Biophysical modeling and diffusion kurtosis imaging reveal microstructural alterations in normal-appearing white-matter regions of the brain in obstructive sleep apnea.

Study Objectives: Studies have indicated that sleep abnormalities are a strong risk factor for developing cognitive impairment, cardiomyopathies, and neurodegenerative disorders. However, neuroimaging modalities are unable to show any consistent markers in obstructive sleep apnea (OSA) patients. We hypothesized that, compared with those of the control cohort, advanced diffusion MRI metrics could show subtle microstructural alterations in the brains of patients with OSA. Methods: Sixteen newly diagnosed patients with moderate to severe OSA and 15 healthy volunteers of the same age and sex were considered healthy controls. Multishell diffusion MRI data of the brain, along with anatomical data (T1 and T2 images), were obtained on a 3T MRI system (Siemens, Germany) after a polysomnography (PSG) test for sleep abnormalities and a behavioral test battery to evaluate cognitive and executive brain functions. Diffusion MRI data were used to compute diffusion tensor imaging and diffusion kurtosis imaging (DKI) parameters along with white-matter tract integrity (WMTI) metrics for only parallel white-matter fibers. Results: OSA was diagnosed when the patient's apnea-hypopnea index was ≥ 15. No significant changes in cognitive or executive functions were observed in the OSA cohort. DKI parameters can show significant microstructural alterations in the white-matter region, while the WMTI metric, the axonal-water-fraction (fp), reveals a significant decrease in OSA patients concerning the control cohort. Conclusions: Advanced diffusion MRI-based microstructural alterations in the white-matter region of the brain suggest that white-matter tracts are more sensitive to OSA-induced intermittent hypoxia.

Racemose neurocysticercosis: a case series.

Neurocysticercosis (NCC) is a common parasitic condition of the central nervous system in certain parts of the world. The racemose variety of NCC is distinct from the commonly seen parenchymal form. It frequently infiltrates the basal cisterns and Sylvian fissures. Imaging plays a vital role in the diagnosis; however, as their signal intensity is similar to cerebrospinal fluid and due to the absence of enhancement in most cases, imaging diagnosis is often difficult on the conventional MRI sequences. Here, we present five cases of racemose NCC to emphasize the importance of a heavily T2-weighted sequence (Fast Imaging Employing Steady-state Acquisition) sequence in the diagnosing this entity.

Nonsurgical hypoparathyroidism is associated with skeletal muscle dysfunction and restrictive lung disease.

CONTEXT: Systematic assessment of skeletal muscle function is lacking in patients with nonsurgical hypoparathyroidism (HP). Whether muscle dysfunction involves respiratory muscles and results in restrictive lung disease (RLD) is not studied. OBJECTIVE: To assess skeletal muscle and pulmonary functions in patients with HP. DESIGN: Observational case-control study. METHODS: Thirty patients with HP (mean age 37.7 years, 60% males) and 40 age-, sex-, and body mass index (BMI)-matched healthy controls were assessed for skeletal muscle function by handgrip strength, the short physical performance battery (SPPB) test, dual-energy X-ray absorptiometry (DXA), and electromyography (EMG). Pulmonary function was assessed by spirometry, body plethysmography, diffusion lung capacity for carbon monoxide, and diaphragmatic ultrasound (DUS). RESULTS: Patients with HP had lower serum calcium (2.25 ± 0.15 vs 2.4 ± 0.12 mmol/L, P < .001), serum magnesium (median [interquartile range] 0.74 [0.69-0.82] vs 0.78 [0.69-0.90] mmol/L, P = .04), handgrip strength (18.08 ± 8.36 vs 22.90 ± 7.77 kg, P = .01), and composite SPPB scores (9.5 [7-10] vs 12 [12-12], P < .001) compared to healthy controls. Electromyographic evidence of myopathy was seen in 23% (5 of 22) of patients with HP but in none of the controls (P = .08). The prevalence of RLD was higher in the HP cohort compared to that in controls (24% vs 0%, P = .01). Diaphragmatic excursion (DE) (4.22 ± 1.38 vs 5.18 ± 1.53 cm, P = .01) and diaphragmatic thickness (DT) (3.79 ± 1.18 vs 4.28 ± 0.94 mm, P = .05) on deep inspiration were reduced in patients with HP. CONCLUSION: Detailed testing of patients with HP without overt muscle and lung diseases revealed significant impairment in parameters of skeletal muscle function. Myopathy and RLD were observed in a considerable proportion of patients with HP.

The Psychosocial Impact of COVID-19 on an Adult Indian Population.

