Can change in gut microbiota composition be used as a surrogate marker of treatment efficacy of ketogenic diet in patients with drug-resistant epilepsy?

To answer the question posed in the title of the manuscript, we critically examined the connection between ketogenic diet (KD), gut microbiota (GM), and epilepsy. We conclude that although the evidence for a KD-GM-epilepsy link is fairly robust in rodent epilepsy models, it is very hard to draw meaningful conclusions in humans. The limitations of human studies that have investigated the KD-microbiota-epilepsy relationship include small sample size, a heterogeneous patient population with regard to age and epilepsy type, failure to account for the effect of dietary habits, antiseizure drugs (ASDs) and comedications on GM composition, variability in the KD administered and in the duration of the intervention, and different approaches used in sequencing the microbiome. Although alteration in the GM composition may be a potential indicator of responsiveness/resistance to a KD, we need well-designed randomized case-control and cohort studies involving a large number of a fairly homogenous population of patients with epilepsy adjusted to their habitual dietary habits and region of residence before labeling it as a surrogate marker. Research in this direction may also help us to unravel the mysteries of GM-brain axis not only concerning epilepsy but also in other neurological diseases.

Socioeconomic consequences of drug-resistant epilepsy in an adult cohort from southern India.

OBJECTIVE: The objective of this study was to describe the socioeconomic consequences of drug-resistant epilepsy (DRE). METHODS: This study comprised 132 (equal males and females) consecutive patients aged ≥18 years, who fulfilled the International League Against Epilepsy (ILAE) definition for DRE, prospectively seen in a tertiary care center in South India. We used a structured questionnaire to gather relevant information. RESULTS: The mean age was 31 (range 18-70) years. Mean age of onset of epilepsy was 17 years and mean duration of epilepsy 14 years. The most common epilepsy type and etiology were focal epilepsy and gliotic lesions secondary to perinatal insults, respectively. The average out of the pocket expenditure on antiseizure drugs annually amounted to 19% of the gross national product (GNP)/capita, which was borne by family members in more than two-thirds of the subjects. Almost 60% reported epilepsy having affected their education, 40% their employment, and 90% their marital prospects. Female patients were less often employed outside their homes and had more marital problems compared with males. CONCLUSIONS: In addition to high seizure burden, DRE adversely affects the pursuit of higher education, employment, and marriage. Besides the direct cost of epilepsy, these issues augment both the patient and the caregiver's liability. Socioeconomic consequences of DRE are widely prevalent in developing countries, and this study highlights the need to address them.

Sexual dysfunction in people with epilepsy.

Sexual dysfunction is a common comorbidity in people with epilepsy (PWE) that adversely affects their quality of life. Nearly one-half of men and women with epilepsy have sexual dysfunction, but in the majority, this often goes unnoticed. The wide variation in the reported prevalence of sexual dysfunction in PWE is due to the significant heterogeneity among the studies with regard to patient population, type and severity of epilepsy, number and type of antiseizure drugs (ASDs) used, and the tools used for assessing sexual dysfunction. Generally, patients with uncontrolled epilepsy, longer duration of epilepsy, focal epilepsy, higher seizure frequency, and those receiving enzyme-inducing and multiple ASDs are more likely to have sexual dysfunction. Women generally have dysfunction in the domains of desire, while males usually have arousal disorders such as erectile dysfunction and premature ejaculation. There is limited evidence to indicate that sexual function improves in patients rendered seizure-free following epilepsy surgery. Multiple mechanisms including direct effects of epilepsy, effects of ASDs, and psychosocial factors contribute to sexual dysfunction in epilepsy. Circumstantial evidence indicates that seizures and interictal epileptiform discharges can directly affect the hypothalamic-pituitary axis as well as production of gonadal steroids. Enzyme-inducing ASDs cause sexual dysfunction by affecting the metabolism of gonadal steroids. Limited data suggest that newer ASDs including oxcarbazepine, lamotrigine, and levetiracetam cause no or minimal sexual dysfunction. Depression and anxiety significantly contribute to sexual dysfunction in PWE. A multipronged and multidisciplinary approach is essential for optimizing the sexual functions. Every effort should be made to identify and treat reversible causes including changing to nonenzyme-inducing ASDs and to provide symptomatic relief. Large, prospective studies are required to improve our understanding on prevalence and mechanisms of sexual dysfunction in PWE.

