The Clinical Outcome in AChR-Positive Generalized Myasthenia Gravis: A Retrospective Observational Study.

Background: Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction, and in over 80% of cases, antibodies are identified against the nicotinic type of acetylcholine receptor (AChR) on the muscle endplate. Despite the availability of various treatment options, patients with MG experience relapses and remission during the course of the disease. Aims and Objective: To understand the clinical profile, predictors of outcomes in acetyl choline receptor (AChR) antibody positive generalized MG. Methods: This is a retrospective, single-centre, observational study of 108 patients with AChR positive generalized MG. We collected data on clinical and demographical profiles, treatments received, and treatment responses from those who fulfilled inclusion criteria over a mean follow up period of 33.75 ±7.30 months. Clinical outcomes were studied in terms of the type of remission and crisis or disease exacerbations patients had, considering different variables and treatment received. Results: We found the commonest initial symptoms were ocular or oculo-bulbar, which progressed to generalized MG in the first year of disease onset. 36 (33.3%) patients experienced a crisis requiring mechanical ventilation within a mean period of 9.4 ±4.77 months from the disease onset. Multivariate regression analysis showed late-onset MG (age of onset between 50-70 years) and treatment with rituximab were better correlated with remission, (odd ratio of 4.7; 95 % CI ,1.12 -12.6; P value < 0.05 and odd ratio of 4.56; 95 % CI ,1.2 -10.04; P value < 0.05) respectively. While treatment with Mycofenolate Mofetile (MMF) was associated with a higher number of relapses (odd ratio of 1.8; 95 % CI ,0.08 -0.96; P value < 0.05). Treatment with Rituximab showed a higher rate of remission as compared to treatment refractory (TR) on conventional immunosuppressant therapy (IST). Out of 35(32 %) thymoma patients, 21 patients underwent thymectomy and these patients showed significantly greater rate of remission as compared both thymoma patients who denied thymectomy as a treatment option (N = 10 ;55.60 % vs N = 4; 23.50%). Conclusion: In this study of AChR antibody positive generalized MG patients, we found that nearly one-third of them experienced myasthenic crisis despite receiving the best medical care. Rituximab appeared to be effective in the treatment of refractory MG and those who failed thymectomy. Thymectomy was associated with better outcomes in patients, both with or without a thymoma.

Essential Oil Composition Analysis of Cymbopogon Species from Eastern Nepal by GC-MS and Chiral GC-MS, and Antimicrobial Activity of Some Major Compounds.

Cymbopogon species essential oil (EO) carries significant importance in pharmaceuticals, aromatherapy, food, etc. The chemical compositions of Cymbopogon spp. Viz. Cymbopogon winterianus (citronella) Cymbopogon citratus (lemongrass), and Cymbopogon martini (palmarosa) were analyzed by gas chromatography−mass spectrometry (GC-MS), enantiomeric distribution by chiral GC-MS, and antimicrobial activities of some selected pure major compound and root and leaves EOs of citronella. The EO of leaves of Cymbopogon spp. showed comparatively higher yield than roots or other parts. Contrary to citral (neral and geranial) being a predominant compound of Cymbopogon spp., α-elemol (53.1%), α-elemol (29.5%), geraniol (37.1%), and citral (90.4%) were detected as major compounds of the root, root hair with stalk, leaf, and root stalk with shoot of citronella EO, respectively. Palmarosa leaves' EO contains neral (36.1%) and geranial (53.1) as the major compounds. In the roots of palmarosa EO, the prime components were α-elemol (31.5%), geranial (25.0%), and neral (16.6%). Similarly, lemongrass leaves' EO contains geraniol (76.6%) and geranyl acetate (15.2%) as major compounds, while the root EO contains a higher amount of geraniol (87.9%) and lower amount of geranyl acetate (4.4%). This study reports for the first time chiral terpenoids from Cymbopogon spp. EOs. Chiral GC-MS gave specific enantiomeric distributions of nine, six, and five chiral terpenoids in the root, root stalk with a shoot, and leaves of citronella EOs, respectively. Likewise, four and three chiral terpenoids in the root and leaves of lemongrass oil followed by two chiral terpenoids in the leaves and root of palmarosa EOs each. Additionally, the root and leaves' EOs of citronella exhibit noticeable activity on bacteria such as Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pyogenes and fungus such as Candida albicans, Microsporum canis, and Trichophyton mentagrophytes. So, geranial-, neral-, geraniol-, and citronellal-rich EOs can be used as an alternative antimicrobial agent.

