Influence of Time to Achieve Target Systolic Blood Pressure on Outcome After Intracerebral Hemorrhage: The Blood Pressure in Acute Stroke Collaboration.

OBJECTIVE: To investigate whether an earlier time to achieving and maintaining systolic blood pressure (SBP) at 120 to 140 mm Hg is associated with favorable outcomes in a cohort of patients with acute intracerebral hemorrhage. METHODS: We pooled individual patient data from randomized controlled trials registered in the Blood Pressure in Acute Stroke Collaboration. Time was defined as time form symptom onset plus the time (hour) to first achieve and subsequently maintain SBP at 120 to 140 mm Hg over 24 hours. The primary outcome was functional status measured by the modified Rankin Scale at 90 to 180 days. A generalized linear mixed models was used, with adjustment for covariables and trial as a random effect. RESULTS: A total of 5761 patients (mean age, 64.0 [SD, 13.0], 2120 [36.8%] females) were included in analyses. Earlier SBP control was associated with better functional outcomes (modified Rankin Scale score, 3-6; odds ratio, 0.98 [95% CI, 0.97-0.99]) and a significant lower risk of hematoma expansion (0.98, 0.96-1.00). This association was stronger in patients with bigger baseline hematoma volume (>10 mL) compared with those with baseline hematoma volume ≤10 mL (0.006 for interaction). Earlier SBP control was not associated with cardiac or renal adverse events. CONCLUSIONS: Our study confirms a clear time relation between early versus later SBP control (120-140 mm Hg) and outcomes in the one-third of patients with intracerebral hemorrhage who attained sustained SBP levels within this range. These data provide further support for the value of early recognition, rapid transport, and prompt initiation of treatment of patients with intracerebral hemorrhage.

A study on the clinical and electrographic profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG).

Background: Coma is one of the frequently encountered clinical conditions in any intensive care unit (ICU), which is responsible for considerable morbidity and mortality. Therefore, this study was designed to look at the clinical and EEG profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG). Methods: In all 102 patients of unresponsive coma (GCS ≤ 8), who remained in poor sensorium despite 48 h of optimum treatment in ICU, were included in the study. All patients underwent 1 h of electroencephalography (EEG) monitoring with a portable EEG machine. All EEGs were screened according to Salzburg Consensus Criteria (SCC) for Nonconvulsive Status Epilepticus (NCSE). Patients with evidence of NCSE were administered parenteral Antiepileptic Drugs (AED). A repeat EEG was done after 24 h of baseline to ascertain the effect of AED. The primary outcome was the recognition of patients with NCSE on the basis of established EEG criteria. The secondary outcome measure was the Glasgow outcome scale (GOS) at the time of discharge. Results: Out of 102 cases enrolled, 12 (11.8%) cases were detected to have NCSE on portable EEG. The mean age of patients with NCSE was 52.2 years. In terms of gender distribution, 2/12 (17%) were female, and 10/12 (83%) were male (M: F = 5:1). Median GCS was 6 (range 3-8). Looking at CNS infections, 4/12 (33.3%) had evidence of some form of CNS infection in the NCSE group, compared to 16/90 (18%) in the group without NCSE. This difference was statistically significant (P-value < 0.05). The EEG recordings of patients with NCSE showed dynamicity with fluctuating rhythms and ictal-EEG patterns associated with spatiotemporal evolution. All twelve cases showed reversal of EEG changes with AED administration. In 5 out of 12, transient improvement in GCS (>2 points) after administration of AED' was noted with good clinical outcomes (GOS 5). In five of these 12 cases, death was the final outcome (GOS 1). Conclusions: NSCE should be considered in the differential diagnosis of all unresponsive comatose ICU patients. In resource-limited settings, where continuous EEG monitoring may not be feasible, bedside portable EEG testing can be used to diagnose patients with NCSE. Treating NCSE reverses epileptiform EEG changes and improves clinical outcomes in a subset of comatose ICU patients.

Two unusual cases of Guillain-Barre syndrome after snake bite: the rare immune mediated complication of Elapid venom.

In this report, we present a series of two unusual cases of elapid snakebite with acute neuroparalysis, that after initial response to standard anti-snake venom therapy, developed recurrence of disabling quadriparesis with dysautonomia, that on detailed evaluation turned out to be immune-mediated polyradiculoneuropathy (GB syndrome). Both the cases then responded to therapy with intravenous immunoglobulins. These cases bring out the rare immune-mediated late complication of snake venom, which if recognized and treated in time, can significantly reduce the morbidity and mortality.

Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data.

OBJECTIVE: To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH). METHODS: A prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults <7 days after ICH onset. The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation. Radiological outcomes were absolute (>6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect. RESULTS: Of 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6-5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (pinteraction=0.031) and agent (pinteraction<0.0001). Active/intensive BP-lowering interventions clearly reduced absolute (>6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth. INTERPRETATION: Overall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent. PROSPERO REGISTRATION NUMBER: CRD42019141136.

Clinical Explainability Failure (CEF) & Explainability Failure Ratio (EFR) - Changing the Way We Validate Classification Algorithms.

Adoption of Artificial Intelligence (AI) algorithms into the clinical realm will depend on their inherent trustworthiness, which is built not only by robust validation studies but is also deeply linked to the explainability and interpretability of the algorithms. Most validation studies for medical imaging AI report the performance of algorithms on study-level labels and lay little emphasis on measuring the accuracy of explanations generated by these algorithms in the form of heat maps or bounding boxes, especially in true positive cases. We propose a new metric - Explainability Failure Ratio (EFR) - derived from Clinical Explainability Failure (CEF) to address this gap in AI evaluation. We define an Explainability Failure as a case where the classification generated by an AI algorithm matches with study-level ground truth but the explanation output generated by the algorithm is inadequate to explain the algorithm's output. We measured EFR for two algorithms that automatically detect consolidation on chest X-rays to determine the applicability of the metric and observed a lower EFR for the model that had lower sensitivity for identifying consolidation on chest X-rays, implying that the trustworthiness of a model should be determined not only by routine statistical metrics but also by novel 'clinically-oriented' models.

Efficacy and Safety of Edaravone in Amyotrophic Lateral Sclerosis Patients in Indian Population.

Amyotrophic lateral sclerosis (ALS), is a progressive fatal neurodegenerative disease. It leads to scarring or hardening of Motor neurons. The cause of ALS remains unknown. Oxidative stress caused by free radicals might be an essential factor in the progression of the disease. Edaravone, is a free-radical scavenger, it has been shown to inhibit motor neuron death in animal models by reducing oxidative stress & it has shown efficacy in a small subset of people with ALS. This study was planned to see the efficacy and safety of Edaravone in Indian population. MATERIAL: This study was a single centric observational study, on use of Edaravone in ALS patients. Who were more than 18 years of age and diagnosed to have possible, probable or definite ALS as per the El Escorial Criteria 2014. Total 30 patients were included. All patients had their Revised ALSFRS-R recorded & SFEMG was done at the time of diagnosis then after 6 months of completion of treatment protocol. They were given Edaravone as per as per defined treatment protocol. The treatment protocol consists of 24 weeks (6 cycles). In cycle 1, the study drug was administered for 14 consecutive days followed by a 2 week drug-free period. In cycle 2 and thereafter, the study drug was administered for first 10 days, followed by 18 days drug-free period. The primary efficacy endpoint was a difference in ALSFRS-R score of at least 20% from base line. Secondary endpoints were change in increase in jitter by 10%. Safety endpoints was include the incidence of adverse drug reactions. OBSERVATION: Total of 30 patients were included in the study and 23 patients completed the treatment protocol. 93.3% of patients reported with weakness of limbs while 80% suffered from atrophy of limbs. 96.7% of patients was having fasciculation.2 patients (6.6%) of subjects receiving Edaravone therapy reported with adverse side-effects.After completing the treatment protocol in the study group. On comparing the mean values of ALSFRS-R score at different end-points, no statistical significance was obtained. CONCLUSION: This study failed to demonstrate efficacy of Edaravone to delay the progression of ALS. While the primary desired endpoint was not achieved but there was small improvement in SF-EMG jitter difference of the patients that was not significant statistically. We consider that the study with large sample size results can be helpful to identify the patient population in which Edaravone could be expected to show efficacy.

Glasgow Coma Scale ≤ 12 at Admission is a Predictor of Poor Functional Outcome (mRS 2-6) at One Year in Patients with Cerebral Venous Thrombosis.