The comparative efficacy of theta burst stimulation or functional electrical stimulation when combined with physical therapy after stroke: a randomized controlled trial.

OBJECTIVE:: To study the long-term effectiveness of Theta Burst Stimulation (TBS) or Functional Electrical Stimulation (FES) combined with Physical therapy (PT) as compared to PT alone for improving arm functions in patients with acute stroke. DESIGN:: Single blind randomized controlled trial. SETTING:: Outpatient clinics and inpatient wards at tertiary care neurology center. SUBJECTS:: Adult patients with acute middle cerebral artery territory ischemic stroke. INTERVENTIONS:: 60 patients were randomized into three groups of 20 each: TBS+PT; FES+PT; and PT alone. TBS group received intermittent TBS of ipsilesional hemisphere and continuous TBS of contralesional hemisphere while FES group received FES of paretic limb, both for four weeks. All groups received supervised physical therapy for four weeks followed by home physiotherapy for one year. OUTCOME MEASURES:: Fugl Meyer Assessment upper limb score (FMA-UL) was primary outcome measure. Patients were evaluated at baseline and subsequently at one, three and six months and one year. RESULTS:: Compared to PT group, mean FMA-UL scores were higher in TBS and FES groups at all follow-ups ( P < 0.001). From baseline to one year, mean (SD) FMA-UL scores increased from 14.9(2.1) to 55.55(2.46) in TBS group, 15.5(1.99) to 55.85(2.46) in FES group, and 14.3(2.2) to 43.3(4.22) in PT group indicating an increase of 273%, 260%, and 203% respectively. There was no difference between FES and TBS groups. CONCLUSION:: A four-week intervention with TBS or FES combined with PT produces better long-term arm functions as compared to PT alone in patients with acute stroke.

Sleep Apnea-Predictor of Functional Outcome in Acute Ischemic Stroke.

BACKGROUND: Sleep apnea is increasingly being recognized as 1 of the important, modifiable risk factors of stroke and cardiovascular diseases. Sleep apnea is thought to impair the functional recovery following stroke. Hence, we evaluated the patients with acute ischemic stroke for prevalence of sleep apnea and compared the functional outcomes of patients with and without sleep apnea, at 3rd month of acute ischemic stroke. METHOD: This study was conducted in Kasturba Medical College (KMC) hospital, Manipal, India, between May 2015 and August 2016. We included 102 consecutive patients of acute ischemic stroke with hemiplegic upper limb power of Medical Research Council (MRC) 3 or less. Sleep apnea was diagnosed in these patients using the sleep disordered Questionnaire, Berlin Questionnaire, and Epworth sleepiness scale. Functional outcome was measured using Barthel score on day 7 and at 3rd month following the onset of stroke. RESULT: Out of 102 patients, sleep apnea was present in 31 (30.6%) patients, more in males (67.7%) and elderly. Hypertension was present in 66.6% of patients with sleep apnea. NIHSS score at admission did not differ between the 2 groups. At 3rd month, the Barthel score calculated was better among patient with no apnea, but this was not statistically significant (P = .119). When mean Barthel score at baseline and 3rd month was calculated using repeated measure Analysis of Variance (ANOVA) between the 2 groups, gain in functional independence in no apnea group was statistically significant (P < .001). CONCLUSION: Sleep-disordered breathing is an independent risk factor for stroke, and sleep apnea is also associated with other known stroke risk factors like hypertension. In acute ischemic stroke, sleep apnea has a negative impact on functional recovery. Sleep apnea is amenable to treatment and should be considered in patients with acute ischemic stroke to improve the chance of recovery, and to reduce the risk of recurrence.

Randomized controlled trial on the effectiveness of a multicomponent intervention on migraine: A study protocol.

