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Objectives To assess the efficacy of exercises in early-stage Parkinson’s disease (PD).Design Single-blind, randomised controlled trial.Setting Tertiary rehabilitation care centre.Participants Forty individuals (≥18 years, either gender) with newly diagnosed PD (Hoehn and Yahr stage ≤2) on a stable dose of PD medications were randomised (1:1) to the intervention group (IG) and control group (CG).Interventions The IG received strengthening (30 min/day, 2 days/week), aerobic (30 min/day, 3 days/week) and agility (30 min/day, 2 days/week) exercises in a structured format for 12 weeks. CG received stretching exercises for 12 weeks.Main outcome measures Unified PD Rating Scale (UPDRS) III (motor) at week 12 (primary), UPDRS I (mentation, behaviour and mood), UPDRS II and VI (Schwab and England Activities of daily living Scale) and Parkinson’s Disease Quality of Life (PDQL) at week 12 (secondary).Results 36 participants completed 12-week study period. UPDRS III (lesser scores reflect improvement) at 12 weeks showed a significant between-group difference (−5.05 points (95% CI: −9.38 to −0.71), p=0.02). At 4 and 8 weeks, UPDRS III did not show a statistically significant between-group difference (−2.15 points (95% CI: −6.77 to 2.47) and −4.1 points (95% CI: −8.54 to 0.34), respectively). From baseline to 12 weeks, UPDRS III in the IG showed a 6.5-point (95% CI (4.85 to 8.14)) reduction, and the CG showed a 0.8-point increase (95% CI (−3.06 to 1.46)), PDQL (higher scores reflect improvement) in the IG showed a 8.45-point (95% CI (–12.78 to –4.11)) increase and CG showed a 2.75-point (95% CI (0.16 to 5.33)) reduction.Conclusions Structured exercises improve motor symptoms and quality of life in early-stage PD. Consistent adherence for at least 12 weeks is crucial for clinical improvement. Early initiation of exercises as neurorehabilitation is recommended. Further research on specific types, dosing and intensity of exercises with a larger sample size is warranted in early-stage PD.Trial registration number CTRI/2018/05/014241.

Background and Purpose: Cerebral small vessel disease (CSVD) markers have not been widely studied in relation to hematoma volume and growth in hypertensive intracerebral hemorrhage (ICH). The objectives to assess the relationship of white matter hyperintense lesions (WMHL), microbleeds (MBs), and cortical siderosis (CSS) with hematoma volume, hematoma expansion (HE), and 3 months outcome in patients with hypertensive ICH. Methods: All consecutive acute hypertensive supratentorial ICH presenting to the emergency were prospectively recruited. Baseline and 24 hours computed tomography (CT) to assess hematoma volume and magnetic resonance imaging (MRI) for CSVD markers were performed in all subjects. WMHL (graded using Fazekas's scale), MBs, and CSS were assessed and compared with baseline variables and outcomes. All the images were assessed by an experienced stroke neurologist/neuroradiologist. Results: One hundred and fifty-seven patients were screened and 60 were included. Mean age was 54.08 ± 11.57 years and 47 (78%) were males. Of 60, 19 (28.1%) had HE, 31 (51.6%) had major bleed (>30 ml), and 28 (47.46%) had poor 3 month outcome (mRS 4-6). On univariate analysis, high grade WMHL was associated with greater HE [odds ratio (OR): 2.65, confidence interval (CI) 1.48–4.72, P = 0.001), greater proportion with volume >30 ml (OR: 7.16, CI: 1.09–47.13, P = 0.001) and poor outcome (OR: 2.1, CI: 0.05–3.27, P = 0.001). MBs were associated with poor outcome (P = 0.029) but not with HE/volume. CSS was related to HE (P = 0.031), a large volume bleed (P = 0.023), and poor outcome (P = 0.021). On multivariate model, only WMHL independently predicted HE (P = 0.034), greater proportion with bleed volume >30 ml (P = 0.041), and poor outcome (P = 0.042). Conclusions: WMHL in MRI serves as a predictor of hematoma expansion, a large volume bleed, and poor outcome in hypertensive ICH and may be incorporated into existing prediction models.