Atypical Optic Neuritis: The Potential Red Flags.

Background: Many potential causes of optic nerve inflammation exist, including typical and atypical causes, which require different management strategies. Objective: The objective of this study is to identify red flags that help differentiate typical from atypical optic neuritis (ON). Materials and Methods: This prospective study included 66 patients (100 eyes) with immune-mediated ON from January 2016 to June 2019, carefully excluding the nonimmune causes. The clinico-radiological features, investigations, therapy, and outcome were analyzed. Results: We evaluated 33 cases each of typical and atypical ON. The typical group included 29 idiopathic ON and four associated with multiple sclerosis. Atypical ON included 19 neuromyelitis optica (NMO), seven MOG-associated ON (MOG-ON), and others due to Sjogren's syndrome, granulomatous polyangiitis, sarcoidosis, and IgG4 disease. Atypical ON occurred significantly and more frequently with extremes of ages (<10 or >70 years), bilateral simultaneous or severe vision loss with early disc pallor, multiple attacks, symptoms/neuro-imaging indicating non-MS disease e.g., long segment ON/myelitis, large confluent lesions, the involvement of optic tract, chiasma, area postrema or diencephalon, and (pachy) meningitis. Systemic involvement and poor outcomes despite steroids and second-line immunosuppression were observed more often in the atypical ON. Conclusions: The red flags indicating atypical ON are onset at extremes of age, multiple attacks, bilateral simultaneous or severe to very severe vision loss, early disc pallor, neurological symptoms, or imaging abnormalities suggesting non-MS disease, systemic involvement, and poor steroid responsiveness. The awareness might help the clinician promptly identify and escalate therapy to ensure a better outcome.

Thermochemical study of Cr(VI) sequestration onto chemically modified Areca catechu and its recovery by desorptive precipitation method.

A new biosorbent for Cr(VI) sequestration was investigated from betel nut waste (BNW), Areca catechu, by H2SO4 charring. Aqueous insolubility and Cr(VI) uptake capacity of native BNW were potentially improved after H2SO4 modification due to cross-linking reaction of betel nut cellulose, thereby creating suitable complexation sites for Cr(VI) ion removal. Langmuir isotherm and pseudo second order (PSO) kinetic models described well with the experimental data. A trace amount of Cr(VI) was effectively removed below the safe drinking water standard (WHO, 0.05 mg/L) using charred BNW (CBNW). The negative value of ΔG° evaluated for all the temperatures suggested the spontaneous nature of Cr(VI) sequestration and positive value of ΔH° (42.43±0.13 kJ/mol) confirmed an endothermic reaction. Co-existing NO 3 - , Cl-, Na+ and Zn2+ ions showed negligible interferences, whereas SO 4 2 - and PO 4 3 - notably reduced Cr(VI) uptake capacity of CBNW. More than 98% of adsorbed Cr(VI) was desorbed using 1M NaOH solution. A light yellow precipitate of BaCrO4 was recovered from the desorbed solution after precipitation with BaCl2 solution. Therefore, the CBNW biosorbent investigated in this work is expected to be a promising material for Cr(VI) sequestration and its recovery from polluted water.

Validation of a New Graphic Facial Nerve Grading System: FAME Scale.