AIM: To describe a randomized controlled trial protocol that evaluates the effectiveness of a multicomponent intervention in improving the outcomes (quality of life, disability, intensity, frequency and duration) of patients with migraine. BACKGROUND: Migraine affects various facets of Quality of Life and results in moderate to high levels of disability among migraineurs. Migraine pain can be intense and unremitting that can interfere with the daily routine and reduce the ability to think and function normally. Many people can lower their risk of a migraine by simply avoiding stress, getting enough sleep, eating regularly and by avoiding triggers. Hence, the present study aims at evaluating the effectiveness of a multicomponent intervention in managing migraine headaches. The multicomponent intervention includes behavioural lifestyle modification program and sessions of pranayama (a form of yogic breathing exercise). DESIGN: The study is a prospective, randomized, controlled, single-blinded trial with parallel arms. METHODS: The study participants are randomized to intervention and control arms. The participants randomized to the intervention arm would receive the specific multicomponent intervention based on the protocol. The participants in the control arm would receive routine care. They are followed up for 24 weeks and the outcomes are assessed. DISCUSSION: Various studies report that non-pharmacological therapies and integrative therapies play a major role in the management of migraine headaches. The findings of the study are expected to open up new horizons in health care arena emphasizing the use of non-pharmacological therapy for less focused areas of primary care health problems such as migraine. TRIAL REGISTRATION: The trial is registered with the Clinical Trials Registry India (CTRI). The CTRI India is one of the primary registries in the WHO registry network (Ctri.nic.in, ). CTRI reference ID: CTRI/2015/10/006282.

Epidemiology of epilepsy surgery in India.

Epilepsy surgery in India has seen remarkable advances over the last twenty years. Presently 39 centers are undertaking epilepsy surgeries in India on a regular basis. Out of these, 18 centers have become operational in the last five years. Many of them are well equipped with high end technologies and have expertise to undertake all kinds of epilepsy surgeries. Till July 31st, 2016, approximately 7143 epilepsy surgeries have been performed in India. Presently, 734 epilepsy surgeries are carried out in India every year representing an increase of approximately 58% over the last three and a half years as compared to the previous years. The reported postoperative outcomes from all these centers are comparable to those reported from the well-established centers in high income countries. Still, only 2 in 1000 eligible patients In India undergo epilepsy surgery, because of which, the enormous surgical treatment gap continues to persist. To tackle this, by the year 2020, India should have at least 60 state-level epilepsy surgery centers (with each undertaking at least 50 surgeries per year) and 6 national centers of excellence. Here, we discuss the current prevalence and practice of epilepsy surgery in India and suggest pragmatic steps and solutions to make epilepsy surgery affordable and widely available. The steps also include a framework for the development of a national epilepsy surgery program.

Role of magnetoencephalography and stereo-electroencephalography in the presurgical evaluation in patients with drug-resistant epilepsy.

In selected patients with drug-resistant focal epilepsies (DRFE), who otherwise are likely to be excluded from epilepsy surgery (ES) because of the absence of a magnetic resonance imaging (MRI)-demonstrable lesion or discordant anatomo-electro-clinical (AEC) data, magnetoencephalography (MEG) may help to generate an AEC hypothesis and stereo-electroencephalography (SEEG) may help to verify the hypothesis and proceed with ES. The sensitivity of MEG is much better in localizing the spiking zone in relation to lateral temporal and extratemporal cortical regions compared to the mesial temporal structures. MEG has a dominant role in the presurgical evaluation of patients with MRI-negative DRFEs, insular epilepsies, and recurrent seizures after failed epilepsy surgeries, and in guiding placement of invasive electrodes. Moreover, postoperative seizure freedom is better if MEG spike source localized cortical region is included in the resection. When compared to subdural grid electrode recording, SEEG is less invasive and safer. Those who are otherwise destined to suffer from uncontrolled seizures and their consequences, SEEG guided ES is a worthwhile and a cost-effective option. Depending on the substrate pathology, there is > 80-90% chance of undergoing ES and 60-80% chance of becoming seizure-free following SEEG. Recent noninvasive techniques aimed at better structural imaging, delineating brain connectivity and recording specific intracerebral EEG patterns such as high frequency oscillations might decrease the need for SEEG; but more importantly, make SEEG exploration more goal-directed and hypothesis-driven.