BACKGROUND: Coronavirus disease (COVID-19) was a pandemic with many physical, psychological, and socioeconomic effects. COVID-19 caused a global increase in anxiety and depression because of its novelty, high infectivity, varied presentation, and unpredictable mortality. In the face of collapsing healthcare facilities, monetary setbacks, and loneliness because of lockdowns, people were anxious, and this was compounded by media sensationalism. We aimed to study the psychosocial impact of COVID-19 on the adult Indian population. METHODS: An online survey using SurveyMonkey was floated through WhatsApp messages in April 2020, using the 'chain-referral sampling' method. Responses from individuals >18 years were included, and questions included age, sex, occupation, demographics, and socioeconomic conditions. The prevalence of anxiety and depression was assessed using the Generalized Anxiety Disorder (GAD-7) and the Patient Health Questionnaire (PHQ-9) scales. Data was analyzed using IBM SPSS software, and predictors of anxiety and depression were assessed. RESULTS: A total of 2640 responses from individuals between 18 years and 81 years were analyzed, of which 39% were from females and 85% from those <50 years of age. There were students (15.6%), teachers (10.7%), healthcare workers (16.8%), homemakers (9%), and daily wage laborers (4.1%), among others. Nearly 80% lived in cities, 55% had salaried jobs, 37% were working from home, 22% were temporarily unemployed, 10% were feeling work stress, 11% had increased alcohol intake, and 7.5% saw an increase in domestic violence. The income of 50% was adversely affected. Nearly 50% of our respondents had some symptoms of anxiety, and 23% had significant anxiety (GAD ≥5). The presence of anxiety was significantly higher in females, younger adults, city dwellers, healthcare workers, unemployed people, individuals living away from home, those without fixed salaries, those with work stress, and in people whose incomes had been adversely affected by the pandemic. On logistic regression analysis, female sex, younger age, unemployment, lack of salaried jobs, work stress, being a healthcare worker, and media reports were independent predictors of anxiety. About 60% of our respondents had some symptoms of depression, with 26% having significant depression (PHQ-9 ≥5). The presence of depression was significantly higher in females, younger adults, city dwellers, unemployed people, individuals living away from home without fixed salaries, and people with work stress. On logistic regression analysis, younger age, female sex, unemployment, lack of salaried jobs, work stress, and media reports were independent predictors of depression. Among our respondents, 70% used the time during the lockdown to study, 77% caught up with their families, and 56% reconnected with hobbies. Nearly 88% of our respondents had adjusted to their changing circumstances, helped by their religious beliefs and faith, the support of family and friends, good government measures, and the assurance of healthcare. CONCLUSIONS:  Significant anxiety and depression were seen in 23% and 26% of respondents, respectively. Being a healthcare worker was an independent predictor of anxiety. Female sex, younger age, unemployment, work stress, and sensational media reports were independent predictors of both anxiety and depression.

Alien-hand syndrome with mirror movements in hereditary diffuse leukoencephalopathy with spheroids.

Hereditary diffuse leukoencephalopathy with spheroids is a rare genetic disorder caused by mutations of the colony-stimulating factor 1 receptor gene. It is an adult-onset leukodystrophy, with a wide spectrum of neurological and psychiatric manifestations that includes Parkinsonism, dementia, seizures, limb weakness, spasticity and abnormal motor behaviour. Alien-hand syndrome and mirror movements are rare manifestations of this and other neurodegenerative disorders. We describe a woman with progressive limb and trunk rigidity, Parkinsonism and dementia, who also had involuntary left arm levitation (part of the posterior variant of alien-hand syndrome) and left-hand mirror movements. We discuss the different types of alien-hand syndrome, and the likely mechanisms of arm levitation and mirror movements.

Seizure Outcome after Lesionectomy With or Without Concomitant Anteromedial Temporal Lobectomy for Low-Grade Gliomas of the Medial Temporal Lobe.

