG) shows characteristic periodic discharges. Neuroimaging demonstrates periventricular white matter signal abnormalities. In advanced stages, there is marked cerebral atrophy. Definitive diagnosis requires demonstration of elevated measles antibody titers in cerebrospinal fluid (CSF). Many drugs have been used to stabilize the course of the disease but without evidence from randomized clinical trials. Six percent of patients may experience prolonged spontaneous remission. Fusion inhibitor peptide may, in the future, be exploited to treat SSPE. A universal vaccination against measles is the only proven way to tackle this menace currently., (© 2019 John Wiley & Sons, Ltd.)

Most deaths in tuberculous meningitis occur in the early part of the illness. We assessed the determinants of early deaths, occurring within 2 months of intensive therapy. We prospectively included consecutive newly diagnosed adults with HIV-negative tuberculous meningitis. Patients were given WHO-recommended antituberculosis treatment and were followed up for 9 months. We enrolled 152 patients. A total of 26 deaths were recorded during 2 months. The logistic regression analysis revealed that papilledema ( P = 0.029, odds ratio (OR) = 4.8 [1.2-19.8]), increasing age ( P = 0.001, OR = 1.07 [1.03-1.1]), stage-III disease (Glasgow coma scale score ≤ 10; P = 0.01, OR = 4.2 [1.4-12.3]), and hydrocephalus ( P = 0.003, OR = 8.4 [2.1-33.6]) were independently associated with death. In addition, cerebral infarcts ( P = 0.012, OR = 5.6 [1.5-21.3]), paraparesis ( P = 0.004, OR = 8.8 [2.02-38.1]), and age ( P = 0.005, OR = 1.05 [1.02-1.09]) were associated with poor functional outcome. In conclusion, disease severity predicts early deaths in tuberculous meningitis.

Subacute sclerosing panencephalitis (SSPE) is still a common disease in India which is characterized by a progressive mental decline, myoclonus, periodic encephalographic abnormalities, and raised anti-measles antibody titter in the cerebrospinal fluid. Acute fulminant SSPE is characterized by a rapid course of disease culminating in death, within 6 months. We report of a 10-year-old boy, who came with a 14-day history of continuous involuntary jerky movements of the left half of the body, including the head. There was a highly increased anti-measles IgG antibody titer, both in the cerebrospinal fluid and serum. We conclude that acute rapidly progressive SSPE can present as acute encephalitis syndrome.

Background: Studies have shown that alterations in the sleep cycle can predispose to several disorders. Most of the previous studies were done on the adults. Hence, the aim of the study was to see the effect of circadian disruption on the health of adolescent population., Materials and Methods: In this cross-sectional study, 203 subjects were enrolled. Study subjects were divided into three groups: definite evening chronotype, intermediate chronotype, and definite morning chronotype. Sleep quality was measured by Pittsburgh Sleep Quality Index (PSQI). Daytime sleepiness and chronotype were measured by Epworth Sleepiness Score and Morningness-Eveningness Questionnaire Self-Assessment version, respectively. Two hours postprandial glucose was measured after oral glucose tolerance test. Fasting blood glucose and fasting insulin were measured. Homeostasis model of assessment for insulin resistance (HOMA-IR) was calculated. Data were summarized as mean ± standard deviation. Crude odds ratios and Karl Pearson's correlation coefficient of metabolic parameters with poor sleep were calculated., Results: Statistically significant difference was found in the mean value of poor sleep quality, 2 h postprandial blood glucose level, and insulin resistance among subjects of three groups. Subjects of evening chronotype have more significant positive correlation of 2 h postprandial blood glucose level and HOMA-IR value with poor sleep quality when compared with subjects of intermediate and morning chronotypes., Conclusion: Subjects with evening chronotype are more prone for development of metabolic syndrome compared with subjects of intermediate and morning chronotypes if proper health policies are not adopted for adolescents., Competing Interests: There are no conflicts of interest.

Objectives: Aspirin is a drug that has been found to be useful in reducing the incidence of infarctions. This systemic is aimed at review evaluating the benefits of aspirin in the management of tuberculous meningitis., Methods: A systematic literature search was performed using PubMed, Cochrane Central Register of Controlled Trials, and SCOPUS for articles published on or before September 22, 2018. The meta-register of controlled trials and bibliography was also searched. Randomized controlled trials wherein aspirin was used were included in the systematic review. The data was extracted using a predetermined format. The risk ratio (RR) for dichotomous data was calculated and a random-effects model was used to combine the data. Death and occurrence of new infarctions were considered as primary outcomes. The quality of evidence was assessed using the GRADE approach., Results: Four trials including 546 patients were found eligible. The addition of aspirin to anti-tuberculosis drug regimens did not significantly reduce mortality [RR = 0.66 (0.42-1.02); low-quality evidence] but significantly reduced the risk of new infarctions [RR = 0.52 (0.29-0.92); moderate-quality evidence]. Aspirin did not differ from the placebo with regard to the adverse event outcome., Conclusion: Aspirin reduces the risk of new infarctions in patients with tuberculous meningitis but does not affect mortality (moderate-to-low level of evidence)., Competing Interests: None