Memory outcome following left anterior temporal lobectomy in patients with a failed Wada test.

PURPOSE: This study aimed to compare the memory outcome following left anterior temporal lobectomy (ATL) between patients with a failed Wada test and patients who passed the Wada test. METHODS: From 1996 to 2002, we performed the Wada test on all patients with unilateral left mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) and concordant electroclinical data before ATL. We used a 12-item recognition paradigm for memory testing and awarded a score of +1 for each correct response and -0.5 for each incorrect response. No patient was denied surgery on the basis of Wada scores. We assessed cognitive and memory functions using the Wechsler Adult Intelligence Scale and the Wechsler Memory Scale preoperatively and at one year after ATL. We compared the number of patients who showed decline in memory scores, as per the published reliable change indices, between the patients with a failed Wada test and the patients who passed the Wada test. RESULTS: Out of the 116 eligible patients with left MTLE-HS, 88 underwent bilateral Wada test, while 28 underwent ipsilateral Wada test. None of them developed postoperative amnesia. Approximately, one-third of patients with a failed Wada memory test when the failure was defined as a contralateral score of <4, as an ipsilateral score of >8, and as an asymmetry score of <0. The patients with Wada memory failure had a longer pre-ATL duration of epilepsy (p<0.003). The memory and quality-of-life outcomes did not differ between the group with a failed Wada memory test and the group who passed the Wada memory test. The results remained the same when analyses were repeated at various other cutoff points. CONCLUSION: The patients with left MTLE-HS with concordant electroclinical, MRI, and neuropsychological data should not be denied ATL solely on the basis of Wada memory test results.

Concept of epilepsy surgery and presurgical evaluation.

Epilepsy surgery is a well-accepted treatment for drug-resistant epilepsy. The success of the epilepsy surgery depends upon an appropriate presurgical evaluation process which should ensure the selection of suitable patients who are likely to become seizure-free following surgery without any unacceptable deficit. The two basic goals of the presurgical evaluation are the accurate localization and delineation of the extent of the epileptogenic zone, and its complete and safe resection. The process of the presurgical evaluation requires a multimodality approach wherein each modality provides unique and complimentary information which is combined with the information provided by other modalities to generate a hypothesis with regard to the likely epileptogenic zone. The basic modalities for the presurgical evaluation are clinical history, long-term video-EEG recording, high-resolution MRI, and neuropsychological evaluation. The additional modalities include functional imaging studies, electrical and magnetic source imaging, functional MRI, and intracranial monitoring. Each modality has its own limitations and the information provided by none of them is absolute. Hence, a concordance among the different modalities is the key to surgical success. The presurgical evaluation is a step-wise process starting form the most basic and most reliable tests and progressing to more complex and invasive modalities. The number of tests required varies according to the complexity involved and may include very basic minimum investigations in a given case, to the use of all the available investigations in more complex cases. The proper selection of various investigations and their accurate interpretation at each stage is required to ensure a successful outcome. In this article, we intend to review some of these basic concepts of presurgical evaluation and epilepsy surgery, and try to provide a frame work of the presurgical evaluation process.

National epilepsy surgery program: realistic goals and pragmatic solutions.

There are multiple social, economic, and medical challenges in establishing successful epilepsy surgery programs in India and in other low- and middle-income countries (LAMIC). These can be overcome by reproducing pragmatic and proven epilepsy surgery models throughout the country with a larger aim of developing a national epilepsy surgery program so as to provide affordable and quality surgical care to all the deserving patients. An organized national epilepsy surgery support activity can help interested centers in India and in neighboring countries in developing epilepsy surgery programs.

GABRG2, rs211037 is associated with epilepsy susceptibility, but not with antiepileptic drug resistance and febrile seizures.

