Sleep Related Rhythmic Movement Disorder in older children and adults and their association with comorbid conditions - experience from two centres and literature review.

Sleep related rhythmic movement disorders (SRRMD) are highly prevalent among infants and children and tend to disappear into adolescence and adulthood. However, few reports have identified patients who had rhythmic movements at wake-sleep transition persisting into adulthood. This is a case series of SRRMD diagnosed on video-polysomnography from retrospective chart review of patients, who were 6 years or older, seen in Sleep Neurology clinics in two centres by the senior author, over a 10 years period. In addition, an updated review of all papers published on the topic, since year 2000 is being reported. A total of nine patients (2 females) with SRRMD were included in this series with age ranging between 9 and 62 years. Five patients had comorbid primary sleep disorders and four others had associated neurodevelopmental disorders. Association with other primary sleep disorders like sleep apnea and restless legs syndrome and relief with treatment of the latter, has been highlighted.

Comprehensive Outcome Assessment and Quality of Life Following Epilepsy Surgery.

BACKGROUND: Seizure freedom without deficits is the primary goal for epilepsy surgery. However, patients with medically refractory epilepsy commonly suffer from many co-morbidities related to mood, cognition, and sleep as well as social problems and resultant stigma. While epilepsy surgery literature does describe quality of life (QOL) and neuropsychological outcomes, there is a paucity of information on various common non-seizure outcomes, especially pertaining to mood, sleep, cognition, and social aspects. The objective of this study was to evaluate the role of various non-seizure parameters on post-epilepsy surgery QOL. METHODS: Consecutive adult patients operated for refractory epilepsy at least 1 year prior to initiation of this study were included and classified as seizure-free (group 1) or non-seizure-free (group 2). QOL was assessed using the QOLIE-31 instrument; patients with a T score less than 40 were categorized as "poor QOL." Non-seizure parameters assessed were cognition, mood disturbances, social improvement, social stigma, and sleep disturbances. Categorization into "good" and "poor" outcome subgroups on each item was carried out by dichotomization of scores. RESULTS: Thirty-seven patients (16 F) [mean age 23.5 ± 5.6 years] were evaluated; 26 were seizure-free (group 1). In this group, impaired memory, lower language scores, depression, not having been employed, not receiving education prior to surgery, and experiencing social stigma were factors significantly associated with poor QOL. In group 2, all patients had poor QOL scores. CONCLUSION: Non-seizure factors related to common epilepsy co-morbidities and social issues are highly prevalent among seizure-free patients reporting poor QOL after epilepsy surgery.

Effect of yoga-based lifestyle and dietary modification in overweight individuals with sleep apnea: A randomized controlled trial (ELISA).

BACKGROUND: Obesity is recognised as an important risk factor for obstructive sleep apnea (OSA), with obese individuals at a four times higher risk of being diagnosed with the syndrome. Treating obesity with lifestyle modification is associated with a reduction in the severity of obstructive sleep apnea. Yoga comprises lifestyle modification that includes asana (postures), pranayama (breathing techniques), dhyana (meditation) and guideline principles for healthy living (Yama and Niyama). There is a scarcity of data to evaluate the effect of yoga on OSA. This study was conducted to evaluate the efficacy of Yoga based lifestyle modification on OSA. METHODS: Consenting obese patients (BMI >23) diagnosed with obstructive sleep apnea (OSA) (AHI>5) on Polysomnography (PSG) were enrolled. Eligible patients were randomized into two groups. The control group received counselling for dietary modification (staple Indian) with regular exercise and the active intervention group received Yoga intervention as treatment (OSA module) in addition to similar dietary modification and regular exercise counselling. Polysomnography (PSG) was conducted at baseline and one year follow-up. All patients were evaluated at baseline, six months, and one year for compliance and anthropometric parameters. Additional assessment with Hamilton scales for depression and anxiety, SF-36, and the Pittsburgh sleep quality index was also conducted. RESULTS: A total of 37 eligible patients (19 in the control group and 18 in the yoga group) were recruited for the study. The age [45.73 ± 10.71 vs. 46.22 ± 9.39 years, p = 0.88] and gender [15(78.95%) vs. 12(66.67%), p = 0.48 (males)] distribution was similar in both groups. After adjusting for age and gender, the percentage reduction in weight between the two groups did not reach statistical significance at one year. There was no significant difference in mean AHI between the two groups at one year. However, the number of patients with more than 40% AHI reduction [2/19 (10.52%) vs 8/18 (44.44%), p = 0.02] was significantly higher in the yoga group. Additionally, within the groups, the mean AHI at one year was significantly reduced in the yoga group [51.2 ± 28.0 to 36.8 ± 21.0/hour, p = 0.003], while no significant change was found in the control group [47.2 ± 23 to 38.8 ± 19.9/hour, p = 0.08]. CONCLUSIONS: Lifestyle alteration using Yoga intervention and modification of staple Indian diet may be effective in reducing OSA severity among obese patients. CTRI NUMBER: CTRI/2017/05/008462.