OBJECTIVE: To determine factors at hospitalization of cerebral venous thrombosis (CVT) which determine outcome at one year. METHODS: This was an ambispective study with outcome at one year follow up. Patients angiographically proven as CVT were included in study and functional modified Rankin Scale (mRS) determined at one year. They were dichotomized into "good" outcome (mRS 0-1) and "poor" outcome (mRS 2-6). Variables at admission were compared on univariate and then by cox proportional hazard regression for significance. Complications during follow up period were also compared. RESULTS: One hundred and seventy five patients were included, data of 71 was collected prospectively. One hundred and seventeen (66.9%) had "good" outcome while 58 (33.1%) had "poor" outcome. Univariate analysis showed poor outcome associated with age < 30 years, female sex, focal deficit, GCS ≤ 12, ≥3 sinuses involved and intracerebral haemorrhage. On Cox proportional hazard regression only GCS ≤ 12 was significant. Around 96% had complete/ partial recanalization at 6 months. Over one year, the complications included dural AV fistula in 10 (5.7%), intracranial hypertension in 4 (2.3%), venous thromboembolism in 6 (3.4%) and arterial infarct in 4 (2.3%). Proportions with complications in each group were similar. At one year 41 patients (25.2%) were continued on anticoagulation and 97 (55.2%) on antiepileptic drugs. Proportion in each group were similar. CONCLUSION: In patients with CVT, GCS ≤ 12 at admission was a predictor of poor functional outcome (mRS 2-6) at one year. During this period, complications were few and similar in the both the groups.

Myositis in a patient with coronavirus disease 2019: A rare presentation.

The world is presently struggling with coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A patient with COVID-19 typically presents with fever, non-productive cough, dyspnea, and myalgia. A 49-year-old female presented with complaints of subacute onset and progressive symmetrical proximal muscle weakness of both upper limbs and lower limbs with no sensory, cranial nerve deficit. She had elevated creatine phosphokinase levels of 906 U/L, an aspartate aminotransferase level of 126 IU/L, a lactate dehydrogenase level of 354 U/L, and an erythrocyte sedimentation rate of 68 mm/1 hr, and magnetic resonance imaging of the pelvis and thigh revealed muscle edema suggestive of myositis. Her reverse transcriptase-polymerase chain reaction result for SARS-CoV-2 was positive. Her evaluation for other causes of myositis was negative. She was managed with intravenous immunoglobulins and supportive care. She showed rapid improvement in symptoms and motor weakness. To our knowledge, this is the first reported case of COVID-19 related disabling myositis in India.

Survey of prevalence of anxiety and depressive symptoms among 1124 healthcare workers during the coronavirus disease 2019 pandemic across India.

BACKGROUND: A prospective study was conducted during the second phase of the coronavirus disease 2019 (COVID-19) pandemic in India to assess the prevalence of anxiety and depressive symptoms among healthcare workers (HCWs) and factors that influence the outcome. METHODS: A self-administered questionnaire was completed by 1124 HCWs during the COVID-19 pandemic (March 30, 2020, to April 2, 2020). Demographic data, questions on COVID-19 and scores of the Hospital Anxiety and Depression Scale were analysed using the chi-square test (Bonferroni correction) and binary logistic regression. RESULTS: The study consists of 1124 HCWs, including 749 doctors, 207 nurses, 135 paramedics, 23 administrators and ten supporting staff members. The prevalence of anxiety and depressive symptoms were reported as 37.2% and 31.4%, respectively. The risk factors for anxiety were female gender (30.6% vs 45.5%), age group (20-35 years) (50.4% vs 61.2%), unmarried (21.2% vs 30.6%) and job profile (nurse) (14.7% vs 26.4%). The protective factor was having service of more than 20 years (23.4% vs 14.8%). The risk factors for depression were age group (20-35 years) (51.3% vs 61.3%) and employed at a primary care hospital (16.2% vs 23.4%). The protective factors were job profile (doctor) (69.9% vs 59.6%) and having service of more than 20 years (22.3% vs 15.5%). CONCLUSION: Approximately one-third of the HCWs reported anxiety and depressive symptoms. The risk factors for anxiety symptoms were female gender, younger age and job profile (nurse) and for depressive symptoms were younger age and working at a primary care hospital. Future research studies should identify strategies for providing a safer and supportive work environment for HCWs to face epidemics/pandemics.

Open-label randomized control trial of hydroxychloroquine in patients with moderate to severe coronavirus disease 2019 infection.