OBJECTIVE: Several antiepileptic drugs (AEDs) are known to target the GABA(A) receptor through positive allosteric modulation of the receptors, thereby enhancing GABA(A) receptor-mediated inhibition. The large diversity of GABA(A) receptors has been reported in the central nervous system; some of these have been implicated in epilepsy susceptibility and AED resistance, which we aimed to examine. MATERIALS AND METHODS: We investigated the association of single-nucleotide polymorphisms in GABA(A) receptor subunit subtype genes namely; rs2279020 (GABRA1), rs3219151 (GABRA6), rs2229944 (GABRB2), and rs211037 (GABRG2) with predisposition to epilepsy and AED resistance. This was assessed in three cohorts of ethnically matched South Indian ancestry: mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) (prototype of AED-resistant epilepsy syndrome), juvenile myoclonic epilepsy (prototype of AED-responsive epilepsy syndrome), and nonepilepsy controls. RESULTS: A significant allelic (P=0.0006, odds ratio=1.6, 95% confidence interval=1.22-2.08) and genotypic (P=0.001) association of a synonymous variant in GABRG2, rs211037 (Asn196Asn) was observed with epilepsy irrespective of its phenotype, that is, MTLE-HS or juvenile myoclonic epilepsy. However, this association was not retained in epilepsy patients with a history of febrile seizures. The GABA(A) receptor subunit subtype genes were not found to have any association with AED resistance. In-silico analysis indicated that rs211037 plays a significant role in the transcriptional regulation and splicing regulation. CONCLUSION: We could substantiate that among the GABA(A) receptor subunit gene cluster polymorphisms, the GABRG2, rs211037 predisposes susceptibility to epilepsy, irrespective of its phenotype, but not to AED resistance.

Calcified neurocysticercosis lesions and antiepileptic drug-resistant epilepsy: a surgically remediable syndrome?

PURPOSE: In contrast to the well-recognized association between acute symptomatic seizures and neurocysticercosis, the association between antiepileptic drug (AED)-resistant epilepsy and calcified neurocysticercosis lesions (CNLs) is poorly understood. We studied the association between AED-resistant epilepsy and CNLs, including the feasibility and outcome of resective surgery. METHODS: From the prospective database maintained at our epilepsy center, we reviewed the data of all patients with AED-resistant epilepsy who underwent presurgical evaluation from January 2001 to July 2010 and had CNL on imaging. We used clinical, neuroimaging, and interictal, ictal, and intracranial electroencephalography (EEG) findings to determine the association between CNL and epilepsy. Suitable candidates underwent resective surgery. KEY FINDINGS: Forty-five patients fulfilled the inclusion criteria. In 17 patients, CNL was proven to be the causative lesion for AED-resistant epilepsy (group 1); in 18 patients, CNL was associated with unilateral hippocampal sclerosis (HS; group 2); and in 10 patients, CNLs were considered as incidental lesions (group 3). In group 1 patients, CNLs were more common in frontal lobes (12/17), whereas in group 2 patients, CNLs were more commonly located in temporal lobes (11/18; p = 0.002). Group 2 patients were of a younger age at epilepsy onset than those in group 1 (8.9 ± 7.3 vs. 12.6 ± 6.8 years, p = 0.003). Perilesional gliosis was more common among patients in group 1 when compared to group 3 patients (12/17 vs. 1/10; p = 0.006). Fifteen patients underwent resective surgery. Among group 1 patients, four of five became seizure-free following lesionectomy alone. In group 2, four patients underwent anterior temporal lobectomy (ATL) alone, of whom one became seizure-free; five underwent ATL combined with removal of CNL (two of them after intracranial EEG and all of them became seizure-free, whereas one patient underwent lesionectomy alone and did not become seizure-free. SIGNIFICANCE: In endemic regions, although rare, CNLs are potential cause for AED-resistant and surgically remediable epilepsy, as well as dual pathology. Presence of perilesional gliosis contributes to epileptogenicity of these lesions. For those patients with CNL and HS, resection of both lesions favors better chance of seizure-free outcome.

A critical evaluation of the lateralizing significance of material-specific memory deficits in patients with mesial temporal lobe epilepsy with hippocampal sclerosis.

