Guillain-Barre syndrome of acute motor axonal neuropathy (AMAN) type associated with herpes zoster: a case report.

Guillain Barre syndrome (GBS) following Varicella zoster is a rare presentation and has only been reported in a few cases around the world. Of the reported cases, the type of GBS is not specified in the majority, and where specified is of the acute inflammatory demyelinating polyradiculoneuropathy (AIDP) type. We report a case of acute motor axonal neuropathy (AMAN) type GBS following herpes zoster in a 27-year-old male who presented with bilateral lower limb weakness and left sided lower motor neuron type facial nerve palsy a week after herpes zoster infection.

Neurological disorders associated with COVID-19 in Sri Lanka.

BACKGROUND: Neurological manifestations of SARS-CoV-2 infection have been reported from many countries around the world, including the South Asian region. This surveillance study aimed to describe the spectrum of neurological disorders associated with COVID-19 in Sri Lanka. METHODS: COVID-19 patients manifesting neurological disorders one week prior and up to six weeks after infection were recruited from all the neurology centres of the government hospitals in Sri Lanka from May 2021 - May 2022. Data was collected using a structured data form that was electronically transmitted to a central repository. All patients were evaluated and managed by a neurologist. Data were analysed using simple descriptive analysis to characterise demographic and disease related variables, and simple comparisons and logistic regression were performed to analyse outcomes and their associations. RESULTS: One hundred and eighty-four patients with neurological manifestations associated with COVID-19 were recruited from all nine provinces in Sri Lanka. Ischaemic stroke (31%) was the commonest neurological manifestation followed by encephalopathy (13.6%), Guillain-Barre syndrome (GBS) (9.2%) and encephalitis (7.6%). Ischaemic stroke, encephalitis and encephalopathy presented within 6 days of onset of COVID-19 symptoms, whereas GBS and myelitis presented up to 10 days post onset while epilepsy and Bell palsy presented up to 20 - 40 days post onset. Haemorrhagic stroke presented either just prior to or at onset, or 10 - 25 days post onset of COVID-19 symptomatic infection. An increased frequency of children presenting with encephalitis and encephalopathy was observed during the Omicron variant predominant period. A poor outcome (no recovery or death) was associated with supplemental oxygen requirement during admission (Odds Ratio: 12.94; p = 0.046). CONCLUSIONS: The spectrum and frequencies of COVID-19 associated neurological disorders in Sri Lanka were similar to that reported from other countries, with strokes and encephalopathy being the commonest. Requiring supplemental oxygen during hospitalisation was associated with a poor outcome.

The burden, risk factors and unique etiologies of stroke in South-East Asia Region (SEAR).

The World Health Organization (WHO) South East Asia Region (SEAR) comprises 11 countries, which are one of the most culturally, topographically, and socially diverse areas worldwide, undergoing an epidemiological transition towards non-communicable diseases, including stroke and other cardiovascular diseases (CVDs). This region accounts for over 40% of the global stroke mortality. Few well-designed population-based epidemiological studies on stroke are available from SEAR countries, with considerable variations among them. Ischemic stroke, a common stroke subtype, has higher frequencies of intracerebral hemorrhage in many countries. Along with an aging population, the increased prevalence of risk factors such as hypertension, diabetes mellitus, tobacco and alcohol consumption, lack of physical activity, high ambient pollution, heat, and humidity contribute to the high burden of stroke in this region. SEAR's many unique and uncommon stroke etiologies include cerebral venous thrombosis, tuberculosis, dengue, scrub typhus, falciparum malaria, snake bite, scorpion sting, etc. Current data on stroke burden and risk factors is lacking, compelling an urgent need for high-quality hospital-level and population-level data in all SEAR countries. Strategies towards a consolidated approach for implementing improved stroke prevention measures, stroke surveillance, and established stroke systems of care are the path to bridging the gaps in stroke care.

Emerging tropical neurological infections.

A large majority of neurological infections remain undiagnosed worldwide. Emerging and re-emerging infections are likely to be responsible for a significant proportion of these. Over the last two decades, several new organisms producing neurological infection and the neurotropic potential of many other known pathogens have been identified. Large outbreaks caused by re-emerging pathogens such as Chikungunya virus, Zika virus and Ebola virus have led to better delineation of their neurological manifestations. Recognition of the pandemic potential of emerging pathogens and an improved understanding of their host-vector-environment interactions would help us be better prepared to meet these emerging threats.

Case Report: Dengue Hemorrhagic Fever with Ischemic Stroke.