BACKGROUND: At onset of coronavirus disease 2019 (COVID-19) pandemic, hydroxychloroquine (HCQ) was repurposed for treatment of patients based on reports that it had in vitro activity. The aim of this study was to find out if HCQ reduces number of days of hospitalization when given to patients with moderate to severe COVID-19 infections who require hospitalized care. METHODS: This was an open-label randomized control trial of HCQ administered 400 mg twice on day 1, then 400 mg once daily from day 2 to day 5 in patients with moderate to severe COVID-19 infection. Assessment was not blinded. Standard of care was given to both arms.Primary outcome was number of days of hospitalization till discharge or death. RESULT: One hundred ten patients (55 in each arm) were included. Mean age was 58 years. Baseline characteristics were well matched. There was no difference in the primary outcome (13.67 vs 13.89; p = 0.98). Number of deaths were more in HCQ arm (RR: 1.81; 95% CI: 1.13-2.93; p = 0.03). There was no difference in number of days on oxygen or normalization of oxygen saturation, number who needed ventilator, days to ventilator requirement and days on ventilator. Twenty-nine patients in control arm received remdesivir. When adjusted analysis was done after removal of these patients, there was no difference in primary or secondary outcomes. Number of deaths in adjusted analysis were not significant (RR: 1.28; 95% CI: 0.87-1.88; p = 0.37). CONCLUSION: HCQ does not change the number of days of hospitalization when compared with control.

Autopsy in dengue encephalitis: An analysis of three cases.

Dengue viral infection with unusual presentations has been described in literature, but autopsy is rarely done and is only limited to some cases, based on the literature review. Here, we present the autopsy findings in three cases of dengue encephalitis. All the three patients clinically presented with signs of meningoencephalitis and were positive for dengue non-structural (NS) 1 antigen (Ag) in the serum and cerebrospinal fluid. The postmortem findings revealed cerebral edema, inflammation, hemorrhage, and microinfarcts in all the three cases with herniation of the brain in one case. Sub-massive hepatocellular necrosis was seen in one case. The renal findings included hemorrhage into the Bowman's capsule with red cell cast in two of three cases. The pulmonary findings included a diffuse destruction of the alveoli and hemorrhage into the alveolar spaces in all the three cases.

Randomized trial to assess safety and clinical efficacy of intensive blood pressure reduction in acute spontaneous intracerebral haemorrhage.

BACKGROUND: Haematoma expansion due to raised blood pressure in spontaneous intracerebral haemorrhage may determine outcome. The aim of this study was to determine safety and efficacy of lowering blood pressure in acute spontaneous intracerebral haemorrhage. METHODS: This open label, multicentric trial randomized patients ≥18 years with spontaneous intracerebral haemorrhage with no secondary cause within 72 h of onset to tight BP control arm where treatment was initiated if mean arterial pressure (MAP) was ≥115 mm of Hg and conventional BP control arm where treatment was initiated if MAP was ≥130 mm of Hg. The MAP was maintained in the respective arm for another 72 h after which both arms had MAP below 115 mm of Hg. Primary outcome was modified Rankin Scale at 90 days. RESULTS: 118 patients, 59 in each arm were included. Follow up was available for all. Baseline characteristics were similar. At 90 days there was no significant difference between median mRS between the two arms. Odds Ratio for "poor outcome" (mRS 3-6) in the tight control arm (safety of the intervention) against "good outcome" (mRS 0-2) was not significant (OR 0.70 [95% CI 0.34-1.47] p = 0.35). Efficacy of the intervention in the form of Odds Ratio for "good outcome" in the tight control arm was not significant (OR 1.43 [95% CI 0.68-2.99], p = 0.35). CONCLUSION: In patients with spontaneous intracerebral haemorrhage who present within 72 h of the onset of symptoms, MAP can be safely lowered if it crosses 115 mm of Hg but it does not improve clinical outcome.

Acute Physiology and Chronic Health Evaluation II score of ≥15: A risk factor for sepsis-induced critical illness polyneuropathy.