Correlation of p53 expression with Clinical Presentation and Prognosis of Oral Squamous Cell Carcinoma Patients: A Pilot Study.

Mutations of p53 gene is one of the most common events in human cancers including oral squamous cell carcinoma (OSCC). However, its role in carcinogenesis and association with regard to prognosis is still under investigation and unclear. The aim was to study the expression of p53 in patients of OSCC and correlation with clinical presentation and prognosis. In this retrospective observational pilot study, we examined expression of p53 in 50 histologically diagnosed cases of OSCC and correlated it with initial clinical presentation and clinical events in follow up period. p53 expression was significantly negative (94%) in patients with history of only oral tobacco consumption while cases with additional history of smoking or alcohol were positive (p = 0.0001 and 0.011). On the other hand, aggressive course of the disease was found to be significant with p53 positivity in the form of lymph nodal extension (13 out of 17 cases) (p = 0.011) and recurrence (6 out of 10 cases) (p = 0.024). p53 was overexpressed (positive) in predisposing factors like smoking and alcohol but not in OSCC associated with chewing tobacco. p53 overexpression is also associated with advanced TNM stage. To the best of our knowledge, this is the first report where association of p53 overexpression and oral tobacco consumption associated OSCC was not observed and we recommend that carcinogenic events in chewing tobacco induced OSCC should be studied separately for its unique set of mutations.

A Cross-Sectional Comparative Study of Sleep Disturbances in Children with ADHD and Matched Controls.

Background: Systematic reviews conducted on sleep disturbances in attention deficit hyperactivity disorder (ADHD) have found inconsistent results due to the presence of several moderating variables which were not controlled for in previous studies. The aim of this study was to examine sleep disturbances in children with ADHD compared to their typically developing peers after controlling for moderating variables (age, sex, medication status, body mass index, and psychiatric and medical comorbidities). Methods: ADHD was diagnosed using DSM-IV-TR criteria (Diagnostic and Statistical Manual of Mental Disorders) and Conners' Parent Rating Scales. Children recruited (aged 6−12 years) for the ADHD group (n = 40) met the following criteria: IQ > 80, unmedicated, and no psychiatric or medical comorbidities. The control group consisted of age- and sex-matched typically developing peers (n = 40). Sleep was assessed subjectively (through parent reported questionnaires and sleep logs) and objectively (using video polysomnography). Results: 65% of children with ADHD had a sleep disorder, as compared to 17% of controls. The ADHD group reported more sleep disturbances and disorders, both on subjective measures and objective measures. Conclusions: Sleep disturbances and primary sleep disorders in children with ADHD exist independent of moderating variables and differences in sleep assessment methods, thereby bolstering support for previously documented literature on the ADHD and sleep connection.

Prevalence of psychological outcomes and its associated factors in healthcare personnel working during COVID-19 outbreak in India.