To critically assess the value of material-specific memory deficits in lateralizing temporal lobe dysfunction preoperatively, we compared the neuropsychological data of 50 consecutive patients with unilateral mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS; right: 31, left: 19) with those of 50 age- and education-matched healthy control subjects. On case-control comparison, both the subcohorts with left and right MTLE-HS performed poorly on intelligence tests, in addition to individual memory tests. However, comparison of the verbal and visual memory functions between subcohorts with right and left MTLE-HS revealed that learning trials and delayed word list recall were the only tests that hypothesized left temporal lobe dysfunction. We conclude that material-specific memory deficits are largely test driven, but there is a lateralizing role for task-specific deficits in left MTLE-HS. Although neuropsychological data help to define baseline neuropsychological impairment, caution should be exercised in interpreting the lateralizing value of material-specific memory deficits prior to surgery.

Status epilepticus.

Status epilepticus (SE) is a neurological emergency resulting from prolonged Clinical or electroencephalographic seizure activity. Refractory SE refers to the persistence of seizure activity despite the initiation of first- and second-line anticonvulsant therapy. Sinister outcomes are often attributed to the etiology of SE. Despite randomized multicentre trials of established and promising therapeutic options, the management and prognostication in SE are fraught with challenges. Neither the duration of SE nor time-delay to initiation of therapy should discourage the aggressive approach to the management of SE. Neurointensive care of patients with SE consists of an algorithmic approach tailored to the etiology and systemic complications that arise as a consequence. This approach is also driven by the persistence of electrographic seizure activity, which is best followed with continuous EEG monitoring. The extent of patient support has to be augmentative to the degree of encephalopathy/coma and impairment of vital functions. Potential interactions of anticonvulsant drugs with other co-medications need to be considered during the course of treatment. This review discusses the existing literature on the epidemiological aspects, clinical approach, treatment and prognostication of SE.

Calcified neurocysticercosis lesions and hippocampal sclerosis: potential dual pathology?

In areas where cysticercosis is endemic, calcified neurocysticercosis lesion(s) (CNL) and hippocampal sclerosis (HS) commonly coexist in patients with localization-related epilepsies. To understand the pathogenesis of HS associated with CNL, we compared the characteristics of three groups of patients with antiepileptic drug-resistant epilepsies: CNL with HS, CNL without HS (CNL alone), and HS without CNL (HS alone). In comparison to patients with CNL alone, those with CNL with HS had CNL more frequently located in the ipsilateral temporal lobe. Those with CNL with HS had a lower incidence of febrile seizures, older age at initial precipitating injury and at onset of habitual complex partial seizures, and more frequent clustering of seizures and extratemporal/bitemporal interictal epileptiform discharges as compared to patients with HS alone. Our study illustrates that HS associated with CNL might have a different pathophysiologic basis as compared to classical HS.

Sexual desire and satisfaction after resective surgery in patients with mesial temporal lobe epilepsy with hippocampal sclerosis.

Utilizing a questionnaire, we inquired about the self-perceived sexual behavior of 50 married males with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) before and after anterior temporal lobectomy (ATL) and compared the results with those of 50 age-matched healthy married males. The sexual desire and satisfaction of the patients were poor when compared to the controls. Although a majority of the sexual domains improved following ATL, even after a median duration of five years, the sexual status of the patients did not match with that of the controls. Those who, after ATL, were seizure free, had one or no antiepileptic drug (AED) and had an EEG without epileptiform abnormalities achieved a better sexual outcome. We conclude that sexual dysfunction is frequent in male patients with MTLE-HS. They require preoperative assessment to identify their sexual inadequacies as well as counseling about the expected post-ATL sexual outcome. Discontinuation of enzyme-inducing AEDs facilitates post-ATL improvement in sexual function.

Complications in acute stroke in India (CAST-I): a multicenter study.