BACKGROUND: Critical illness polyneuropathy (CIP) is a common complication of severe sepsis and systemic inflammatory response syndrome (SIRS). The risk factors for sepsis-induced CIP have not been well established. AIM: The aim of this study was to find out the risk factors of sepsis-induced CIP, especially its relationship with the severity of illness. PATIENTS AND METHODS: A cohort of 100 patients with sepsis defined as SIRS of proven or presumed microbial etiology were followed up with nerve conduction studies (NCS) performed within the first 14 days of admission. If the assessment was normal then the study was repeated between day 21 and 28. The two groups (with and without neuropathy) were compared. The following risk factors were evaluated for the development of sepsis-related CIP: Duration of symptoms, stay in Intensive Care Unit, and mechanical ventilation; use of neuromuscular blocking agents (NMBAs), steroids, insulin infusion, and inotropes. The following laboratory parameters recorded in the first 24 h of admission were included: Hemoglobin (Hb), total leukocyte count, serum urea, creatinine, aminotransaminases (aspartate aminotransferase and alanine aminotransferase), total protein, albumin, potassium, creatinine kinase, plasma glucose, HbA1C, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score at admission or within 24 h. RESULTS: Thirty-seven patients had features of neuropathy. Among these 37 patients, 30 patients (81%) developed it in the first 14 days. Multivariate analysis using linear regression showed the APACHE II score and use of NMBAs to be significant factors in its development. An APACHE II score of ≥15 was associated with a significant risk of developing CIP (relative risk: 11.6, 95% confidence interval: 4.9-27.2, P < 0.0001). CONCLUSION: Critically ill patients with sepsis and APACHE II score at admission or within 24 h of ≥15 are at risk for the development of CIP.

Reducing Tourniquet Pressures in Hand Surgery: Are Lower Pressures as Effective?

Background Pneumatic tourniquets are widely used in hand surgery. Elevated pressures can be associated with complications, and thus, guidelines based on patient-specific tourniquet pressures have been recommended. The primary aim of this study was to determine whether lower tourniquet values based on systolic blood pressure (SBP) could be effectively applied in upper extremity surgery. Methods A prospective case series of 107 consecutive patients undergoing upper extremity surgery with use of a pneumatic tourniquet was performed. Tourniquet pressure used was based on the patient's SBP. The tourniquet was inflated based on our predetermined guidelines: 60 mm Hg was added for SBP < 130 mm Hg, 80 mm Hg for SBP between 131 and 190 mm Hg, and 100 mm Hg for SBP > 191 mm Hg. The outcome measures included intraoperative tourniquet adjustment, surgeon-rated quality of bloodless operative field and complications. Results The mean tourniquet pressure was 183 ± 26 mm Hg with a mean tourniquet time of 34 minutes (range: 2-120 minutes). There were no instances of intraoperative tourniquet adjustment. The surgeon-rated quality of bloodless operative field was excellent in all patients. No complications were associated with the use of a tourniquet. Conclusion Tourniquet inflation pressure based on SBP is an effective method to provide a bloodless surgical field in upper extremity surgery at significantly lower inflation pressures than are the current standards.

A Comparative Analysis of Clinical and Imaging Features of Aquaporin 4 (AQP4) Antibody Positive, Myelin Oligodendrocyte Glycoprotein (MOG) Antibody Positive and Double Seronegative Subtypes of Neuro Myelitis Optica Spectrum Disorder (NMOSD).

Objectives: Study was conducted with aim of comparing subtypes types of NMOSD based on serology. Methods: In this retrospective study, patients ≥18 years were included satisfying IPND 2015 criteria. Three groups were created based on seropositivity for AQP4 antibody, MOG antibody or double seronegative. Demographic, clinical and imaging were compared using regression analysis. Results: Forty-six patients, 28 (60.9%) AQP4+, 11 (23.9%) MOG + and remaining 7 (15.2%) double seronegative were included. Thirty-seven patients (80.4%) had presenting symptoms localized to optic nerve and/or cord [AQP4 + 22 (78.5%), MOG + 9 (81.8%) and double seronegative 6 (85.7%)]. Presentation with bilateral optic neuritis was more common in AQP4- patients. Twenty (86.8%) out of the 23 patients who had relapsing disease localized to optic nerve and/or spinal cord [AQP4 + 13/14 (92.8%), MOG + 3/5 (60%) and double seronegative 4/4 (100%)]. Relapses were more common in AQP4+ (77% vs 12% vs10%). In AQP4 negative group disability (EDSS 4.2 vs 3.3) and progression index was relatively less (1.6 vs 1.1). CSF pleocytosis (38.8% vs 17.9%) and raised proteins (66.6% vs 32.1%) were also more common. Optic nerve MRI (>50% optic nerve and chiasma involvement) was more commonly abnormal in AQP4 negative (52.9% vs 31.2%). Regression analysis revealed females to be significantly higher in AQP4 positive NMOSD (89.3%) when compared to MOG positive (36.4%) and double seronegative (42.9%). Conclusion: Gender was the only significant difference between the three groups. There was trend towards greater disability and more relapses in AQP4 + groups.

