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Background: It is essential to identify the burden of poststroke cognitive impairment (PSCI) and to frame strategies for its prevention and progression in a developing country. AIM: The aim of the study was to estimate the prevalence and identify the risk factors of PSCI in older persons who survived an ischemic stroke. MATERIALS AND METHODS: Patients with acute stroke satisfying the inclusion criteria were recruited. Clinical and demographic data, baseline functional capacity, and cognition as assessed by the Barthel index and the Informant Questionnaire on Cognitive Decline in the Elderly, respectively, were collected. The patients were then administered the Confusion Assessment Method, Mini-Cog, Montreal Cognitive Assessment (MoCA), and Frontal Assessment Battery within the 1st week of stroke and were reassessed at 1 month. The diagnosis of PSCI was done based on MoCA score within 1 week and at 1 month after stroke, and the analysis of risk factors for PSCI was done based on MoCA score at 1 month. Results: The prevalence of PSCI in this study was 63.8% within the 1st week and 71.8% at 1 month after the stroke. Lower educational and occupational status, higher Charlson Comorbidity Index, presence of delirium during the 1st week after stroke, poststroke depression, higher National Institutes of Health Stroke Scale score, and higher Modified Rankin Scale score were found to be risk factors for the development of PSCI on univariate analysis. Lower socioeconomic status was found to be a risk factor on both univariate and multivariate analyses. Conclusion: The prevalence of PSCI was 71.8% at 1 month after stroke. Lower socioeconomic status was found to be a risk factor for PSCI. Larger studies are needed to identify various modifiable risk factors, to improve the quality of life in older stroke survivors.

Introduction: Tuberculous meningitis remains the most severe and devastating form of tuberculosis with relatively severe morbidity and mortality. Risk factors for TB meningitis have not focused on the role of the BCG vaccine or social and food insecurity which are known to have a role in pulmonary TB. Methods: We prospectively conducted a Case-Control study among 65 patients with TB meningitis and 41 controls with other forms of meningitis. We evaluated the role of the BCG vaccine, the Household Food Insecurity Access Scale (HFIAS) and the Social Readjustment Rating Scale (SRRS) to look for food and social stress respectively. We also evaluated the known risk factors for TB meningitis including age, HIV co-infection, alcoholism, malignancies, use of immunosuppression, head injury among others. A bivariate followed by multivariate regression analysis was performed. Results: The presence of BCG scar was seen in 64.6 percent of patients with Tuberculous meningitis and 61.0 percent of control (P= 0.71). There was no difference in the size of the scars (P= 0.45) . Household food insecurity using the Household Food Insecurity Access Scale (HFIAS) ( a positive answer in any of the 9 items) was present in 16.9% of the patients in the TBM group and in 14.6% of the patients in the control group. (P= 0.75). Social stress assessed using the Social Readjustment Rating Score (< 150 suggest no social stress, 150 – 300 moderate social stress,> 300 high social stress) showed that a majority of the patients in both the groups reports no social stress. Only 9.8% of patients in the TBM group and 18.5% in the control group reports moderate presence of social stress whereas none of the patients had severe social stress. Logistic regression analysis suggested that only higher BMI was associated with lesser incidence of Tuberculous meningitis, odds ratio 0.83 (95% confidence interval of 0.73 – 0.930) and individuals performing clerical and unskilled and under-skilled jobs- odds ratio 0.13 (95% confidence interval of 0.02 – 0.93) had lower risk for TB Meningitis. Conclusions: In our sample of TB meningitis patients the BCG vaccine, food insecurity nor social stress appear to be risk factors. Bigger BMI and certain occupations appear to be possibly protective.

A large part of the central nervous system is involved in the normal functioning of the vision, and hence vision can be affected in a stroke patient. Transient visual symptoms can likewise be a harbinger of stroke and prompt rapid evaluation for the prevention of recurrent stroke. A carotid artery disease can manifest as transient monocular visual loss (TMVL), central retinal artery occlusion (CRAO), anterior ischemic optic neuropathy or ocular ischemic syndrome (OIS). Stroke posterior to the optic chiasm can cause sectoranopias, quadrantanopias, or hemianopias, which can be either congruous or incongruous. Any stroke involving the dorsal stream (occipito-parietal lobe), or ventral stream (occipito-temporal lobe) can manifest with visuospatial perception deficits. Similarly, different ocular motility abnormalities can result from a stroke affecting the cerebrum, cerebellum, or brainstem. Among these deficits, vision and perception disorders are more difficult to overcome. Clinical, experimental, and neuroimaging studies have helped us to understand the anatomical basis, physiological dysfunction, and the underlying mechanisms of these neuro-ophthalmic signs.