Background and Objective: Most of the existing qualitative facial nerve grading systems are very subjective while the quantitative grading systems are more complex, require longer data input time and specific software. There is a need for having a scoring system with graphic criteria to improve the subjectivity, reliability and convenience. We aimed to develop and validate such a reliable graphic scale for use in Bell's palsy. Methods: Face videos of patients with unilateral facial paralysis were recorded using smartphones and analyzed for six items including five voluntary facial movements apart from complications of facial palsy (synkinesis, hyperkinesis, and contracture). 15 videos were used for pilot study, 75 for the development of scale and 110 for its validation. Each video was rated on two separate occasions by 3 independent raters, a score of 0-4 was assigned to each item using the graphic scoring criteria, and a composite score was obtained (range 0-24). Five disease severity categories: normal (score 0), mild (score 1-6), moderate (score 7-12), severe (score: 13-18) and profound facial weakness (score: 19-24). Results: The proposed scale and its component items had high inter-rater and intra-rater reliability (Kappa >0.7). Good correlation (Pearson co-efficient >0.7) was seen among the voluntary movements. The proposed scale is a valid tool to score motor deficits and complications of facial palsy. Conclusions: The proposed scale is a valid and reliable graphic scale to describe facial motor dysfunction and its secondary defects.

Comparison of Volatile Constituents Present in Commercial and Lab-Distilled Frankincense (Boswellia carteri) Essential Oils for Authentication.

A comparative analysis of the chemical constituents present in twenty-one commercial and two lab-distilled frankincense (Boswellia carteri) essential oils was carried out using gas chromatography-mass spectrometry (GC-MS) and chiral gas chromatography-mass spectrometry (CGC-MS) for authentication. Out of the twenty-one commercial samples, six were adulterated with synthetic limonene, three were contaminated with synthetic octyl acetate, three were adulterated with castor oil, and two samples each were contaminated with frankincense resin and Boswellia occulta species, respectively, and one was contaminated with the Boswellia serrata species. Additionally, one sample was contaminated with phthalates as well as a cheap essential oil with similar compositions. Furthermore, one sample was adulterated with copaiba resin and frankincense resin in combination with synthetic octyl acetate. Additionally, one was contaminated with Boswellia serrata species, which was further adulterated with castor oil and frankincense resin. To the best of our knowledge, this is the first report to compare the enantiomeric distribution of chiral terpenoids present in commercial frankincense essential oil with lab-distilled frankincense oil for authentication. The CGC-MS analysis showed the presence of a total of eight chiral terpenoids in lab-distilled frankincense essential oils, which can be used as chemical fingerprints for the authentication of frankincense essential oil.

Analysis of Volatile Constituents in Curcuma Species, viz. C. aeruginosa, C. zedoaria, and C. longa, from Nepal.

The genus Curcuma, composed of 93 species mainly originating from Asia, Australia, and South America, has been used for medicinal purposes, aromatic, and nutritional values as well as cosmetic. It plays a vital role in flavoring and coloring as well as exhibiting therapeutic agents against different diseases. Nepalese farmers are unaware of the essential oil compositions of Curcuma species, viz. C. aeruginosa, C. zedoaria, and C. longa. The investigation of these three essential oils provides insight into their potential as cash crops and earns a reasonable return from their production. The essential oils were obtained from the rhizomes of each plant by hydrodistillation and subjected to Gas Chromatography/Mass Spectrometry (GC−MS) analysis to identify its volatile chemical constituents as well as chiral GC-MS to identify the enantiomeric distribution of chiral terpenoids. The order of extraction yields were C. longa (0.89%) > C. zedoaria (0.74%) > C. aeruginosa (0.37%). In total, the presence of 65, 98, and 84 compounds were identified in C. longa, C. zedoaria, and C. aeruginosa, representing 95.82%, 81.55%, and 92.59% of the total oil, respectively. The most abundant compounds in C. longa essential oils were ar-turmerone (25.5%), α-turmerone (24.4%), ß-turmerone (14.0%), terpinolene (7.2%), ß-sesquiphellandrene (5.1%), α-zingiberene (4.8%), ß-caryophyllene (2.9%), ar-curcumene (1.6%) and 1,8-cineole (1.3%). The most dominant compounds in C. zedoaria were curzerenone (21.5%), 1,8-cineole (19.6%), curzerene (6.2%), trans-ß-Elemene (5.1%), camphor (2.6%), and germacrone (2.3%). The major components in C. aeruginosa were curzerenone (59.6%), germacrone (5.3%), curzerene (4.7%), camphor (3.6%), trans-ß-Elemene (2.6%), and ß-eudesmol (1.6%). C. zedoaria, and C. aeruginosa essential oil from Nepal for the very first time. This study reports for the first time chiral terpenoids from C. aeruginosa, C. zedoaria, and C. longa essential oil. A chemical blueprint of these essential oils could also be used as a tool for identification and quality assessment.