Several neurological manifestations are recognized in dengue infection, but stroke is a rare complication. We report a case of ischemic stroke in a patient with dengue hemorrhagic fever. A 52-year-old previously healthy male presented with a history of fever for 2 days, and left-sided weakness and numbness of sudden onset. MRI scanning showed a right-sided thalamic lacunar infarct. Diagnosis of dengue fever was made based on leuco-thrombocytopenia, positive dengue nonstructural protein-1 (NS-1) antigen, and positive dengue IgM antibodies. Severity of limb weakness correlated with the critical phase of dengue hemorrhagic fever (DHF). He was discharged home with good recovery from neurological symptoms and disability. Strokes are rare in dengue, and are mainly hemorrhagic strokes related to thrombocytopenia. Ischemic stroke is even rarer. More evidence is needed for confirmation of dengue as a pathogenic mechanism of ischemic stroke.

Prevalence and predictors of new onset depression in the acute phase of stroke.

INTRODUCTION: Post-stroke depression (PSD) is known to be associated with poor functional outcome and high mortality. There is limited data on the prevalence and associated factors of depression in the acute phase after stroke. OBJECTIVES: To determine the prevalence of PSD in the acute phase and its correlates among patients with stroke in a tertiary care hospital in Sri Lanka. METHOD: A cross sectional descriptive study was conducted among patients with stroke admitted to the stroke unit of a tertiary care hospital in Sri Lanka over a 3-year period. Demographic and clinical information was obtained using an interviewer administered questionnaire. Depression was diagnosed using the ICD-10 criteria. Group comparisons were performed using Pearson's Chi-square test and Mann-Whitney U test Multiple logistic regression was used to identify factors associated with PSD. RESULTS: Of 374 patients, 106 patients experienced moderate to severe PSD, with a prevalence of 28.3 % (95 % CI: 23.8 %-32.9 %). Of them, 54.7 % were females, 49 % were above the age of 60 years, and 79.9 % had ischemic strokes. Female gender (OR-2.77, 95 % CI: 1.46-5.07, P = 0.002), a longer duration of hypertension (OR-1.31, 95 % CI: 1.01-1.721, P = 0.004), strokes involving the temporal lobe (OR-7.25, 95 % CI: 2.81-20.25, P < 0.001) and post-stroke functional disability (OR- O.98, 95 % CI:0.97-0.99, P = 0.001) were associated with PSD on multivariate analysis. CONCLUSION: More than one fourth of the patients suffered from PSD in the acute phase of stroke. Female gender, longer history of hypertension, physical dependence and temporal lobe strokes were predictive of PSD.

Stroke in Sri Lanka: How Can We Minimise the Burden?

The burden of stroke in Sri Lanka is high and steadily increasing. Accurate estimation of the burden is hampered by a paucity of epidemiological data. More neurologists, stroke units, facilities for modern treatments and multi-disciplinary rehabilitation services are urgently needed. Essential drugs for risk factor control and secondary prevention are available in many hospitals. Aggressive preventive strategies and promoting stroke awareness are the best ways to minimise the stroke burden in Sri Lanka.

Physical Activity Tracking Among Sri Lankan Adults: Findings From a 7-Year Follow-up of the Ragama Health Study.

Limited data are available on physical activity tracking among adults in low- and middle-income countries. Using a longitudinal design, we assessed trends and correlates of physical activity among Sri Lankan adults. Individuals selected through age-stratified random sampling, were screened initially in 2007 (n = 2986) and reevaluated in 2014 (n = 2148). On both occasions, structured interviews and clinical measurements were completed. Approximately 40% of the participants engaged in recommended levels of physical activity both at baseline and follow-up. One-fifth reported increased physical activity at follow-up, a similar proportion reported being persistently inactive or a reduction in physical activity. In the adjusted analysis, being persistently active was associated with male sex, a lower educational level and income, being free of any chronic disease conditions, better self-rated health, and sitting time <8 hours. Our findings support public health interventions to help maintain recommended physical activity levels over time, particularly for subgroups at high-risk of physical inactivity.

Patterns and predictors of mortality in a semi-urban population-based cohort in Sri Lanka: findings from the Ragama Health Study.