Background: Hanging is a very common mode of deliberate self-harm (DSH) used by patients. The spectrum of the triggers and methods used vary from play to place. Objective: To study the profile and outcome of near hanging. Methods and Materials: A retrospective descriptive study was conducted on patients presenting with near hanging to the Emergency Department (ED) between January 2017 and December 2018. Data were obtained from the triage registry of the ED. Results: During the study period, 1821 presented with DSH with 144 cases of near hanging. The mean age (SD) was 33 (12.9) years and the sex distribution was equal. One-tenth (9.7%) of them had a known psychiatric illness, whereas a quarter of them (22.9%) were under the influence of alcohol at the time of the incident. The most common material used was saree (52.8%). Eight patients were intubated elsewhere and referred to ED, whereas 79% required emergency intubation in ED, with the majority being hypoxic at arrival (84.7%). Of the 144 patients, 58.4% were admitted to the hospital, whereas 20.8% were discharged stable after 24 hours of observation. Among in-patients, the majority (92.7%) were discharged stable, 4.8% left against medical advice, and 2.3% died in the hospital. Conclusions: Hanging as a method of self-harm is used by a tenth of patients who present to the ED with DSH. Saree and rope are the most common materials used for this act. One-fifth of our patients had a bad outcome that was independent of most underlying baseline factors.

Background Opsoclonus–myoclonus–ataxia syndrome (OMAS) is characterised by the combination of opsoclonus and arrhythmic action myoclonus with axial ataxia and dysarthria. In adults, a majority are paraneoplastic secondary to solid organ tumours and could harbour antibodies against intracellular epitopes; however, certain proportions have detectable antibodies to various neuronal cell surface antigens. Anti-N-methyl-D-aspartate (NMDAR) antibodies and ovarian teratomas have been implicated in OMAS.Methods Report of two cases and review of literature.Results Two middle-aged women presented with subacute-onset, rapidly progressive OMAS and behavioural changes consistent with psychosis. The first patient had detectable antibodies to NMDAR in the cerebrospinal fluid (CSF) alone. Evaluation for ovarian teratoma was negative. The second patient had no detectable antibodies in serum or CSF; however, she had an underlying ovarian teratoma. Patient A was treated with pulse steroids, therapeutic plasma exchange (TPE) followed by bortezomib (BOR) and dexamethasone, while patient B was treated with steroids, TPE followed by surgical resection of ovarian teratoma. Both patients had favourable outcomes and were asymptomatic at the 6 monthly follow-up.Conclusions With coexistent neuropsychiatric manifestations, OMAS can be considered a distinct entity of autoimmune encephalitis, pathogenesis being immune activation against known/unknown neuronal cell surface antigens. The observation of absence of anti-NMDAR antibody in patients with teratoma-associated OMAS and vice versa is intriguing. Further research on the potential role of ovarian teratoma in evoking neuronal autoimmunity and its targets is required. The management challenge in both cases including the potential use of BOR has been highlighted.