Background: Care of COVID-19 patients has been shown to affect the mental health of healthcare personnel (HCP), however, there is little data reflecting psychological health of HCP in India. Aims: The present study was undertaken to assess the prevalence of psychological outcomes and its association with various sociodemographic and occupational factors among the HCP in India. Methodology: A cross-sectional, online survey, using snowball sampling method was conducted between June 1, 2020, and June 22, 2020. The HCP working in COVID-19 designated hospitals across India were invited to participate. Patient Health Questionnaire-4 and 19-item stress-related questionnaire were used to evaluate symptoms of overall anxiety, depression, COVID-19 infection specific anxiety, exhaustion, and workload. Results: In this cross-sectional study with 2334 HCP from 27 states and 7 union territories of India; 17.9% of participants had depression, 18.7% had overall anxiety, 26.5% had exhaustion, 30.3% reported heavy workload, and 25.4% had COVID-19 infection-specific anxiety, respectively. The HCP working in states with higher caseload was a common risk factor for overall anxiety (odds ratio [OR], 1.7; P < 0.001), depression (OR, 1.6; P < 0.001), COVID-19 infection-specific anxiety (OR, 2.5; P < 0.001), exhaustion (OR, 3.1; P < 0.001), and heavy workload (OR, 2.6; P < 0.001). Nurses were more at risk for depression (OR, 2.2; P < 0.001), anxiety specific to COVID-19 infection (OR, 1.3; P = 0.034), and heavy workload (OR, 2.9; P < 0.001); while doctors were more at risk for overall anxiety (OR, 2.0; P = 0.001) and exhaustion (OR, 3.1; P < 0.001). Conclusions: Frontline workers, specifically nurses and doctors, and those working in states with high COVID-19 caseload are more at risk for adverse psychological outcomes. The relatively less prevalence compared with other countries, is perhaps a reflection of measures undertaken, including early lockdown, ensuring better all-round preparedness and social norms.

Relationship between location of epileptic focus and occurrence during sleep versus wakefulness.

Different sleep stages exert differential effects on interictal discharges, neural synchrony and seizure threshold. We sought to assess the relationship between localization of the epileptogenic focus and seizure distribution in sleep versus wakefulness among patients with refractory epilepsy. We conducted a retrospective chart review-based study. Video-electroencephalography of patients with refractory epilepsy, planned for resective surgery, were reviewed for seizure localisation and occurrence relative to stage of sleep/wakefulness. Demographic/clinical data, including details of surgery, were also recorded. Bivariate analysis was conducted using the chi-square test for proportions and unpaired t-test/ANOVA to compare the means within groups. We enrolled 175 patients (107 males) with a mean age of 26.1 + 9.8 years (range: 4-53 years). We analysed 1,282 seizures, of which 916 (71.5%) were temporal, 95 (7.4%) frontal, 144 (11.2 %) central/ parietal and 19 (1.5%) arose from the occipital lobe. Temporal lobe onset seizures were more frequent during wakefulness (77.7%) compared to extra-temporal localization (65%) (p<0.0001). Amongst temporal lobe onset seizures, those during wakefulness arose more frequently from the lateral temporal (88.6%) compared to the mesial temporal lobe (75.5%) (p=0.0003). A higher proportion of seizures evolved into secondary generalisation during sleep (23.5%) versus 8.7% during wakefulness (p<0.0001). Our study demonstrates that lobar location of epileptogenic foci is associated with a predilection of seizures to occur, as well as secondarily generalise, during sleep/wakefulness. Seizures with lateral temporal lobe as well as extratemporal lobe onset were more likely to occur during wakefulness. Overall, sleep related seizures were more likely to be of extratemporal lobe onset, though.

Restless legs syndrome/Willis-Ekbom disease among patients with resistant hypertension versus stroke patients-a prospective study.

BACKGROUND: Epidemiological studies have shown an increased prevalence and incidence of hypertension as well as a higher incidence of stroke among patients suffering from RLS. The objective of this study was to estimate the prevalence of RLS among patients with resistant hypertension (RH) and compare the clinical characteristics of these patients with patients of stroke pre-existing RLS and with patients with primary RLS presenting to the Sleep clinic. METHODS: Consecutive patients with RH (without any identifiable cause on extensive work up) and consecutive in-patients with stroke were enrolled over a 3-year-period. Patients with RH fulfilling revised-IRLSSG-criteria for RLS comprised group 1 and those with stroke and RLS formed group 2. These were compared with patients diagnosed to have idiopathic RLS (iRLS) (Group 3). Prevalence of RLS in groups 1 and 2 and RLS characteristics in all groups were compared. RESULTS: Sixteen out of 56 RH patients (29%) formed group 1 and 43 out 346 of stroke patients (12%) formed group 2, while 43 consecutive iRLS patients were included in group 3. Age was significantly higher, with male dominance in group 2. Median age at symptom onset was significantly lower in group 1. Positive family history was similar in RH and iRLS patients and was significantly less common in stroke patients. Asymmetrical/unilateral distribution of symptoms was significantly more common in stroke group, compared to RH and iRLS groups. CONCLUSION: This study demonstrated a high prevalence of RLS among patients with resistant hypertension. RLS characteristics are different from those in patients with stroke, and very similar to primary RLS.