Of Eagle's Syndrome and Finding Some Clarity on Its Management.

Eagle's Syndrome is a much discussed yet controversial and debatable diagnosis of exclusion which is treated by many specialities with often unsatisfactory results. Due to entrapment/impingement on surrounding neurovascular structures by elongated styloid process patient may present with multitude of symptoms. Treatment is controversial and opinions are divided on choice of conservative and surgical management. Aim was to study outcomes of conservative and surgical modalities of treatment of Eagle's Syndrome and bring some clarity on management, what to offer, to whom and when. This prospective observational descriptive study included 15 patients of Eagle's Syndrome, 7 were treated with conservative method and 8 underwent resection of styloid process with intraoral approach. With objectives in mind to study efficacy of both management modalities, pain visual analogue scale (VAS) scores were recorded pre-intervention, post-intervention and during follow up on 1, 3 and 6 months and compared. Conservative management resulted in up to 70% reduction in pain VAS scores till 3 months of therapy (mean pre-intervention score being 3.71, 3 months-1, 6 months-1.29), while surgical modality resulted in nearly 99% reduction in mean pain VAS scores up to 3 months and even improved after 6 months (mean pre-intervention score being 6.75, 3 months-0.5, 6 months-0.13). With this we can conclude that conservative management provide satisfactory short-term (up to 3 months) results but recurrences are known, while surgical resection of elongated styloid process gives better long-term results (6 months and beyond).

Frequency of Missed Findings on Chest Radiographs (CXRs) in an International, Multicenter Study: Application of AI to Reduce Missed Findings.

BACKGROUND: Missed findings in chest X-ray interpretation are common and can have serious consequences. METHODS: Our study included 2407 chest radiographs (CXRs) acquired at three Indian and five US sites. To identify CXRs reported as normal, we used a proprietary radiology report search engine based on natural language processing (mPower, Nuance). Two thoracic radiologists reviewed all CXRs and recorded the presence and clinical significance of abnormal findings on a 5-point scale (1-not important; 5-critical importance). All CXRs were processed with the AI model (Qure.ai) and outputs were recorded for the presence of findings. Data were analyzed to obtain area under the ROC curve (AUC). RESULTS: Of 410 CXRs (410/2407, 18.9%) with unreported/missed findings, 312 (312/410, 76.1%) findings were clinically important: pulmonary nodules (n = 157), consolidation (60), linear opacities (37), mediastinal widening (21), hilar enlargement (17), pleural effusions (11), rib fractures (6) and pneumothoraces (3). AI detected 69 missed findings (69/131, 53%) with an AUC of up to 0.935. The AI model was generalizable across different sites, geographic locations, patient genders and age groups. CONCLUSION: A substantial number of important CXR findings are missed; the AI model can help to identify and reduce the frequency of important missed findings in a generalizable manner.

A real world multi center study on efficacy and safety of natalizumab in Indian patients with multiple sclerosis.

BACKGROUND: Natalizumab (NTZ) is increasingly being used in Indian multiple sclerosis (MS) patients. There are no reports on its safety and efficacy, especially with respect to the occurrence of progressive multifocal leukoencephalopathy (PML). OBJECTIVES: To describe the patient characteristics, treatment outcomes, and adverse events, especially the occurrence of PML in NTZ-treated patients. METHODS: A multicentre ambispective study was conducted across 18 centres, from Jan 2012 to Dec 2021. Patients at and above the age of 18 years treated with NTZ were included. Descriptive and comparative statistics were applied to analyze data. RESULTS: During the study period of 9 years, 116 patients were treated with NTZ. Mean age of the cohort was 35.6 ± 9.7 years; 83/116 (71.6%) were females. Relapse rate for the entire cohort in the year before NTZ was 3.1 ± 1.51 while one year after was 0.20±0.57 (p = 0.001; CI 2.45 -3.35). EDSS of the entire cohort in the year before NTZ was 4.5 ± 1.94 and one year after was 3.8 ± 2.7 (p = 0.013; CI 0.16-1.36). At last follow up (38.3 ± 22.78 months) there were no cases of PML identified. CONCLUSIONS: Natalizumab is highly effective and safe in Indian MS patients, with no cases of PML identified at last follow up.