Background Cerebral venous thrombosis is a devastating condition with, despite optimal medical management, a significant proportion deteriorating due to involvement of the deep venous system, worsening intracranial pressures, and hemorrhage. In this study, we report the characteristics, immediate and long‐term outcomes of mechanical thrombectomy (MT) using a Forgarty balloon catheter among patients with cerebral venous thrombosis. Methods A prospective study conducted at the Christian Medical College, Vellore over 5 years (February 2017–February 2022), wherein patients with cerebral venous thrombosis who had clinical deterioration despite best medical management and requiring MT were included. MT was performed through retrograde venous access through internal jugular veins using a Fogarty balloon. The primary outcome was composite end point of mortality and proportion of patients with favorable clinical response at last follow‐up, defined as a disability score in modified Rankin scale 0–2. Results Among 546 patients treated in our center during the study period, 57(10%), patients required MT. The median age of the study population was 33 years (interquartile range: 17–70 years) with equal gender predilection. Hemorrhagic venous infarction was seen in 28/57 (50%) patients. The mean duration between starting medical treatment and to MT was 43 hours (interquartile range: 5–260 hours) with the most common indication being clinical deterioration (70%). Five patients (9%) required decompressive hemicraniectomy. The mortality at discharge was 5% (n=3), and at last follow‐up visit was 7% (n=4). Younger patients without hemorrhagic venous infarction and non‐involvement of the frontoparietal lobes seem to benefit the most. Favorable functional outcome at discharge (modified Rankin scale 0–2) was seen in 65% which further improved to 77% at 1‐year follow‐up. Conclusion Balloon‐assisted MT is safe and effective in a subset of patients with severe cerebral venous thrombosis, with clinical deterioration despite optimal medical management.

Background: It is essential to identify the burden of poststroke cognitive impairment (PSCI) and to frame strategies for its prevention and progression in a developing country. Aim: The aim of the study was to estimate the prevalence and identify the risk factors of PSCI in older persons who survived an ischemic stroke. Materials and Methods: Patients with acute stroke satisfying the inclusion criteria were recruited. Clinical and demographic data, baseline functional capacity, and cognition as assessed by the Barthel index and the Informant Questionnaire on Cognitive Decline in the Elderly, respectively, were collected. The patients were then administered the Confusion Assessment Method, Mini-Cog, Montreal Cognitive Assessment (MoCA), and Frontal Assessment Battery within the 1st week of stroke and were reassessed at 1 month. The diagnosis of PSCI was done based on MoCA score within 1 week and at 1 month after stroke, and the analysis of risk factors for PSCI was done based on MoCA score at 1 month. Results: The prevalence of PSCI in this study was 63.8% within the 1st week and 71.8% at 1 month after the stroke. Lower educational and occupational status, higher Charlson Comorbidity Index, presence of delirium during the 1st week after stroke, poststroke depression, higher National Institutes of Health Stroke Scale score, and higher Modified Rankin Scale score were found to be risk factors for the development of PSCI on univariate analysis. Lower socioeconomic status was found to be a risk factor on both univariate and multivariate analyses. Conclusion: The prevalence of PSCI was 71.8% at 1 month after stroke. Lower socioeconomic status was found to be a risk factor for PSCI. Larger studies are needed to identify various modifiable risk factors, to improve the quality of life in older stroke survivors. [ABSTRACT FROM AUTHOR]

Introduction: Entrapment of the lateral femoral cutaneous nerve (LFCN) of thigh results in meralgia paresthetica (MP). Standard electrophysiological tests for MP are technically demanding and unreliable. We aimed to study the role of pain-related evoked potentials (PREP) in the diagnosis of MP. Methods: Patients with MP and normal volunteers were included. PREP was recorded by stimulating the skin over the lateral thigh 20 cm below the anterior-superior iliac spine and recording from the cortex at Cz. Results: A total of 28 subjects and 56 LFCNs were studied. 36 nerves had MP and 20 were normal. The mean PREP latency was 118 (8) ms among normal controls and 164 (10.8) ms in MP. The optimal cut-off point for the diagnosis of MP was 134 ms. Area under receiver operator characteristic curve was 0.97; sensitivity was 91.7% and specificity was 100%. Conclusion: PREP is reliable and easy to use electrophysiological test in establishing the diagnosis of MP.