OBJECTIVE: To describe patterns and predictors of mortality in a semi-urban population in Sri Lanka. DESIGN: A prospective population-based cohort study. SETTING: Ragama Medical Officer of Health area in the Gampaha district, Sri Lanka. PARTICIPANTS: Adults between 35 and 64 years of age were recruited using an age stratified random sampling technique in 2007. MEASURES: At baseline, we recorded socio-demographic, lifestyle, anthropometric, biochemical and clinical data of the participants. Over 10 years, we obtained the cause and date of death from the death registration documents of deceased participants. We determined the survival probability of the cohort over 10 years and estimated Hazard ratios (HRs) for all-cause mortality (ACM), cardiovascular mortality (CVM) and cancer-related mortality (CRM) using Cox's proportional hazards model. We also estimated the survival probabilities for men and women in each 10-year age group and standardised mortality ratio relative to the source population. RESULTS: There were 169 deaths over 10 years with standardised mortality rates of 5.3 and 2.4 per 1000 years of follow-up for men and women, respectively. Independent predictors of: ACM were older age, lower income, smoking and diabetes mellitus while gender, education, occupation, harmful alcohol use, waist circumference and hypertension were not; CVM were older age, lower income, smoking, diabetes and hypertension while gender and harmful alcohol use were not; CRM was older age while gender, smoking and diabetes were not. Those engaged in clerical and technical occupations or unemployed had a lower risk of CRM as compared with those engaged in elementary occupations. CONCLUSIONS: Older age, lower income, smoking, diabetes and hypertension strongly predict mortality in this cohort. Addressing the identified modifiable predictors through behavioural modification will improve longevity in similar populations.

Stroke Awareness in Patients with Incident Stroke Compared to Patients without Stroke or Ischemic Heart Disease.

BACKGROUND: Stroke awareness is known to influence treatment seeking and risk reduction behavior, but there is limited data from Sri Lanka and South Asia. AIM: To describe stroke awareness in incident stroke patients and to compare with patients without stroke and/or ischemic heart disease (IHD) in a Sri Lankan tertiary-care center. METHODS: We studied awareness of stroke in all incident stroke patients admitted to a tertiary-care center in Sri Lanka and compared with a group of age- and sex-matched patients without stroke and/or IHD, over 2 years. Knowledge on stroke mechanisms, risk factors, symptoms, prognosis, treatment, and prevention were evaluated using a 40-item interviewer-administered questionnaire and converted to a composite score of 100%. Total awareness was categorized as Very poor (<24%), Poor (25%-49%), Good (50%-74%), and Very good (>74%). RESULTS: One hundred and sixty four incident stroke patients (mean age 62.0 ± 11.5 years; 64.6% males) and 164 patients without stroke and/or IHD were studied. Mean stroke awareness was 47.79% ± 14.6 in stroke patients, and 47.73% ± 14.9 in the nonstroke and/or IHD patients (P = .95). Of the associations studied, better stroke awareness (>50%) was associated only with higher education levels (OR 1.90, 95%CI 1.33-2.72, P < .001) in stroke patients. CONCLUSIONS: Stroke awareness is not satisfactory in incident stroke patients and is no better than in patients without stroke and/or IHD. Better stroke awareness was associated with higher education levels.

Headache: an important symptom possibly linked to white matter lesions in thalassaemia.

Neurological manifestations are reported only occasionally in patients with thalassaemia and are given much less prominence than the complications related to anaemia and iron overload. White matter changes (WMCs) on magnetic resonance imaging (MRI) in patients with thalassaemia were first reported two decades ago but the significance of these lesions remains unclear. We studied the neurological and cognitive manifestations in 82 older patients with thalssaemia [25 Thalassaemia major (TM), 24 thalassaemia intermedia (TI) and 33 haemaglobin E ß thalassaemia (EBT)] and 80 controls, and found that headaches were more common in thalassaemia patients (50/82, 61%) than in controls (18/80, 22·5%: P < 0·001). WMCs on MRI were found in 20/82 (24·3%) patients and 2/29 (6·9%) controls had (P = 0·078). WMC were more common among those with headaches (17/50: 34%) than in those without headache (3/32; 9·3%) (P = 0·023). WMCs were not associated with reduction of cognition. Nevertheless, cognition was lower in the TI and EBT groups compared with those with TM (P = 0·002). The association of headache with WMC in thalassaemia has not been reported before and warrants further study.

Awareness of clinical trial registration among healthcare professionals: An observational study.

AIM: Prospective registration in a freely accessible public platform is a key step in the ethical conduct of clinical trials. Little is known of the awareness of clinical trial registration among the scientific community. This study aimed to assess awareness of clinical trial registration among participants attending a medical congress in Sri Lanka. METHODS: Knowledge of trial registration was assessed using a self-administered questionnaire, which spanned domains such as involvement in research, and knowledge and perceptions regarding trial registration. A knowledge score was calculated and correlated with demographic variables. RESULTS: Of 251 survey respondents, 53.4% were male, 74.9% were below the age of 40 years, and 56.6% were currently engaged in research. Registration was considered necessary for trial publication by 73.3%, and 70.5% agreed that trials should be registered prospectively. Most achieved a knowledge score of 'Acceptable' (41%) or 'Good' (19.9%). Mid- or advanced career stages, postgraduate training, current involvement in research, and recent research publications/presentations were correlated with higher knowledge scores (P < 0.05). Beneficial effects considered to be associated with trial registration were access to findings of all trials (61.4%), access to negative results (47.8%), preventing trial duplication (69.3%), and preventing multiple publications (70.1%). Increasing research workload (49.8%), additional restrictions on research conduct (52.2%), and the possibility of 'intellectual theft' (56.2%) were seen as potential negative effects. CONCLUSIONS: Most participants were aware of the need for prospective registration as a requirement for publication of clinical trials. Concerns were expressed regarding several perceived negative effects of trial registration.