Proximal Dominant Hereditary Motor and Sensory Neuropathy with TFG Mutation: First Case Report from India.

Hereditary motor and sensory neuropathy with proximal predominance (HMSN-P) is a rare degenerative disorder inherited in an autosomal dominant fashion. This disease was described first in Japanese descendants from Okinawa and Shiga prefectures in mainland Honshu in 1997. The disease is characterized by adult onset of proximal weakness and atrophy, muscle cramps, fasciculations, areflexia, high incidence of elevated creatine kinase, hyperlipidemia, and diabetes mellitus, resembling Kennedy disease, though the mode of inheritance is autosomal dominant, rather than X linked. We examined a 56-year-old male patient with clinical features suggestive of HMSN-P and positive family history in an autosomal dominant fashion. Clinical, electrophysiological, and genetic factors were also reviewed. The appearance of HMSN-P in India and elsewhere calls for clinicians in nonendemic regions to be familiar with this rare disorder, which has typically been geographically confined.

Volatile Constituent Analysis of Wintergreen Essential Oil and Comparison with Synthetic Methyl Salicylate for Authentication.

A comparative analysis of Gaultheria fragrantissima (Ericaceae) essential oils based on geographical location, distillation time, and varying distillation conditions was carried out, and their compositions were evaluated by gas chromatography-mass spectrometry (GC-MS), chiral GC-MS, and gas chromatography-flame ionization detection (GC-FID). In addition, each of seven commercial wintergreen essential oil samples from Nepal and China were analyzed. The highest extraction yield was 1.48% and the maximum number of compounds identified in natural wintergreen oil was twenty-two. Based on distillation time, the maximum numbers of identified compounds are present in 120 min. Linalool, phenol, vetispirane, and ethyl salicylate were present in commercial wintergreen oils both from Nepal and China. The presence of compounds such as elsholtzia ketone and ß-dehydroelsholtzia ketone in the China samples represented a significant difference in wintergreen oil between the two geographical sources. Dimethyl 2-hydroxyterephthalate is a well-known synthetic marker for wintergreen oil when synthesis is carried out using salicylic acid, but the synthetic marker was absent while using acetylsalicylic acid as a precursor during synthesis. Adulteration analysis of wintergreen oil showed an increase in the concentration of dimethyl 2-hydroxyterephthalate, whereas the concentrations of minor components decreased and methyl salicylate remained unchanged. To the best of our knowledge, this is the first report of the enantioselective analysis of wintergreen essential oil. Furthermore, three samples showed notable antibacterial activity against Staphylococcus epidermidis, with an MIC value of 156.3 µg/mL. Similarly, one sample showed effectiveness against Aspergillus niger (MIC = 78.1 µg/mL).

Cerebrovascular Involvement in Mucormycosis in COVID-19 Pandemic.