BACKGROUND: Mesial temporal lobe epilepsy attributed to low-grade glioma is known for intractable seizures and choice of surgery range from lesionectomy (Lo) to lesionectomy with anteromesial temporal resection (L0 + AMTR) is still debatable. We intend to analyze the seizure outcome after lesionectomy alone or with AMTR. SUBJECTS AND METHODS: Retrospective analyses of patients operated for medial low-grade temporal lobe tumors with seizures were included in the study. Preoperative records include video-electroencephalographic, magnetic resonance imaging (epilepsy protocol), and neuropsychological evaluation for language, memory, and dominance were assessed. Two groups (Lo [Group I] and Lo + AMTR [Group II]) were assessed after surgery by the international league against epilepsy (ILAE) seizure outcome scale. RESULTS: A total of 39 patients underwent Lo (n = 20) and Lo + AMTR (n = 19) with a mean age of 26.92 ± 12.96 months, and mean duration of seizures was 36.87 46.76 months. A total of 23 patients had long-term intractable seizures for >1 year despite >2 drugs(Group I [n = 10], Group II [n = 13]); remaining 16 had frequent seizures of <1-year duration. In the postoperative period, on a mean follow-up of 49.72 ± 34.10 months, the ILAE outcome scale shown a significant difference (P = 0.05) in seizure outcome between two groups. Four (40%) patients out of 10 having refractory seizures in Group I and 8 (80%) from the Group II out of 10 patients could achieved ILAE Class 1 outcome after surgery. Histopathology analysis includes low-grade astrocytoma (n = 29) and in two patients there were associated CA1 neuronal loss in hippocampus, one patient had mesial temporal sclerosis from Group II attributed to its intractability in seizures. CONCLUSION: For the mesial temporal low-grade glioma presenting with seizures, the seizure outcome by lesionectomy with AMTR is superior than lesionectomy only.

Japanese B Encephalitis.

RNA viruses are not only reported for viral pandemics but also as important agents for emerging/re-emerging diseases. Japanese encephalitis virus (JEV) is reported to cause epidemics of encephalitis in Southeast Asia, India, Korea, China, and Indonesia. In addition, several reports show that JEV has spread to new populations beyond these geographical regions. The disease mostly affects children with a mortality rate up to 30%. In peridomestic settings, pigs are reported as amplifiers of JEV transmission and aquatic birds as maintenance hosts of the virus. The Culex mosquito is the vector for transmission of JEV. This virus is a member of the family Flaviviridae and has a single-stranded positive-sense RNA virus. Five different genotypes (G-I to G-V) of JEV have been reported. Four different kinds of vaccines have been produced to prevent JEV infection. However, there is no FDA-approved antiviral drug available for JEV. How to cite this article: Mehta A, Singh R, Mani VE, Poddar B. Japanese B Encephalitis. Indian J Crit Care Med 2021;25(Suppl 2):S171-S174.

Resistant Temporal Lobe Epilepsy: Initial Steps into a Bigger Epilepsy Surgery Program.

Background Among the patients of drug-resistant epilepsy, a subset which has focal impaired seizures localizes to the temporal lobe region (TLE). A majority of these cases are surgically amenable with anterior-medial temporal lobe resection or "lesionectomy." Objective In India, there is scarcity of "specialized centers" providing "comprehensive epilepsy care" and this dearth is further worse in populous states. In this article, we share our single center, observational, and retrospective experience of TLE in background of limited resources and utmost requirement. Methodology Our study is a retrospective analysis medically refractory epilepsy patients (2016-2019). Patients with medically refractory epilepsy were selected based upon our noninvasive protocol (clinical semiology, interictal scalp electroencephalography (EEG), long-term video EEG monitoring data, and magnetic resonance injury [MRI]). The follow-up was noted from the last out-patient visit record or through telephonic conversation (International League Against Epilepsy score). Results Of 23 cases of TLE ( n = 7, mesial temporal sclerosis; n = 16 temporal lobe like cavernomas, tumors, or arterio-venous malformations). Single photon emission computed tomography/positron emission tomography (SPECT/PET) was performed in five cases (three cases of ictal/interictal SPECT and two cases of PET scan) where there was discordance between EEG/clinical and MRI. The median follow-up was of 19 months with 18 cases being seizure free. Five cases were fully off the antiepileptic drug (AEDs) while in 15 cases, the AEDs dosages or the number were reduced. Average number of AEDs reduced from 2.9 in preoperative period to 1.2 postoperatively. Two cases had quadrantanopia and one case of cerebrospinal fluid leak. Conclusion A multidisciplinary and holistic approach is required for best patient care. The results of our initial surgical experience are encouraging.

A Cost-Effective Approach to the Diagnosis and Management of Acute Infectious Encephalitis.