Ten years of clinical trial registration in a resource-limited setting: Experience of the Sri Lanka clinical trials registry.

AIM: We describe our experience of the first 10 years at the Sri Lanka Clinical Trials Registry (SLCTR). METHODS: We analyzed all trial records of the SLCTR over the study period. We collected information regarding trial characteristics and completeness of data entry in the SLCTR data set. RESULTS: During the study period, 210 trials (63% of all applications) were registered with the SLCTR. The number of registered trials showed an increasing trend over the years. All trial registrations had complete entries for all the data fields studied. Only 17.6% of the trials were registered retrospectively. All the registered trials were interventional studies, and the majority (87.6%) were randomized controlled trials. A significant proportion of trials (28.6%) were on noncommunicable diseases, and 12.4% were on pregnancy and its outcomes. Several trials (9.5%) were international collaborative studies. A majority of the Principal Investigators (70.9%) were affiliated to a university. Most of the studies (41.9%) were self-funded by the investigators. Details of ethics review committee approval were available for 96.7% of registered trials. Over a third of the registered trials (37.1%) had completed recruitment at the time of analysis. A majority of the trials (72.8%) had updated trial data since registration. CONCLUSIONS: There is a steady increase in the number of trials registered at the SLCTR. Complete entries for all the data fields were seen in all trial registrations. The SLCTR has made a positive contribution to the emergence of a healthy clinical research environment in Sri Lanka.

Case report of hypnic headache: a rare headache disorder with nocturnal symptoms.

BACKGROUND: Headache is one of the commonest complaints reported to physicians worldwide. Yet, arriving at the proper diagnosis can be a challenge in many patients. Although most headaches belong to common categories of migraine and tension-type headache, which are diagnosed and managed relatively easily, several uncommon headache disorders can lead to delays in diagnosis. Certain medications are more efficacious than others in managing these headache disorders, hence establishing the correct diagnosis is of paramount importance. CASE PRESENTATION: An 86-year-old female presented with chronic daily headache of 1 year duration. Her headaches were exclusively nocturnal and woke her up daily around midnight. Clinical examination was unremarkable. All basic investigations were normal. Subsequent gadolinium enhanced Magnetic Resonance Imaging (MRI) brain did not show any significant pathology. There was no satisfactory response to paracetamol, diclofenac sodium, mefenamic acid, tramadol, flunarizine and sodium valproate. Indomethacin was started with the provisional diagnosis of hypnic headache. There was absolute response by day 3 of indomethacin. She remains headache free on low dose indomethacin maintenance at 1 year after the diagnosis. CONCLUSION: Better understanding of uncommon headache syndromes can help in early diagnosis and appropriate treatment. Hypnic headache should be considered in the differential diagnosis of chronic daily headaches, especially when nocturnal and occurs during sleep.

Small circular single stranded DNA viral genomes in unexplained cases of human encephalitis, diarrhea, and in untreated sewage.

Viruses with small circular ssDNA genomes encoding a replication initiator protein can infect a wide range of eukaryotic organisms ranging from mammals to fungi. The genomes of two such viruses, a cyclovirus (CyCV-SL) and gemycircularvirus (GemyCV-SL) were detected by deep sequencing of the cerebrospinal fluids of Sri Lankan patients with unexplained encephalitis. One and three out of 201 CSF samples (1.5%) from unexplained encephalitis patients tested by PCR were CyCV-SL and GemyCV-SL DNA positive respectively. Nucleotide similarity searches of pre-existing metagenomics datasets revealed closely related genomes in feces from unexplained cases of diarrhea from Nicaragua and Brazil and in untreated sewage from Nepal. Whether the tropism of the cyclovirus and gemycircularvirus reported here include humans or other cellular sources in or on the human body remains to be determined.

Human bocavirus in patients with encephalitis, Sri Lanka, 2009-2010.

We identified human bocavirus (HBoV) DNA by PCR in cerebrospinal fluid from adults and children with encephalitis in Sri Lanka. HBoV types 1, 2, and 3 were identified among these cases. Phylogenetic analysis of HBoV1 strain sequences found no subclustering with strains previously identified among encephalitis cases in Bangladesh.