BACKGROUND: Many countries have seen an unprecedented rise of cases of coronavirus disease 2019 (COVID-19) associated mucormycosis (CAM). Cerebrovascular involvement in CAM has not been studied so far. We describe clinico-radiological manifestations of cerebrovascular complications observed in CAM. METHODS: In this multicentric retrospective observational study from India, patients with CAM who developed cerebrovascular involvement were studied. Their demographics, risk factors, clinical manifestations, imaging, laboratory profile and outcomes were noted. RESULTS: Out of 49 subjects with cerebrovascular involvement, 71.4% were males while average age was 52.9 years. Ischemic stroke was commonest (91.8%) followed by intracranial haemorrhage (6.1%) and subarachnoid haemorrhage (2%). The incidence of cerebrovascular complications in CAM was found to be 11.8% in one center. Cerebrovascular symptoms appeared a median of 8.3 days from the onset of mucormycosis. Commonest presentation of mucormycosis was rhino-orbito-cerebral syndrome in 98%. Diabetes mellitus was present in 81.7%. Forty percent developed stroke despite being on antiplatelet agent and/or heparin. Amongst subjects with ischemic strokes, location of stroke was unilateral anterior circulation (62.2%); bilateral anterior circulation (17.8%); posterior circulation (11.1%) and combined anterior and posterior circulation (8.9%). Vascular imaging revealed intracranial occlusion in 62.1%; extracranial occlusion in 3.4% and normal vessels in 34.5%. Mortality was 51% during hospital stay. CONCLUSIONS: Cerebrovascular involvement was seen in 11.8% patients of CAM. Angio-invasive nature of the fungus, prothrombotic state created by COVID-19, and diabetes were important causative factors. Subjects with CAM should be screened for involvement of the brain as well as its vessel. Antiplatelet agents/heparin did not seem to provide complete protection from this type of stroke.

Acute haemorrhagic leukoencephalitis (AHLE) - our experience and a short review.

BACKGROUND: Acute haemorrhagic leukoencephalitis (AHLE), a rare variant of acute disseminated encephalomyelitis (ADEM), often presents differently from classical ADEM, thereby posing a diagnostic challenge to the clinician. AIM: To report AHLE, its clinic-radiological manifestations, process of diagnosis and prognosis. METHOD AND RESULTS: Eight patients presented with altered sensorium, acute focal deficits with or without seizures. Initial workup showed evidence of haemorrhagic lobar or thalamic lesions in seven patients. All patients underwent extensive evaluation for collagen vascular disease and vasculitis profile, autoimmune encephalitis panel and aquaporin-4 antibody, which were found to be normal. Cerebrospinal fluid (CSF) biochemistry and microscopy was non-contributory and CSF viral PCRs, toxoplasma antibodies, cryptococcal antigen were also negative. All patients had progressively worsening sensorium and neurological deficits. Repeat MRIs showed increase in oedema in the lesions and appearance/expansion of haemorrhage in the thalamic/hemispherical lesions. All patients received intravenous methylprednisolone (IVMP) without any benefit. Four patients underwent plasmapheresis (PLEX), one received intravenous immunoglobulin (IVIG) and one received both second line immunotherapies, without significant improvement. Brain biopsy (performed in three patients) showed inflammatory demyelination and areas of haemorrhage, thus confirming the diagnosis. Six patients succumbed in 7-30 days of the illness, despite aggressive treatment and only two survived, albeit with a significant disability. CONCLUSION: AHLE is a rare, yet very severe variant of ADEM. MRI shows lesions with haemorrhages, oedema and mass effect and histology findings reveal inflammatory infiltrates, haemorrhagic foci and fibrinoid necrosis of vessel walls. Prognosis is worse as compared to the classic ADEM, with a high mortality rate. To the best of our knowledge, this is one of the largest series of AHLE to have been reported anywhere in the world. KEYMESSAGE: Acute encephalopathy, multifocal deficits accompanied by haemorrhagic CNS demyelinating lesions with oedema and mass effect are the key features of AHLE. It is a rare, yet very severe form of ADEM with very high morbidity and mortality.

The Chemical Profiling of Essential Oils from Different Tissues of Cinnamomum camphora L. and Their Antimicrobial Activities.