Malignant Phyllodes Tumor with Heterologous Sarcomatous Differentiation: a Case Series and Review of Literature.

Malignant phyllodes tumor (MPT) with heterologous sarcomatous differentiation is extremely rare. We reviewed eleven cases of MPT with heterologous sarcomatous differentiation at our institute between 2009 and 2020. Demographic and clinical data were collected from patient records in hospital information system and population-based cancer registry. Each case reviewed retrospectively for the clinical features, prior treatment history, radiological imaging, histopathological and immunohistochemical details, disease stage, outcome and follow-up. On histopathology, four cases showed heterologous liposarcomatous differentiation, three cases showed fibrosarcomatous differentiation, two cases showed osteosarcomatous, and each case had angiosarcomatous and undifferentiated sarcomatous differentiation. Meticulous histopathological sampling along with a correct histopathological diagnosis and subtyping of the heterologous sarcomatous components is essential for planning treatment modality and prognostication of patients, although there are no clear-cut guidelines for surgical management and targeted therapy of these patients due its rarity and paucity of literature.

Activation of CD44-Lipoprotein lipase axis in breast cancer stem cells promotes tumorigenesis.

Breast cancer stem cells (CSCs) are distinct CD44+-subpopulations that are involved in metastasis and chemoresistance. However, the underlying molecular mechanism of CD44 in breast CSCs-mediated tumorigenesis remains elusive. We observed high CD44 expression in advanced-stage clinical breast tumor samples. CD44 activation in breast CSCs sorted from various triple negative breast cancer (TNBC) cell lines induced proliferation, migration, invasion, mammosphere formation that were reversed in presence of inhibitor, 4-methyl umbelliferone or CD44 silencing. CD44 activation in breast CSCs induced Src, Akt, and nuclear translocation of pSTAT3. PCR arrays revealed differential expression of a metabolic gene, Lipoprotein lipase (LPL), and transcription factor, SNAI3. Differential transcriptional regulation of LPL by pSTAT3 and SNAI3 was confirmed by promoter-reporter and chromatin immunoprecipitation analysis. Orthotopic xenograft murine breast tumor model revealed high tumorigenicity of CD24-/CD44+-breast CSCs as compared with CD24+-breast cancer cells. Furthermore, stable breast CSCs-CD44 shRNA and/or intratumoral administration of Tetrahydrolipstatin (LPL inhibitor) abrogated tumor progression and neoangiogenesis. Thus, LPL serves as a potential target for an efficacious therapeutics against aggressive breast cancer.

Association of Sleep Apnea With Development and Behavior in Down Syndrome: A Prospective Clinical and Polysomnographic Study.

BACKGROUND: The prevalence of sleep-disordered breathing is high in children with Down syndrome. Although the association between sleep-disordered breathing and developmental delay and behavioral abnormalities are proven among typically developing children, there are few such studies of children with Down syndrome. This study assesses the relationship between the severity of sleep apnea and development and behavioral abnormalities in individuals with Down syndrome. METHODS: In a cross-sectional prospective study, 53 children with Down syndrome were assessed for sleep-disordered breathing by overnight polysomnography. Behavior was assessed using Child Behavior Checklist (CBCL) and developmental quotient (DQ) using Developmental Profile 3. The association between various domains of behavior and development with the Apnea-Hypopnea Index (AHI) was assessed using Spearman rank correlation. Multiple linear regression assessed the independent effects of various factors on development and behavior. RESULTS: Of 53 subjects (three to 11.8 years), 51 (96%) were found to have obstructive sleep apnea (OSA). In both three to five year and six to 12 year age groups, there was a statistically significant positive correlation between the CBCL scores and the AHI (rho = 0.77 and 0.83, respectively). There was a statistically significant negative correlation between the DQ and the AHI (rho = -0.62). In multiple linear regression, AHI was the only independent variable that was associated with CBCL and DQ. CONCLUSIONS: This study provides robust evidence that OSA can negatively influence the development and behavior in children with Down syndrome as in typically developing children. Moreover, with increasing severity of OSA, children with Down syndrome have more behavioral abnormalities, especially attention deficit and hyperactivity, and also have poorer development scores.