Background: Vision impairment, blindness in particular is a devastating complication in patients with tuberculous meningitis. However, information regarding ophthalmological manifestation and its impact on vision is sparse in the literature. This study evaluated the spectrum of ophthalmological manifestations in tuberculous meningitis, including retinal nerve fiber layer thickness assessment by optic coherence tomography and its correlation with visual and clinical outcome., Methods: This was a prospective observational study done from October 2015 to March 2017. Consecutive patients of tuberculous meningitis, diagnosed as per consensus case definition were included in the study. The patients were divided into two categories: uncomplicated and complicated tuberculous meningitis. Clinical evaluation, cerebrospinal fluid examination and contrast enhanced MRI of brain was done. Detailed ophthalmological evaluation including optic coherence tomography was done in all patients. All the patients were followed for 6 months. The primary outcome was blindness or low vision after 6 months. The secondary outcome was death or severe disability after 6 months. It was defined as modified Barthel index (MBI) ≤ 12 at 6 months (including disability plus death). Appropriate statistical analysis was done., Results: Out of 101 patients of tuberculous meningitis, 47 patients of TBM belonged to uncomplicated category, while 54 patients were of complicated group. The visual impairment was present in 24 out of 101 (23.76%) patients out of which 20 (19.8%) patients had low vision while 4 (3.96%) had blindness. The visual impairment was more evident in complicated group, low vision 0.03 (1.2-31.5). The most common abnormality on fundus examination was papilledema (22.8%). The complicated group had more incidence <0.0001 (19.6-48). Optic atrophy was found in three patients while choroid tubercles were found in eight patients (all complicated TBM group). RNFL thinning was noted in 10 patients in both the eyes. On univariate analysis, presence of diplopia at baseline, impairment of color vision at baseline, visual impairment at baseline, cranial nerve VIth involvement, optic atrophy and papilledema at baseline, RNFL thinning, abnormal VEP and baseline MBI were associated with poor visual outcome. On multivariate analysis, none of the factors were found to be independently associated with poor visual outcome. On univariate analysis, many factors including baseline MRC staging, altered sensorium, seizure, hemiparesis, basal exudates, infarcts, optochiasmaticarachnoiditis, visual impairment at baseline were found to be associated with poor clinical outcome at 6 months. On multivariate analysis, presence of seizure (P = 0.047, odds ratio = 78.59, 95% confidence interval (1.07-578.72)) was the only factor found to be independently associated with poor outcome., Conclusion: Wide spectrum of ophthalmological manifestation was observed in patients of tuberculous meningitis. The visual impairment was more evident in complicated tuberculous meningitis. Ophthalmological findings like optic atrophy, papilledema and RNFL thinning were associated with poor visual outcome on univariate but not multivariate analysis. Visual impairment at baseline, among other factors was associated with poor clinical outcome on univariate analysis, whereas seizure was the only factor independently associated with poor outcome on multivariate analysis., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Gall bladder cancer (GBC) is associated with abdominal pain, lump, nausea, vomiting, and jaundice due to either gall bladder mass or the involved adjacent peritoneal structures. Gall bladder cancer presenting as refractory epilepsy is rare. Here we report a young female GBC patient who presented with an atypical and refractory frontal lobe seizures as the first manifestation of gall bladder cancer., Case Presentation: A 46 years young female presented first time to the hospital with uncontrolled seizures and headache in 5 months duration. Seizures were very atypical in semiology with ptosis and mydriasis to either side along with ipsilateral ocular deviation. The episodes were bilateral but right eyelid ptosis, mydriasis and right horizontal conjugate deviation were frequent. MRI brain showed encephalomalacia in the left frontal region on axial T2 and coronal T1 weighted images without any enhancement on gadolinium contrast. CECT abdomen revealed a heterogeneously enhancing gall bladder mass with the evidence of lung metastasis from chest CT scan. CSF for malignant cytology was negative. Seizures were refractory to the treatment., Conclusion: Though CNS involvement is uncommon but it can be the only presentation in gall bladder cancer.

Competing Interests: There are no conflicts of interest