Cinnamomum camphora L. is grown as an ornamental plant, used as raw material for furniture, as a source of camphor, and its essential oil can be used as an important source for perfume as well as alternative medicine. A comparative investigation of essential oil compositions and antimicrobial activities of different tissues of C. camphora was carried out. The essential oils were extracted by hydrodistillation with a Clevenger apparatus and their compositions were evaluated through gas chromatography-mass spectrometry (GC-MS), enantiomeric composition by chiral GC-MS, and antimicrobial properties were assayed by measuring minimum inhibitory concentrations (MICs). Different plant tissues had different extraction yields, with the leaf having the highest yield. GC-MS analysis revealed the presence of 18, 75, 87, 67, 67, and 74 compounds in leaf, branch, wood, root, leaf/branch, and leaf/branch/wood, respectively. The significance of combining tissues is to enable extraction of commercial quality essential oils without the need to separate them. The oxygenated monoterpene camphor was the major component in all tissues of C. camphora except for safrole in the root. With chiral GC-MS, the enantiomeric distributions of 12, 12, 13, 14, and 14 chiral compounds in branch, wood, root, leaf/branch, and leaf/branch/wood, respectively, were determined. The variation in composition and enantiomeric distribution in the different tissues of C. camphora may be attributed to the different defense requirements of these tissues. The wood essential oil showed effective antibacterial activity against Serratia marcescens with an MIC of 39.1 µg/mL. Similarly, the mixture of leaf/branch/wood essential oils displayed good antifungal activity against Aspergillus niger and Aspergillus fumigatus while the leaf essential oil was notably active against Trichophyton rubrum. C. camphora essential oils showed variable antimicrobial activities against dermal and pulmonary-borne microbes.

INSTRuCT: Protocol, Infrastructure, and Governance.

Background and Purpose: Very few large scale multicentric stroke clinical trials have been done in India. The Indian Council of Medical Research funded INSTRuCT (Indian Stroke Clinical Trial Network) as a task force project with the objectives to establish a state-of-the-art stroke clinical trial network and to conduct pharmacological and nonpharmacological stroke clinical trials relevant to the nation and globally. The purpose of the article is to enumerate the structure of multicentric stroke network, with emphasis on its scope, challenges and expectations in India. Methods: Multiple expert group meetings were conducted by Indian Council of Medical Research to understand the scope of network to perform stroke clinical trials in the country. Established stroke centers with annual volume of 200 patients with stroke with prior experience of conducting clinical trials were included. Central coordinating center, standard operating procedures, data and safety monitoring board were formed. Discussion: In first phase, 2 trials were initiated namely, SPRINT (Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India) and Ayurveda treatment in the rehabilitation of patients with ischemic stroke in India (RESTORE [Rehabilitation of Ischemic stroke Patients in India: A Randomized controlled trial]). In second phase, 4 trials have been approved. SPRINT trial was the first to be initiated. SPRINT trial randomized first patient on April 28, 2018; recruited 3048 patients with an average of 128.5 per month so far. The first follow-up was completed on May 27, 2019. RESTORE trial randomized first patient on May 22, 2019; recruited 49 patients with an average of 3.7 per month so far. The first follow-up was completed on August 30, 2019. Conclusions: In next 5 years, INSTRuCT will be able to complete high-quality large scale stroke trials which are relevant globally. REGISTRATION: URL: http://www.ctri.nic.in/; Unique Identifier: CTRI/2017/05/008507.

Myelin Oligodendrocyte Glycoprotein (MOG)-IgG Associated Demyelinating Disease: Our Experience with this Distinct Syndrome.