SETTING: A tertiary care teaching hospital in India. OBJECTIVE: To report a syndromic approach to acute encephalitis syndrome (AES) and propose a cost-effective model. STUDY DESIGN: AES patients were categorized by the presence or absence of myalgia/rash into systemic and neurological AES. The patients with systemic AES were investigated for dengue, scrub typhus, leptospira, chikungunya, and malaria, and those with neurological AES were investigated for herpes and Japanese encephalitis (JE). Sensitivity and specificity of syndromic categorization were tested, and cost effectiveness was calculated. RESULTS: There were 210 patients with infectious AES; neurological in 45 and systemic in 165. Specific etiology could be found in 130 (62%) patients, and after excluding 36 patients with co-infections, 94 patients were tested for sensitivity and specificity. Twenty patients had neurological AES (herpes 12, JE 8), and 74 systemic (scrub typhus 42, dengue 20, malaria 6, leptospira 6). The absence of myalgia/rash categorized neurological AES with 100% specificity. In neurological AES, thalamic involvement predicted JE with 100% specificity. In systemic AES, differentiation could not be made between etiologies based on hypotension, thrombocytopenia, and muscle, liver, and kidney dysfunction. In these patients, MRI and acyclovir therapy were warranted, saving cost. By targeted investigations and treatment, the cost was reduced by 70%. CONCLUSIONS: A syndromic approach to AES and goal-directed investigations and treatment substantially reduces the cost of management.

Can we differentiate between herpes simplex encephalitis and Japanese encephalitis?

BACKGROUND: Herpes simplex encephalitis (HSE) occurs without regional and seasonal predilections. HSE is important to differentiate from arboviral encephalitis in endemic areas because of therapeutic potential of HSE. This study evaluates clinical features, MRI and laboratory findings which may help in differentiating HSE from Japanese encephalitis (JE). METHODS: Confirmed patients with JE and HSE in last 10years were included. The presenting clinical symptoms including demographic information, seizure, behavioral abnormality, focal weakness and movement disorders were noted. Cranial MRI was done and location and nature of signal alteration were noted. Electroencephalography (EEG), cerebrospinal fluid (CSF), blood counts and serum chemistry were done. Outcome was measured by modified Rankin Scale (mRS). Death, functional outcome and neurological sequelae were noted at 3, 6 and 12months follow up, and compared between HSE and JE. Outcome was categorized as poor (mRS;>2) and good (mRS≤2). RESULTS: 97 patients with JE and 40 HSE were included. JE patients were younger than HSE and occurred in post monsoon period whereas HSE occurred throughout the year. Seizure (86% vs 40%) and behavioral abnormality (48% vs 10%) were commoner in HSE; whereas movement disorders (76% vs 0%) and focal reflex loss (42% vs 10%) were commoner in JE. CSF findings and laboratory parameters were similar in both the groups. Thalamic involvement in JE and temporal involvement in HSE were specific markers of respective encephalitis. Delta slowing on EEG was more frequent in JE than HSE. 20% JE and 30% HSE died in the hospital, and at 1year follow up JE patients showed better outcome compared to HSE (48% vs 24%). Memory loss (72% vs 22%) was the predominant sequelae in HSE. CONCLUSION: Seizure and behavioral abnormality are common features in HSE whereas focal reflex loss is commoner in JE. In a patient with acute encephalitis, thalamic lesion suggests JE and temporal lobe involvement HSE. Long term outcome in JE is better compared to HSE.

Status epilepticus in scrub typhus.

Scrub typhus is an emerging infection, and there is little information about status epilepticus (SE) in scrub typhus. We report the clinical spectrum and outcome of SE in scrub typhus. In a 3-year prospective hospital-based observational study, all scrub typhus patients with SE were included. Scrub typhus was diagnosed by immunochromatography assay. SE was defined if convulsions lasted longer than 5 min. The patients' demographic, clinical, computed tomography (CT), magnetic resonance imaging (MRI), and electroencephalography (EEG) findings were noted. Response to antiepileptic drugs (AEDs) and outcome at 1 month and 1 year were recorded. Between 2012 and 2014, there were 66 patients with scrub typhus admitted with central nervous system (CNS) involvement, 10 (15.2%) of whom had SE (generalized convulsions in 5, secondary generalized in one). The median age of the patients was 34 (range 18-71) years and seven were female. The duration of SE ranged between 10 min and 48 h. SE responded to one AED in five patients, two AEDs in three patients, and more than two AEDs in two patients. Cranial MRI findings were normal. All patients recovered completely with doxycycline by 1 month and AED was withdrawn by 8 months in all. Although 15% patients with scrub typhus may have SE, they have good outcome.

Central nervous system and muscle involvement in dengue patients: A study from a tertiary care center.