Internet Addiction, Sleep Quality and Depressive Symptoms Amongst Medical Students in Delhi, India.

Today, the internet has become an important element in people's lives, and owing to internet access becoming widespread, it has resulted in internet addiction. It is a major concern amongst medical students aiming to develop into health professionals. The implications of this addiction as well as its association with sleep and depression affects their studies, impacts their career goals and has detrimental consequences for society as a whole. The objectives of this study were to assess the proportion of medical undergraduate students and interns with internet addiction (IA), depressive symptoms and poor sleep quality and to study the association of IA with sleep quality and depressive symptoms. A cross-sectional questionnaire-based study was carried out in a medical college in Delhi. Universal sample consisting of all the medical students from first to final year (n = 185) and interns (n = 37) enrolled during the time of the study were included. Sleep quality, internet addiction and depressive symptoms in these students was assessed using Pittsburgh Sleep Quality Index (PSQI) Young's Internet Addiction Test (YIAT) and Patient Health Questionnaire-9 (PHQ) respectively. The average YIAT score was 33.16 ± 15.68. Overall 18%, 59.9%, 46.8% of students scored above validated cutoff scores for internet addiction, poor sleep quality and depression respectively. Prevalence of IA among males and females were 20.4% and 12.9% respectively. Significant correlations were found between potential IA, sleep quality and depression (p < 0.001). The study concluded a strong correlation between IA, disturbed sleep quality and depression. Identifying medical students with potential IA is important because this addiction often coexists with other psychological problems. Thus timely remedial actions and tailored interventions are required to combat IA among medical students.

Ultrasound-guided transversus abdominis plane block versus caudal block for postoperative analgesia in children undergoing inguinal hernia surgery: A comparative study.

BACKGROUND AND AIMS: Ultrasound-guided (USG) transversus abdominis plane (TAP) block has emerged as a safe and effective regional anesthesia technique as it provides adequate postoperative pain relief for lower abdominal surgeries. Caudal block is a gold standard technique in pediatric surgeries. Our aim was to compare the duration of postoperative analgesia between TAP block and caudal block in children undergoing inguinal hernia surgeries. MATERIAL AND METHODS: In a prospective, randomized, controlled study, 112 children of age 2-8 years and ASA grade I and II, undergoing elective inguinal hernia surgery were randomly allocated into two groups: Group T (n = 56) received USG-guided TAP block with 0.5mL/kg of 0.2% ropivacaine and Group C (n = 56) received caudal block with 1mL/kg of 0.2% ropivacaine. The primary outcome variable was the duration of postoperative analgesia and the secondary outcome variables included variation in hemodynamic parameters and adverse effects, if any. RESULTS: There was no significant difference in median of CHEOPS score till 5 postoperative hours, thereafter till 24 postoperative hours, significantly lower CHEOPS score were found in Group T. Mean duration of analgesia was 523.44 ± 61.30 min in Group T, whereas in Group C, it was 352.59 ± 32.54 min. No significant difference was observed in hemodynamic variations and adverse effects. CONCLUSION: TAP block and caudal block both are effective in providing postoperative analgesia in children undergoing inguinal herniotomy. USG-guided TAP block was found to be superior as it provided longer duration of analgesia and reduced rescue analgesic dose without any significant adverse effects as compared with caudal block after inguinal herniotomy.

Rapid Eye Movement (REM) Sleep Behavior Disorder and REM Sleep with Atonia in the Young.