Background: Aggressive pancreatobiliary tumors often require oxaliplatin-based therapies, instead of standard gemcitabine-based therapy and biomarker studies at diagnosis to decide the appropriate therapeutic regimen. The ribonucleotide Reductase catalytic subunit M1 (RRM1) and excision repair cross-complementing gene-1 (ERCC1) are related to DNA synthesis and repair and essential in this regard. However, apart from the therapeutic benefit, their prognostic implication is controversial. Methods: In this retrospective study, paraffin-embedded tissue from 51 cases of pancreatic cancer and 29 cases of cholangiocarcinoma were evaluated for RRM1 and ERCC1 expression by immunohistochemical technique along with 18 control pancreatic and biliary tissues. The semiquantitatively H score was calculated based on stain distribution and stain intensities. Results: Both RRM1 and ERCC1 expression were high in tumor epithelium than in controls (RRM1: the difference was statistically significant in cholangiocarcinoma (P = 0.008); ERCC1: the difference was statistically significant both in pancreatic and cholangiocarcinoma (P < 0.05)]. However, no correlation was noted between RRM1 and ERCC1-low and high tumors with histological markers of prognosis and overall survival in these patients. Conclusions: The present study adds further evidence against the controversy that if RRM1 and ERCC1 expression in pancreatic and biliary carcinomas have any prognostic significance apart from their proven therapeutic benefits in these tumors.

Context: In view of the rising burden of type 2 diabetes mellitus (DM) cases in India, there is an urgent need for an effective, low-cost, sustainable intervention controlling diabetes thus preventing complications. Aims: This study aimed to assess the effect of structured yoga programs on diabetes. Subjects and Methods: This was a community-based interventional study that was conducted in an urban resettlement colony of Delhi, India. Known diabetes patients with glycated hemoglobin (Hb1Ac) ≥6.5% were enrolled from 12 randomly selected blocks of the community with a sample size of 192 in each intervention and wait-listed control arm. The intervention was structured yoga of 50 min daily, 2 consecutive weeks in a nearby park and health center followed by twice a week home practice up to the 3rd month. The primary outcome measure was HbA1c% and secondary outcome measures were lipid profile and fasting blood glucose. Statistical Analysis Used: Aper-protocol analysis was done. Mean, standard deviation (SD), and 95% confidence interval were estimated. The level of significance was considered for 0.05. Results: There was a significant decrease of Hb1Ac (0.5%, SD = 1.5, P = 0.02), total cholesterol (11.7 mg/dl, SD = 40.5, P < 0.01), and low-density lipoprotein (3.2 mg/dl, SD = 37.4, P < 0.01) from baseline to end line in the intervention group. These changes in intervention group were also significantly different from the change in the wait-listed control group. The other variables did not change significantly. Conclusions: It revealed that structured yoga program improved glycemic outcome and lipid profile of individuals in a community-based setting. Yoga can be a feasible strategy to control hyperglycemia, lipid levels, and can help better control type 2 DM.

Background and Purpose Various neurological findings including stroke in patients with coronavirus disease 2019 (COVID-19) have been described, although no clarity exists regarding the nature and pattern of this association. This systematic review aims to report the characteristics of stroke in patients with COVID-19. Methods Three authors independently searched Web of Science, Embase, Scopus, and PubMed starting from inception up to May 22, 2020. The data for individual patients was extracted where available from published reports including clinical and laboratory parameters and analysed for any significant associations between variables. Results We identified 30 relevant articles involving 115 patients with acute or subacute stroke with COVID-19. The mean±standard deviation age was 62.5±14.5 years. Stroke was ischemic in majority of the patients (101 [87.8%]). Hypertension (42 [42%]), dyslipidaemia (24 [26.1%]), and diabetes (23 [23.2%]) were the major vascular risk factors. Most of the patients (80 [85.1%]) had COVID-19 symptoms at the time of stroke with a median interval of 10 days to stroke from the diagnosis of COVID-19. Three-fourths (86 [74.8%]) of the patients were critically ill which frequently delayed the diagnosis of stroke. High levels of D-dimer, and ferritin were observed in these patients. Patients with COVID-19 and stroke had a high mortality (47.9%). Factors associated with mortality were intensive care unit admission, having two or more vascular risk factors, particularly smoking and high levels of D-dimer, C-reactive protein, and lactate dehydrogenase. Conclusions The association between stroke and COVID-19 is probably multifactorial including an amalgamation of traditional vascular risk factors, proinflammatory and a prothrombotic state. Prospectively collected data is required in the future to confirm this hypothesis.