The prognosis and final outcome in patients who sustain stroke are significantly affected by medical complications occurring during the acute phase of stroke. Only limited information is available from India and other developing countries regarding acute complications of stroke. This study examined the frequency of acute stroke and the factors associated with complications of stroke in India. In this prospective multicenter study, running from March 2008 to September 2009, 6 hospitals collected information on complications of first-ever stroke during admission. Complications were defined in accordance with standard criteria. Outcome at 30 days poststroke was assessed using the modified Rankin Scale. Stroke characteristics, length of hospital stay, and stroke severity (based on the National Institutes of Health Stroke Scale) were documented. Hematologic (ie, hemoglobin) and biochemical (ie, total proteins and albumin) parameters also were obtained. A total of 449 patients out of the recruited 476 completed follow-up. The mean age was 58.1 ± 13.7 years (range, 16-96 years), and the majority were men (n = 282; 62.8%). The mean National Institutes of Stroke Scale score was 10.2 ± 5.3. Overall, 206 patients (45.9%) experienced complications during admission. In the logistic regression analysis, limb weakness (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.02-0.67; P = .01), anemia (OR, 0.35; 95% CI, 0.15-0.81; P = .01), length of hospital stay (OR, 0.89; 95% CI, 0.85-0.94; P < .0001), and stroke severity (OR, 0.27; 95% CI, 0.10-0.72; P = .01) were the variables associated with complications. Such complications as urinary tract infection (OR, 0.31; 95% CI, 0.13-0.78; P = .01), chest infection (OR, 1.81; 95% CI, 1.12-2.93; P = .02), bedsores (OR, 3.52; 95% CI, 1.02-12.08; P = .05), other pain (OR, 0.21; 95% CI, 0.09-0.49; P < .0001), and depression (OR, 2.22; 95% CI, 1.30-3.80; P < .01) were associated with poor outcome. Our study shows high rates of complication in acute stroke. Limb weakness, stroke severity, length of hospital stay, and anemia were the factors associated with complications. Other complications, such as urinary tract infection, chest infection, bedsores, other pain, and depression, can lead to poor outcome.

Prevalence and Diagnosis of Sexual Dysfunction in People with Epilepsy.

Even though sexual dysfunction occurs in about half of people with epilepsy (PWE), it is mostly under-reported, under-recognized, and under-treated. Sexual dysfunctions are more common in patients with uncontrolled epilepsy, frequent seizures, and those receiving enzyme-inducing antiseizure medicines (ASMs). The presence of underlying anxiety or depression is associated with a higher frequency of sexual dysfunction in PWE. Even though the evidence is limited, the newer and non-enzyme-inducing ASMs do not largely cause sexual dysfunction. A multidisciplinary and multipronged approach is required for the comprehensive evaluation and management of sexual dysfunction in PWE.

Premorbid nutrition and short term outcome of stroke: a multicentre study from India.

BACKGROUND: Little is known about the impact of premorbid undernutrition on stroke outcome in developing countries. AIM: To study the impact of premorbid undernutrition status, measured by the Subjective Global Assessment (SGA) tool, on short term stroke outcome. METHODS: First ever stroke patients admitted to six major hospitals in North and South India participated in this study from 1 March 2008 to 30 September 2009. The SGA tool was administered within 48 h of stroke onset, and 6 months premorbid nutritional status was rated as well nourished (A rating) and undernourished (B and C ratings) using this tool. Stroke outcome was assessed after 30 days using the modified Rankin scale (mRs), and a mRs score >3 was defined as a poor outcome. Statistical analyses were performed using SPSS Statistics V.17.0. RESULTS: Of 477 patients enrolled, 448 patients were included in the analyses. Mean age was 58.1±13.7 years (range 16-96) and 281 (62.7%) patients were men. At admission, premorbid undernutrition was found in 121 (27.2%) patients. Older age (OR 4.99, CI 1.26 to 19.64, p=0.021), hypertension (OR 1.99, CI 1.04 to 3.79, p=0.037) and patients from Andhra Pradesh State (OR 1.87, CI 1.05 to 3.32, p=0.032) were predictors of undernutrition in multiple logistic regression analysis. Premorbid undernutrition (OR 1.99, CI 1.20 to 3.31, p=0.007) and length of hospital stay (OR 3.41, CI 1.91 to 6.06, p<0.0001) were the independent predictors of poor outcome in the multiple logistic regression model. CONCLUSIONS: High rates of premorbid undernutrition in stroke patients were found. Age, hypertension and patients from Andhra Pradesh State were predictors of premorbid undernutrition. Premorbid undernutrition was associated with poor stroke outcome. The results provide opportunities for primary prevention and improving stroke outcome.