BACKGROUND: Discovery of serum myelin oligodendrocyte glycoprotein (MOG) antibody testing in demyelination segregated MOG-IgG disease from AQ-4-IgG positive NMOSD. AIMS: To study clinico-radiological manifestations, pattern of laboratory and electrophysiological investigations and response to treatment through follow up in MOG-IgG positive patients. METHOD: Retrospective data of MOG-IgG positive patients was collected. Demographics, clinical manifestations at onset and at follow up and relapses, anti AQ-4-IgG status, imaging and all investigations were performed, treatment of relapses and further immunomodulatory therapy were captured. RESULTS: In our 30 patients, F: M ratio was 2.75:1 and adult: child ratio 4:1. Relapses at presentation were optic neuritis {ON}(60%), longitudinally extensive transverse myelitis {LETM}(20%), acute disseminated encephalomyelitis {ADEM}(13.4%), simultaneous ON with myelitis (3.3%) and diencephalic Syndrome (3.3%). Salient MRI features were ADEM-like lesions, middle cerebellar peduncle fluffy infiltrates, thalamic and pontine lesions and longitudinally extensive ON {LEON} as well as non-LEON. Totally, 50% patients had a relapsing course. Plasma exchange and intravenous immunoglobulin worked in patients who showed a poor response to intravenous methylprednisolone. Prednisolone, Azathioprine, Mycophenolate and Rituximab were effective attack preventing agents. CONCLUSIONS: MOG-IgG related manifestations in our cohort were monophasic/recurrent/simultaneous ON, myelitis, recurrent ADEM, brainstem encephalitis and diencephalic Syndrome. MRI features suggestive of MOG-IgG disease were confluent ADEM-like lesions, middle cerebellar peduncle fluffy lesions, LETM, LEON and non-LEON. Where indicated, patients need to go on immunomodulation as it has a relapsing course and can accumulate significant disability. Because of its unique manifestations, it needs to be considered as a distinct entity. To the best of our knowledge, this is the largest series of MOG-IgG disease reported from India.

Myelin Oligodendrocyte Glycoprotein (MOG) Antibody-Associated CNS Demyelination: Clinical Spectrum and Comparison with Aquaporin-4 Antibody Positive Neuromyelitis Optica Spectrum Disorder.

BACKGROUND: The clinical phenotypes of myelin oligodendrocyte glycoprotein (MOG) antibody disease, its disease course, and treatment are poorly understood and much work needs to be done towards this. OBJECTIVE: To characterize the clinico-radiologic spectrum and treatment outcomes of MOG antibody disease and differentiate it from aquaporin-4 (AQP-4) antibody positive neuromyelitis optica spectrum disorders (NMO-SD). METHODS: A single-center, observational study from Western India during 2017-2019, of 48 patients with either MOG antibody positive (21 patients) or AQP-4 antibody positive (27 patients) central nervous system demyelination. RESULTS: MOG antibody group had median age 32.2 years, no gender bias, median disease duration 40 months, relapses in 9 patients (43%), and median 2.5 (1-16) episodes per patient. Onset phenotypes included isolated bilateral optic neuritis (ON) (43%), isolated unilateral ON (19%), acute brainstem syndrome (19%), simultaneous ON with myelitis (9%), isolated myelitis (5%), and acute disseminated encephalomyelitis optic neuritis (ADEM-ON) (5%). Characteristic neuroimaging abnormalities were anterior segment longitudinally extensive ON, upper brainstem, and thoracic cord involvement (both short and long segment lesions). Most patients (86%) responded well to steroids, only 3/21 required rescue immunotherapy. In total, 6 out of 46 eyes affected developed permanent visual disability, while one patient had motor disability. The features differentiating MOG from AQP-4 antibody group were: no female predilection, preferential optic nerve involvement, characteristic neuroimaging abnormalities, and favorable therapeutic response and outcome. CONCLUSIONS: MOG disease commonly presents as severe ON, myelitis, acute brainstem syndrome, ADEM or their combinations. Early identification, treatment, and maintenance immunosuppression are necessary. It can easily be differentiated from NMO-SD using clinico-radiological features and therapeutic response.

Systematic Development of Structured Semi-interactive Stroke Prevention Package for Secondary Stroke Prevention.