Background: Research has implicated hypofrontality in the pathogenesis of Negative symptoms of schizophrenia.These symptoms are often resistant to treatment. Repetitive Transcranial Magnetic Stimulation (rTMS) has been shown to reverse this hypofrontality. Higher frequency rTMS has shown better promise, but so far there has been very little research in this area. Objective: We aimed to evaluate the efficacy of high-frequency (20 Hz) unilateral rTMS over the left Dorso-Lateral Pre-frontal Cortex (DLPFC) in the improvement of Negative symptoms in Schizophrenia. Methods:100 patients of schizophrenia with predominantly negative symptoms, were enrolled for this randomized, sham-controlled, double-blind trial.Each participant received 20 sessions of rTMS at 20 Hz frequency and 100% motor threshold, via either the active or the sham coil, over 4 weeks. A total of 2000 pulses were imparted in 10 trains per session. Negative symptoms were assessed with the SANS and PANSS. CDSS was used to rule out depressive symptoms. Assessments were carried out at baseline, post-intervention, and 1-month, 2-months, 3-months and 4-months follow ups. Results: The improvement in the negative symptoms (Anhedonia, Alogia, Avolition, Attention impairment) in active group was statistically significant at 0.01 and 0.05 (p-value) as compared to sham group. Conclusions: These results suggest that high-frequency rTMS may lead to improvement in negative symptoms of schizophrenia. It may be worth considering its use as an adjunct to pharmacological treatment of negative symptoms.

PURPOSE: The information about the outcome of primary CNS lymphoma (PCNSL) in India is scarce, because there is no population-based or large hospital-based data. MATERIALS AND METHODS: This is a retrospective study that spanned 17 years (2001 to 2017) to study the outcome of PCNSL at the All India Institute of Medical Sciences (AIIMS), which is a tertiary care center in Northern India. RESULTS: Only one of 99 patients was positive for HIV serology. Diffuse large B-cell lymphoma was the most common histology (97.7%). The median patient age was 50 years (range, 13 to 70 years), and the ratio of men to women was 1.9. The median duration of symptoms before diagnosis was 3.5 months (range, 0.5 to 48 months), and 58.5% had a performance status (PS) of 3 or more. Multiple intracranial lesions were present in 81.8% of patients. Surgical resection was performed in 45%, and approximately 22% of patients were ineligible for treatment. Most patients (n = 73) were treated with high-dose methotrexate (HDMTX)–based regimens (ie, methotrexate, vincristine, and procarbazine with or without rituximab). Pharmacokinetic monitoring of methotrexate was not available at our center. HDMTX-related mortality was 3.9%. The median follow-up duration, event-free survival (EFS), and overall survival (OS) were 34 months, 20.4 months, and 31.7 months, respectively. Addition of rituximab (n = 27) to MVP resulted in a higher objective response rate (88.9% v 73.9% without rituximab; P = .12), complete remission (81.5% v 56.5%; P = .03), 2-year EFS (57.3% v 40.4%; P = .02), and 2-year OS (61.6% v 53.4%; P = .056). CONCLUSION: This is the largest study of PCNSL from India. The patients were immunocompetent and young but presented with a high-burden disease that precluded treatment in approximately 22%. The treatment with HDMTX appears safe without pharmacokinetic monitoring. The outcome is comparable to those observed in the West, and rituximab use showed additional benefit. There are notable barriers with respect to management of PCNSL in the real world, and efforts are required to improve the outcome more.