BACKGROUND: Rapid eye movement (REM) sleep behavior disorder (RBD) and REM sleep without atonia (RWA) have assumed much clinical importance with long-term data showing progression into neurodegenerative conditions among older adults. However, much less is known about RBD and RWA in younger populations. This study aims at comparing clinical and polysomnographic (PSG) characteristics of young patients presenting with RBD, young patients with other neurological conditions, and normal age-matched subjects. METHODS: A retrospective chart review was carried out for consecutive young patients (<25 years) presenting with clinical features of RBD; and data were compared to data from patients with epilepsy, attention deficit hyperactivity disorder (ADHD), and autism, as well as normal subjects who underwent PSG during a 2-year-period. RESULTS: Twelve patients fulfilling RBD diagnostic criteria, 22 autism patients, 10 with ADHD, 30 with epilepsy, and 14 normal subjects were included. Eight patients with autism (30%), three with ADHD (30%), one with epilepsy (3.3%), and six patients who had presented with RBD like symptoms (50%) had abnormal movements and behaviors during REM sleep. Excessive transient muscle activity and/or sustained muscle activity during REM epochs was found in all patients who had presented with RBD, in 16/22 (72%) autistic patients, 6/10 (60%) ADHD patients compared to only 6/30 (20%) patients with epilepsy and in none of the normal subjects. CONCLUSION: We observed that a large percentage of young patients with autism and ADHD and some with epilepsy demonstrate loss of REM-associated atonia and some RBD-like behaviors on polysomnography similar to young patients presenting with RBD.

Troubles du comportement en sommeil paradoxal et sommeil paradoxal sans atonie musculaire chez les jeunes. Contexte: Les troubles du comportement en sommeil paradoxal (TCSP) et le sommeil paradoxal sans atonie musculaire ont acquis une grande importance clinique. En effet, des données à long terme ont montré de quelle façon ils pouvaient progresser chez des adultes âgés atteints de maladies neurodégénératives. Toutefois, on en sait beaucoup moins au sujet des TCSP et du sommeil paradoxal sans atonie musculaire au sein des groupes d'âges plus jeunes. Cette étude entend donc comparer les caractéristiques cliniques et polysomnographiques (PSG) de jeunes patients donnant à voir des signes de TCSP à celles d'autres jeunes patients atteints d'autres troubles neurologiques et de sujets en bonne santé appariés en fonction de l'âge. Méthodes: Nous avons passé en revue de façon rétrospective les dossiers de jeunes patients (< 25 ans) donnant à voir des signes cliniques de TCSP et ayant été vus consécutivement. Les données recueillies ont été comparées aux données de patients atteints d'épilepsie, de troubles de l'attention avec hyperactivité et d'autisme ainsi qu'à celles de sujets en bonne santé soumis à des examens de PSG pendant une période de deux ans. Résultats: Au total, on a diagnostiqué chez 12 patients des TCSP. Ajoutons que 22 d'entre eux étaient atteints d'autisme alors que 10 étaient atteints de troubles de l'attention avec hyperactivité et 30 d'épilepsie. Mentionnons par ailleurs que 14 sujets en bonne santé ont été inclus dans cette étude. Après analyse, il s'est avéré que 8 patients atteints d'autisme (30 %), 3 de troubles de l'attention avec hyperactivité (30 %), 1 d'épilepsie (3,3 %) et 6 ayant donné à voir des symptômes ressemblant à ceux des TCSP (50 %) montraient des mouvements et des comportement anormaux en sommeil paradoxal. Des signes d'activité musculaire transitoire excessive et/ou d'activité musculaire durable lors d'épisodes de sommeil paradoxal ont été détectés chez tous les patients satisfaisant aux critères des TCSP, chez 16 patients autistes sur 22 (72 %), chez 6 patients atteint de troubles de l'attention avec hyperactivité sur 10 (60 %) en comparaison avec seulement 6 patients épileptiques sur 30 (20 %) et aucun parmi les sujets en bonne santé. Conclusion: Lors d'examens polysomnographiques, nous avons en définitive observé qu'une forte proportion de jeunes patients atteints d'autisme et de troubles de l'attention avec hyperactivité, ainsi que quelques-uns atteints d'épilepsie, donnaient à voir des signes de perte de sommeil paradoxal associés à l'atonie musculaire ainsi que des comportements ressemblant à ceux de jeunes patients atteints de TCSP.