Congenital adrenal hyperplasia (CAH), screened for in neonates, is the second most common endocrinopathy after congenital hypothyroidism.Newborn screening for CAH due to CYP21A2 deficiency is performed by immunologic assay for 17-hydroxyprogesterone (17-OHP). The second-tier test for confirmation of diagnosis is carried out on recall venous blood sample from screen positives measuring 17-OHP, or other metabolites of steroid metabolism by liquid chromatography–tandem mass spectroscopy. However, as steroid metabolism is dynamic, it can affect these parameters even in the recall sample of a stressed neonate. Moreover, there is some time delay in recalling the neonate for repeat testing. Reflex genetic analysis of blood spot from the initial Guthrie cards of screen positive neonates, if used for confirmatory testing, can avoid this time delay as well as the effect of stress on steroid metabolism. In this study, we used Sanger sequencing and MLPA in a reflex manner for molecular genetic analysis to confirm CYP21A2-mediated CAH. Out of 220,000 newborns screened, 97 were positive on the initial biochemical screen, of which 54 were confirmed true positives with genetic reflex testing, giving incidence of CAH as 1:4074. Point mutations were more common than deletions, indicating that Sanger sequencing should be used ahead of MLPA for molecular diagnosis in India. Amongst the variants detected, the most common was I2G-Splice variant (44.5%), followed by c.955C>T (p.Gln319Ter) (21.2%); Del 8 bp and c.-113G>A were detected with frequencies of 20.3% and 20%, respectively. In conclusion, reflex genetic testing is an effective strategy for identifying true positives in CAH screening in neonates. This will obviate need for recall samples and also aid effective counselling and timely prenatal diagnosis in the future. In Indian newborns, as point mutations are more common than large deletions, Sanger sequencing should be the initial method of choice for genotyping, ahead of MLPA.

Byline: Rajeshwar. Sahonta, Ivy. Sebastian, Sanjit. Aaron, Appaswamy. Prabakhar, Anupriya. Arthur, Jeyaraj. Pandian A large part of the central nervous system is involved in the normal functioning of the vision, [...]

Purpose The brainstem plays an important role in the control of micturition, and brainstem strokes are known to present with micturition dysfunction. Micturition dysfunction in cases of lateral medullary infarction (LMI) is uncommon, but often manifests as urinary retention. In this study, we investigated the neuro-anatomical correlates of urinary retention in patients with LMI. Methods This was a hospital-based retrospective study conducted in the neurology unit of a quaternary-level teaching hospital. Inpatient records from January 2008 to May 2018 were searched using a computerized database. Cases of isolated LMI were identified and those with micturition dysfunction were reviewed. MRI brain images of all patients were viewed, and individual lesions were mapped onto the Montreal Neurological Institute (MNI) space manually using MRIcron. Nonparametric mapping toolbox software was used for voxel-based lesion-symptom analysis. The Liebermeister test was used for statistical analysis, and the resultant statistical map was displayed on the MNI template using MRIcron. Results During the study period, 31 patients with isolated LMI were identified. Their mean age was 48 years and 28 (90%) were male. Six of these patients (19%) developed micturition dysfunction. All 6 patients had urinary retention and 1 patient each had urge incontinence and overflow incontinence. In patients with LMI, the lateral tegmentum of the medulla showed a significant association with urinary retention. Conclusions In patients with isolated LMI, we postulate that disruption of the descending pathway from the pontine micturition centre to the sacral spinal cord at the level of the lateral tegmentum results in urinary retention.

We have previously shown that Lactobacillus gasseri Kx110A1, a human stomach isolate, can colonize mouse stomach and reduce the initial colonization of Helicobacter pylori. Here, we investigated the role of sortase-dependent proteins (SDPs) involved in these functions by the construction of a mutant for srtA, the gene encoding the housekeeping sortase that covalently anchors SDPs to the cell surface. The srtA mutant showed a decrease in hydrophobicity and autoaggregation under acidic conditions, indicating the effect of SDPs on cell surface properties. Correspondingly, the srtA mutant lost the capacity to adhere to gastric epithelial cells, thus resulting in an inability to provide a physical barrier to prevent H. pylori adherence. These results indicate that sortase A is a key determinant of the cell surface properties of L. gasseri Kx110A1 and contributes to Lactobacillus-mediated exclusion of H. pylori. Understanding the molecular mechanisms by which lactobacilli antagonize H. pylori might contribute to the development of novel therapeutic strategies that take advantage of health-promoting bacteria and reduce the burden of antibiotic resistance.

Byline: Appaswamy. Prabhakar, Murali. Rayani, Vamsi. Krishna, Atif. Sheikh, Ajith. Sivadasan, Aditya. Nair, Vivek. Mathew To the Editor, Myelin oligodendrocyte glycoprotein (MOG) is an essential component of the oligodendrocytes and [...]