Background: It is hypothesized that the duodenal mucosal damage in patients with celiac disease (CeD) is caused by the mucosa-infiltrating lymphoid cells. This study aimed to analyze the immune effective and regulatory T (Treg) cells in duodenal biopsies from treatment-naive adult patients with CeD having different histological grades and controls. Patients and Methods: Dual-color immunohistochemical staining was done in a total of 234 duodenal biopsies, including 132 controls and 102 adult patients with CeD using CD20, CD3:CD4, CD3:CD8, CD4:FoxP3, CD8:FoxP3, and TCRαβ:TCRγδ antibodies. The density of these lymphoid cells in lamina propria and mucosal epithelium was compared between controls and CeD, with different modified Marsh grades. Results: Densities of CD4+ T cells in lamina propria and CD8+γδ intraepithelial lymphocytes (IELs) were significantly more in biopsies from patients with CeD, than in controls. An increasing linear pattern of IELs, CD3+ T cells, and CD20+ B cells was observed with increasing grades of villous abnormalities. Although CD8+ FoxP3+ Treg cells were significantly more in biopsies from patients with CeD, there was no significant difference in CD4+ FoxP3+ Treg cell infiltrate between both the groups. Conclusion: Our finding in this observational study generates interest to study the local intestinal mucosal immunity in CeD in detail. A study to prove the failure of CD4+ FoxP3+ Treg cell recruitment in CeD and its direct functional impact may yield valuable information regarding loss of mucosal tolerance.

Context: Improvement in perioperative care can reduce anesthesia-related morbidity. Noncompliance to protocols and poor working practices can compromise patient safety. Aims: The objective was to survey the working practices of anesthesiologists in India and find out the most commonly overlooked aspects in perioperative period. Setting and Design: Prospective cross-sectional survey involving practicing anesthesiologists in India, conducted over a period of 2 months. Methods: An online questionnaire, including questions pertaining to pre-, intra- and post-operative phases during conduct of anesthesia was mailed to anesthesiologists (members of the Indian Society of Anesthesiologists) over a period of 2 months through the online survey builder SurveyMonkey. The questionnaire was delivered to 13,700 anesthesiologists, of which 2055 responded. Results are expressed as numbers or percentages. Results: Checklist compliance, equipment check, and perioperative record-keeping are the most commonly overlooked aspects by anesthesiologists in perioperative period. The survey also highlights the shortage of postanesthesia care units across the country. Conclusions: Checklist compliance, equipment check, and record-keeping are potential areas for improvement. Professional societies should promote better practices, monitoring standards and should also formulate minimum standards for different setups where anesthesia can be delivered safely.

Background: Sub-inflammation and insulin resistance characterize women with PCOS. Data on dietary modulation of inflammation among PCOS women is scant, particularly from Indian subcontinent. The present study aimed to assess the effect of plant based vs. animal origin diets on serum markers of inflammation (primary outcome measure).Methods: This observational case-control study compared age and BMI matched PCOS and apparently healthy women from two populations following different dietary practices. The vegetarian women from New-Delhi (n = 82 PCOS and n = 179 healthy) and non-vegetarian women from Srinagar (n = 62 PCOS and n = 141 healthy) formed the groups. Using a uniform methodology, detailed clinical, biochemical, hormonal, and inflammatory marker assessment was undertaken.Results: The mean age of the overall cohort was 26.23 ± 4.59 years with a mean BMI of 24.39 ± 3.72 kg/m2. Overall pro-inflammatory markers (TNF-α, IL-6, IL-1β, hs-CRP and serum resistin) were significantly higher (p ≤ 0.05) and anti-inflammatory markers (IL-10 and adiponectin) were lower among women with PCOS than healthy subjects. On comparing vegetarian women with non-vegetarians, higher daily calorie intake (1895.46 ± 258.19 vs. 1860.13 ± 323.96 Kcal) with a higher protein and fat and lower carbohydrate intake was recorded in the latter, although the percent energy derived from carbohydrates was higher among vegetarians. Clinical and biochemical parameters were comparable among the groups except mFG score, total serum testosterone and serum lipid levels which were higher among non-vegetarian women as compared to their vegetarian counterparts from both categories (PCOS and healthy). Interestingly, vegetarian women with PCOS and healthy women had higher serum pro-inflammatory and lower anti-inflammatory markers compared to their non-vegetarian counterparts.Conclusion: Women with PCOS consuming Indian vegetarian diet have higher pro-inflammatory and lower anti-inflammatory marker levels than their age and BMI matched healthy non-vegetarian counterparts. This interesting observation can be attributed to the dietary composition, among other factors and needs confirmation from well-designed randomized studies on a larger cohort.Clinical Trial Registration: The study was registered with CTRI database under registration number CTRI/2013/09/003996.