Immunological host responses as surveillance and prognostic markers in tubercular infections.

Background: Tuberculosis (TB) control is challenging due to failure of drug compliance and resistance. Mycobacterial antigen-induced cytokine secretions are helpful in detecting Mycobacterium tuberculosis infection and to determine prediction for the fate of TB infection and its cure. Considering immunological response to be a crucial factor in pathogenesis and cure of TB, it can be explored to determine clinical prospects in different categorical tubercular infections. This study was designed to compare serum levels of inflammatory (tumor necrosis factor [TNF]-alpha and interferon [IFN]-gamma) and anti-inflammatory cytokines/chemokines (interleukin [IL]-10 and IL-8) among different TB groups (freshly diagnosed, relapse, cases on antitubercular treatment [ATT], and healthy controls). Methods: This cross-sectional study included total 100 subjects. The study subjects were further divided into four study groups with 25 cases in each of freshly diagnosed TB, TB relapse cases, cases on ATT, and 25 healthy controls. Levels of serum cytokines/chemokines (TNF-alpha, IFN-gamma, IL-10, and IL-8) were measured by flow cytometry. Results: Data analysis observed statistically significant differences in serum levels of TNF-alpha and IFN-gamma among the studied groups with significantly low levels in subjects on ATT and markedly high levels in TB relapse subjects. No statistically significant difference was observed in IL-10 and IL-8 levels. However, subjects with relapse revealed low IL-8 and high IL-10 levels. Conclusion: TNF-alpha and IFN-gamma have important roles in immune response and might be considered as indicators for response to ATT. However, high levels of IL-10 with low IL-8 appear to be associated with poor outcome and possibility of relapse.

Multipronged Treatment of Insomnia - Outcomes from an Apex Sleep Disorders Clinic in India.

INTRODUCTION: A large proportion of the population suffers from disturbed sleep and a majority of these present to clinicians with the complaint of insomnia. Many of these people possibly suffer from other primary sleep disorders such as sleep apnea; however, insomnia disorder also remains an extremely common condition directly impacting the quality of life and work efficiency of affected people. While a number of approaches are used for treatment by many clinicians, a much smaller percentage can seek help from specialty sleep clinics. Since very little data are available regarding the effectiveness of treatment offered, this retrospective study aims at examining the outcome of chronic insomnia patients attending to a quaternary care specialty sleep center. METHODS: Consecutive patients with the presenting complaint of and diagnosis of insomnia, during a study period of 2 years between 2013 and 2015, were identified and analyzed. Patients were classified based on the comorbidity and types of treatment received. Life stressors were also identified and analyzed. Outcomes were reviewed for those who had follow-up data available. RESULTS: Based on the defined inclusion criteria, 102 patients could be analyzed. Among these, at least 3-month follow-up was available for 48 patients. It was observed that among patients for whom at least 3-month follow-up was available, 91.4% (43/48) showed a good response to treatment with physician-administered cognitive behavioral therapy for insomnia along with treatment for comorbid conditions. CONCLUSION: With correct diagnostic classification, as well as appropriate and easily available treatment strategies, excellent treatment outcomes are observed at specialty sleep clinics.

Effect of sleep quality on memory, executive function, and language performance in patients with refractory focal epilepsy and controlled epilepsy versus healthy controls - A prospective study.

We aimed to evaluate the effect of sleep quality on memory, executive function, and language performance in patients with refractory focal epilepsy and controlled epilepsy and compare these with healthy individuals. We prospectively enrolled 37 adolescent and adult patients with refractory focal epilepsy (Group 1) and controlled epilepsy (Group 2) in each group. History pertaining to epilepsy and sleep were recorded, and all patients underwent overnight polysomnography. Language, memory, and executive function assessments were done using Western Aphasia Battery, Post Graduate Institute (PGI) memory scale, and battery of four executive function tests (Trail Making Test A & B, Digit symbol test, Stroop Task, and Verbal Fluency Test), respectively. Forty age- and sex-matched controls were also included in the study. Significant differences were noted in both objective and subjective sleep parameters among all the groups. On polysomnography, parameters like total sleep time, sleep efficiency, sleep latency, and rapid eye movement (REM) latency were found to be significantly worse in Group 1 as compared with Group 2. Cognitive and executive parameters were significantly impaired in Group 1. Shorter total sleep time, poorer sleep efficiency, and prolonged sleep latencies were observed to be associated with poor memory and executive function in patients with refractory epilepsy. Our study strongly suggests that sleep disturbances, mainly shorter total sleep time, poor sleep efficiency, and prolonged sleep latencies, are associated with impaired memory and executive function in patients with refractory focal epilepsy and to a lesser extent, among those with medically controlled epilepsy.