BACKGROUND: Lack of compliance to medication and uncontrolled risk factors are associated with increased risk of recurrent stroke and acute coronary syndrome in patients with recent stroke. Multimodal patient education may be a strategy to improve the compliance to medication and early adoption of nonpharmacological measures to reduce the vascular risk factor burden in patients with stroke. We thus aim to develop multilingual short messaging services (SMS), print, and audio-visual secondary stroke prevention patient education package. The efficacy of the package will be tested in a randomized control trial to prevent major cardiovascular and cerebrovascular events. METHODS: In the formative stage, intervention materials (SMS, video, and workbook) were developed. In the acceptability stage, the package was independently assessed and modified by the stakeholders involved in the stroke patient care and local language experts. The modified stroke prevention package was tested for implementation issues (implementation stage). RESULTS: Sixty-nine SMS, six videos, and workbook with 11 chapters with 15 activities were developed in English language with a mean ± SD SMOG index of 9.1 ± 0.4. A total of 355 stakeholders including patients (24.8%), caregivers (24.8%), doctors (10.4%), nurses (14.1%), local language experts (2.8%), physiotherapists (13.2%), and research coordinators (9.8%) participated in 10 acceptability stage meetings. The mean Patient Education Material Assessment Tool understandability score in all languages for SMS, video scripts, and workbook was 95.2 ± 2.6%, 95.2 ± 4.4%, and 95.3 ± 3.6%, respectively. The patients [n = 20, mean age of 70.3 ± 10.6 years and median interquartile range (IQR) baseline NIHSS 1 (0-3)] or the research coordinators (n = 2) noted no implementation issues at the end of 1 month. CONCLUSION: An implementable complex multilingual patient education material could be developed in a stepwise manner. The efficacy of the package to prevent major adverse cardiovascular events is being tested in the SPRINT INDIA study.

Expert Group Meeting on Aphasia: A Report.

A multidisciplinary team of experts took stock of the current state of affairs about many aspects of aphasia in India, including community burden, diagnostic assessment, therapy, rehabilitation, research, education, and advocacy. The broad spectrum of aphasiology was matched by the types of participants ranging from neurologists, speech-language pathologists, clinical psychologists, linguists, to experts in neuroimaging and computer sciences. Threadbare discussion in 16 sessions over 3 days leads to the identification of pressing problems and possible solutions. Many action plans have been envisaged and recommendations made. A few examples with high priority are community-based and hospital-based study incidence and prevalence of aphasia, development of test batteries for the assessment of many components of speech and communication in Indian languages which are validated on rigorous psychometric, and linguistic criteria, national registry for aphasia, educational modules about aphasia for different target groups, resources for advocacy and its training, a bank of research questions and outlines of research protocols for young professionals to pursue. The expert group will continue to oversee execution of some of the actionable plans in short and long term.

Does the Tempo and Pattern of Neurological Syndrome Help Diagnose Paraneoplastic Etiology?

BACKGROUND: Paraneoplastic neurological syndromes (PNS) are defined as remote effects of cancer that are not caused by the tumor and its metastasis, or by infection, ischemia or metabolic disruptions. In most patients, the neurological disorder is the manifesting condition and cancer is not detectable clinically at that time. Hence, most often it will be upon the neurologist and not the oncologist to detect paraneoplastic syndrome. AIMS AND OBJECTIVES: To identify characteristic features of a neurological syndrome (presentation pattern and tempo of illness- onset, duration, progression and response to treatment) which indicate a paraneoplastic etiology. MATERIALS AND METHODS: This is a retrospective study. Medical records of all patients who were discharged/ died in Neurology unit of a tertiary care center over a study period of two years with a diagnosis of Paraneoplastic neurological syndrome as per the diagnostic criteria given by F Graus et al1 were studied. RESULTS: Seven PNS cases were identified of which, five had peripheral and two had central nervous system syndrome consistent with the anatomical localisation. Painful pure motor quadriparesis was present in three cases. Subacute onset and rapid progression was seen in six out of seven patients. Ill sustained response to corticosteroid treatment was seen in three patients whereas the remaining four showed no response. In five patients, tumour was detected after the diagnosis of neurological syndrome, as against one patient which had an antecedent tumour and the remaining one patient had classical onconeural antibody without evidence of any detectable tumor. Average time to tumor diagnosis from neurological symptom was 3.5 months. CONCLUSION: A subacute onset, rapidly progressive painful, pure motor quadriparesis; Ganglionopathy in elderly and autoimmune encephalitis with ill sustained or no response to corticosteroids merits consideration of paraneoplastic etiology.