Byline: Atif. Ahmed Shaikh, Monika. Das, Anupama. Roy, Bini. Baby, Dolcy. Dhar, Jebalin. Abigayil, Vitty. Varghese, Vivek. Mathew, Sanjith. Aaron, Ajith. Sivadasan, Paul. Premkumar, Tharan. Suresh, Appaswamy. Prabhakar Introduction: Entrapment [...]

Byline: Arun. Mani, Appaswamy. Prabhakar, P. Alexander, Aditya. Nair, Asish. Vijayaraghavan, Atif. Shaikh, Rohit. Benjamin, Ajith. Sivadasan, Vivek. Mathew, Sanjith. Aaron, Mathew. Alexander Background: Guillain-Barre syndrome can be electrophysiologically classified [...]

Byline: Aditya. Nair, Appaswamy. Prabhakar, Shaik. Iqbal, Ajith. Sivadasan, Vivek. Mathew The human body requires equilibrium to assume the vertical posture and balance for walking which is maintained by righting [...]

Introduction/Aims: In Guillain–Barré syndrome (GBS), the sensitivity and specificity of phrenic compound muscle action potential (CMAP) measurements to predict endotracheal mechanical ventilation are unknown. Hence, we sought to estimate sensitivity and specificity. Methods: We performed a 10‐year retrospective analysis of adult GBS patients from our single‐center laboratory database (2009 to 2019). The phrenic nerve amplitudes and latencies before ventilation were recorded along with other clinical and demographic features. Receiver operating curve (ROC) analysis with area under the curve (AUC) was used to determine the sensitivity and specificity with 95% confidence interval (CI) for phrenic amplitudes and latencies in predicting the need for mechanical ventilation. Results: Two hundred five phrenic nerves were analyzed in 105 patients. The mean age was 46.1 ± 16.2 years, with 60% of them being male. Fourteen patients (13.3%) required mechanical ventilation. The average phrenic amplitudes were lower in the ventilated group (P =.003), but average latencies did not differ (P =.133). ROC analysis confirmed that phrenic amplitudes could predict respiratory failure (AUC = 0.76; 95% CI, 0.61 to 0.91; P <.002), but phrenic latencies could not (AUC = 0.60; 95% CI, 0.46 to 0.73; P =.256). The best threshold for amplitude was ≥0.6 mV, with sensitivity, specificity, and positive and negative predictive values of 85.7%, 58.2%, 24.0%, and 96.4%, respectively. Discussion: Our study suggests that phrenic CMAP amplitudes can predict the need for mechanical ventilation in GBS. In contrast, phrenic CMAP latencies are not reliable. The high negative predictive value of phrenic CMAP amplitudes ≥0.6 mV can preclude mechanical ventilation, making these a useful adjunct to clinical decision‐making. [ABSTRACT FROM AUTHOR]

Cactus pear (Opuntia ficus-indica (L.) Mill.) can survive extreme environmental condition and is known for its fodder potential in many parts of the world. The morphological diversity of 15 introduced accessions was evaluated at Jhansi, Uttar Pradesh, India. The plants were established in 2013. Survival and nutrient status were evaluated after two years. Above-ground plant height, biomass, primary and secondary cladode numbers, primary and secondary cladode lengths and below-ground root length, weight, and surface area measurements were done six years after cladode planting. Yellow San Cono, White Roccapalumba, and Seedless Roccapalumba survived 100%. The discriminant traits according to principal component analysis were: primary cladodes plant−1 (component loading, 0.87), primary cladodes biomass (0.95), secondary cladodes plant−1 (0.83), canopy width (0.84), and plant biomass (0.92). Hierarchical cluster analysis grouped 15 accessions into two main clusters based on 17 morphological traits. Cluster I showed favorable values for many above- and below-ground morphological traits while Cluster II showed higher performance for root system width, height, and biomass, and primary and secondary cladode numbers. The results indicate that cactus pear accessions have considerable morphological variability and genetic diversity suitable for promotion as alternative fodder resources in semi-arid regions of India. [ABSTRACT FROM AUTHOR]