Cognitive, behavioural and sleep-related adverse effects on introduction of levetiracetam versus oxcarbazepine for epilepsy.

OBJECTIVE: There is limited literature on cognitive, behaviour and sleep-related adverse effects of levetiracetam and oxcarbazepine among adult epilepsy patients, except for what is available from the initial efficacy trials. This study was initiated with the aim to evaluate the incidence and prevalence of various cognitive, behaviour and sleep-related adverse effects of levetiracetam versus oxcarbazepine among people with epilepsy. METHODS: The study was conducted in two parts: part A was a cross-sectional study, and part B was a longitudinal study. Trail making test A & B, digit symbol substitution test, Stroop colour and word test, controlled oral word association test and PGI memory scale, Neuropsychiatric Inventory, sleep log and ESS-I were used for assessment of cognitive, behaviour and sleep-related adverse effects. RESULTS: In the cross-sectional as well as prospective study, no significant difference was observed in the cognitive performance of patients in levetiracetam and oxcarbazepine group in any of the cognitive assessment. Among 120 patients enrolled in the cross-sectional study, significantly higher number of patients in the levetiracetam group compared to the oxcarbazepine group,had agitation/aggression (20% vs10%, p = 0.047) and irritability (26.7% vs 3.3%, p = 0.007).Among 132 patients enrolled in the prospective study, significantly higher increase in the domain score of agitation/aggression (14.5% vs 1.6%, p = 0.028) and irritability (17.7% vs 1.6%, p = 0.018) was observed in the levetiracetam group compared to oxcarbazepine group. A significantly higher proportion of patients in the oxcarbazepine group had hypersomnolence (11.3% vs 1.6%, p = 0.026), as compared to the levetiracetam group. SIGNIFICANCE: On cross-sectional as well as on longitudinal assessment, nearly one-fifth of patients on levetiracetam have behaviour related adverse effects, with dose modification required for half among these. Nearly 11% of patients on oxcarbazepine reported sleep-related adverse effects (higher total sleep duration per 24 h).

Integrating Morphological Edge Detection and Mutual Information for Nonrigid Registration of Medical Images.

BACKGROUND: Medical images are widely used within healthcare and medical research. There is an increased interest in precisely correlating information in these images through registration techniques for investigative and therapeutic purposes. This work proposes and evaluates an improved measure function for registration of carotid ultrasound and magnetic resonance images (MRI) taken at different times. METHODS: To achieve this, a morphological edge detection operator has been designed to extract the vital edge information from images which is integrated with the Mutual Information (MI) to carry out the registration process. The improved performance of proposed registration measure function is demonstrated using four quality metrics: Correlation Coefficient (CC), Structural Similarity Index (SSIM), Visual Information Fidelity (VIF) and Gradient Magnitude Similarity Deviation (GMSD). The qualitative validation has also been done through visual inspection of the registered image pairs by clinical radiologists. RESULTS: The experimental results showed that the proposed method outperformed the existing method (based on integrated MI and standard edge detection) for both ultrasound and MR images in terms of CC by about 4.67%, SSIM by 3.21%, VIF by 18.5%, and decreased GMSD by 37.01%. Whereas, in comparison to the standard MI based method, the proposed method has increased CC by 16.29%, SSIM by 16.13%, VIF by 52.56% and decreased GMSD by 66.06%, approximately. CONCLUSION: Thus, the proposed method improves the registration accuracy when the original images are corrupted by noise, have low intensity values or missing data.