BACKGROUND: Neurological involvement in dengue virus (DENV) infection is being increasingly reported. There is paucity of studies evaluating the relative frequency of central nervous system (CNS) and muscle involvement in dengue. OBJECTIVES: To evaluate the frequency and prognosis of neurological and muscle involvement in dengue, and correlate these with dengue subtypes. STUDY DESIGN: Consecutive dengue patients were included, and their clinical features, laboratory investigations and cerebrospinal fluid (CSF) findings were recorded. Cranial MRI was done in unconscious patients and electromyography and nerve conduction study in patients with flaccid weakness. Patients were categorized into encephalopathy, encephalitis, immune mediated and dengue associated muscle dysfunction (DAMD). Outcome at 1 month and its predictors were evaluated. RESULTS: 116 patients aged 5-70 years were included; 82 had dengue fever (DF), 18 had dengue hemorrhagic fever (DHF), and 16 had dengue shock syndrome (DSS). Neurological manifestations were present in 92 (79%); encephalopathy in 17 (15%), encephalitis in 22 (19%), transverse myelitis in 1 (1%) and DAMD in 52 (45%) patients. Central nervous system (CNS) involvement was commoner in DHF/DSS compared to DF (44% vs 26%). 10 patients with CNS involvement died versus 1 with DAMD. The patients in the CNS group had more frequent hypotension, renal dysfunction and respiratory failure compared to the DAMD group, and had worse outcome. DENV2 and DENV3 were the commonest serotypes, but serotypes did not differ between CNS and DAMD groups. CONCLUSIONS: DAMD is commoner than CNS involvement in dengue. CNS involvement however, is associated with more serious illness and predicts poorer outcome.

A study of muscle involvement in scrub typhus.

OBJECTIVES: Patients with scrub typhus often complain of myalgia, but a comprehensive study on muscle dysfunction is lacking. We therefore report the clinical, electromyographic and muscle biopsy findings in patients with scrub typhus. METHODS: Consecutive patients with scrub typhus were included, and their clinical and laboratory findings were noted. The patients with myalgia or weakness and elevated serum creatine kinase (CK) were considered to have muscle involvement. Electromyography (EMG) and muscle biopsy were done in some patients. Patients were treated with doxycycline 200mg daily for 7 days, and their clinical and biochemical outcome on discharge and one month were evaluated. RESULTS: 13 out of 33 (39.4%) patients had muscle involvement and their CK levels ranged between 287 and 3166 (859 ± 829) U/L. EMG revealed short duration polyphasic potentials, and muscle histopathology revealed evidence of vasculitis. There were significant correlations between severity of weakness and CK levels (r = -0.6; p < 0.001), platelet counts (r = 0.4; p = 0.04), duration of illness (r = -0.4; p = 0.01) and disability on discharge (r = -0.4; p = 0.04). Patients with muscle involvement had more severe illness evidenced by a lower Glasgow Coma Scale score (p < 0.001), thrombocytopenia (p = 0.05) and greater disability on discharge (p = 0.007), when compared to those without muscle involvement. All the patients had complete recovery following doxycycline therapy, and CK levels also normalized. CONCLUSION: Muscle dysfunction was present in 39% patients with scrub typhus. Although muscle histopathology showed evidence of vasculitis, patients responded to doxycycline.

Impact of HbAlc on acute cardiac states.

OBJECTIVES: To find out the impact of HbAlc levels on the severity and short term complications of patients with heart disease admitted to the Intensive Coronary Care Unit (ICCU). METHODS: One hundred and sixty six patients admitted to ICCU in 2006 with acute cardiac states (unstable angina, acute myocardial infarction, heart failure, cardiomyopathy) were prospectively studied. Patients were divided into two groups--Group A (diabetics) and Group B (non diabetics). Patients were followed up till the time of discharge. RESULTS: Out of the 166 patients, 92 were diabetic (group A) and 74 were non diabetic (group B). The mean HbAlc of group A was 8.4+1.9% and that of group B was 5.7+0.6%. Risk factors like dyslipidemia, hypertension, previous history of heart disease and triple vessel disease were found more in group A than in group B. History of smoking, positive family history of heart disease, and angina as a presenting symptom were more in group B. Complications like heart failure and post infarction angina occurred significantly more in patients with diabetes. In group A, unstable angina, ST elevation myocardial infarction, cardiac failure, accelerated hypertension, dilated cardiomyopathy and triple vessel disease were seen in a significantly higher proportion of patients with poor glycemic control (HbAlc>or=7%) compared to patients with HbAlc level<7%. In group B, 72/74 (97.2%) patients had HbAlc levels>or=5%, 68.8% of whom had HbAlc levels of >or=5.6%. CONCLUSION: Severity and complications of heart disease were significantly higher in diabetics and showed a significant correlation with HbAlc. A large number of non diabetics presenting with acute cardiac states i.e. 97.2%, had HbAlc values>or=5%.