Background: Previous studies identified prognostic factors for survival in relapsed pediatric Hodgkin lymphoma (HL) who received salvage chemotherapy followed by autologous stem cell transplant (ASCT). However, data regarding predictors of poor response to salvage chemotherapy is limited. Methods: We conducted retrospective study in all relapsed HL treated from January 2003 to December 2013. Logistic regression analysis was done to identify predictors of response to salvage chemotherapy. Cox regression analysis was done to identify prognostic factors for Freedom from treatment failure (FFTF) and overall survival (OS). Results: Forty six patients had relapsed HL. Among 45 patients who received salvage chemotherapy only 34 (73.4%) underwent ASCT. Stage 4 disease (p=0.02) and bulky disease at relapse (p=0.03) were predictors of poor response to salvage chemotherapy. FFTF and OS at 5 yr for entire cohort were 50.1% and 63.3%, respectively, while the same for patients who underwent ASCT were 66.3% and 80.7%, respectively. Among ASCT patients, those who had primary refractory /early relapse [HR-4.7, (95% CI-1, 22); p=0.05] had significant impact on 5 yr FFTF whereas disease status at transplant (CR vs. No CR) had significant impact on 5 yr OS [HR-4.6, (95% CI-1.03, 20.5); p=0.04]. Conclusions: Identification of predictors of poor response to salvage chemotherapy is an unmet need in the management of pediatric HL since complete response (CR) before transplant is independent predictor of survival. Stage 4 and bulky disease at relapse are high risk factors to predict incomplete response. Future trials should explore newer agents for effective salvage for these patients to attain complete response before ASCT.

Byline: Priyanka. Gupta, Binod. Khaitan, M. Ramam, V. Ramesh, J. Sundharam, Amit. Malhotra, Vishal. Gupta, Vishnubhatla. Sreenivas Background: Segmental vitiligo has a different clinical course and prognosis as compared to [...]

Background: Nosocomial infections (NIs) in the postoperative period not only increase morbidity and mortality, but also impose a significant economic burden on the health care infrastructure. This retrospective study was undertaken to (a) evaluate the incidence, characteristics, risk factors and outcomes of NIs and (b) identify common microorganisms responsible for infection and their antibiotic resistance profile in our Cardiac Surgical Intensive Care Unit (CSICU). Patients and Methods: After ethics committee approval, the CSICU records of all patients who underwent cardiovascular surgery between January 2013 and December 2014 were reviewed retrospectively. The incidence of NI, distribution of NI sites, types of microorganisms and their antibiotic resistance, length of CSICU stay, and patient-outcome were determined. Results: Three hundred and nineteen of 6864 patients (4.6%) developed NI after cardiac surgery. Lower respiratory tract infections (LRTIs) accounted for most of the infections (44.2%) followed by surgical-site infection (SSI, 11.6%), bloodstream infection (BSI, 7.5%), urinary tract infection (UTI, 6.9%) and infections from combined sources (29.8%). Acinetobacter, Klebsiella, Escherichia coli, and Staphylococcus were the most frequent pathogens isolated in patients with LRTI, BSI, UTI, and SSI, respectively. The Gram-negative bacteria isolated from different sources were found to be highly resistant to commonly used antibiotics. Conclusion: The incidence of NI and sepsis-related mortality, in our CSICU, was 4.6% and 1.9%, respectively. Lower respiratory tract was the most common site of infection and Gram-negative bacilli, the most common pathogens after cardiac surgery. Antibiotic resistance was maximum with Acinetobacter spp.