Myositis in H1N1 Infection Compounds to Myasthenic Crisis.

ABSTRACT: Infection is an important trigger of myasthenic crisis (MC), and those infections manifest with pneumonia and muscle involvement may result in more frequent MC. We report two myasthenia gravis (MG) patients with H1N1 infection, and highlight the reasons for deterioration. Two patients with MG had H1N1 infection. The diagnosis of MG was confirmed by neostigmine, repetitive nerve stimulation, and anti-acetylcholine receptor antibody tests. H1N1 was confirmed by nucleic acid detection study, and myositis by creatinine kinase. The patient with pneumonia and myositis had MC needing mechanical ventilation for 10 days, and the other patient without myositis did not have MC. They were treated with oseltamivir 75 mg twice daily for 5 days, and the patients with MC received ceftriaxone intravenously. Both the patients were on prednisolone and azathioprine, and none received prior H1N1 vaccination. The lady with MC with myositis was discharged on day 27 in wheelchair bound state, and the other one patient without myositis or MC was discharged on 6th day with full recovery. These patients highlight the need for evaluation for myositis along with pneumonia in the MG patients with H1N1 infection. Vaccination in MG patients on immunosuppression may be useful.

Predictive factors of symptomatic lumbar pseudoarthrosis following multilevel primary lumbar fusion.

Background: Lumbar spinal fusion surgery is a well-established treatment for various spinal disorders. However, one of its complications, pseudoarthrosis, poses a significant concern. This study aims to explore the incidence, time and predictive factors contributing to pseudoarthrosis in patients who have undergone lumbar fusion surgery over a 10-year period. Methods: Data for this research was sourced from the PearlDiver database where insurance claims of patients who underwent multilevel lumbar spinal fusion between 01/01/2010 and 10/31/2022 were examined for claims of pseudoarthrosis within the 10 years of their index procedure. A variety of demographic, comorbid, and surgical factors were assessed, including age, gender, Elixhauser Comorbidity Index (ECI), surgical approach, substance use disorders and history of spinal disorders. Statistical analyses, including chi-squared tests, multivariate analysis, and cox survival analysis were employed to determine significant associations. Results: Among the 76,337 patients included in this retrospective study, 2.70% were diagnosed with symptomatic lumbar pseudoarthrosis at an average of 7.38 years in a 10-year follow-up. Multivariate and Cox hazard analyses revealed that significant predictors of symptomatic pseudoarthrosis development following multilevel primary lumbar fusion include vitamin D deficiency, osteoarthritis, opioid and NSAID use, tobacco use, and a prior history of congenital spine disorders. Conclusions: In summary, this study revealed a 2.70% incidence of symptomatic lumbar pseudoarthrosis within 10 years of the index procedure. It highlighted several potential predictive factors, including comorbidities, surgical approaches, and substance use disorders, associated with the development of symptomatic pseudoarthrosis. Future research should focus on refining our understanding of these factors to improve patient outcomes and optimize healthcare resource allocation.

Exploring the incidence and risk factors of reoperation for symptomatic adjacent segment disease following cervical decompression and fusion.

Background: Patients with long-term follow-up after cervical decompression and fusion have often been noted to have development of adjacent segment degeneration with a smaller subset of these patients progressing to adjacent segment disease (ASD), which results in the development of new symptomatic radiculopathy or myelopathy referable to a site either directly above or below a prior fused segment. The cause of ASD is multifactorial often involving natural age-related progression of spondylosis, accelerated progression following cervical decompression and fusion, operative technique, and patient-related factors. The effect of age at the time of index cervical decompression and fusion on the need for reoperation for ASD is not fully understood. This study aims to establish underlying risk factors for the development of symptomatic cervical ASD following cervical decompression and fusion requiring reoperation in patients of various age groups. Methods: A retrospective database review of patients aged 20 or greater with insurance claims of primary cervical decompression and fusion over the course of 11 years and 10 months (January 01, 2010-October 31, 2022) was conducted using an insurance claims database. The primary outcome was to evaluate the incidence of cervical ASD requiring reoperation amongst patients stratified by age at the time of their primary procedure. Secondary outcomes included an evaluation of various risk factors for ASD following cervical decompression and fusion including surgeon-controlled factors such as the number of levels fused and approach taken, patient cervical pathology including cervical disc disorder and cervical spondylosis, and underlying patient medical comorbidities including osteoporosis and vitamin D deficiency, and substance use. Results: A total of 60,292 patient records were analyzed, where the overall reoperation incidence for symptomatic ASD was 6.57%, peaking at 8.12% among those aged 30 to 39 and decreasing with age. Regression analysis revealed ages lower than 50 years as more predictive for the development of symptomatic ASD requiring reoperation. Multivariate regression analysis identified predictive factors for reoperation, including age, Elixhauser Comorbidity Index (ECI), multiple-level surgery, cervical spondylosis, cervical disc disorder, osteoporosis, and vitamin D deficiency. Notably, these factors had a variable impact across various age groups, as revealed by subgroup analysis. Conclusions: The incidence of reoperation secondary to symptomatic ASD is 6.57%, highest in those aged 30 to 39. The surgical approach had no significant impact on the need for reoperation, but multiple-level fusions posed a consistent risk in the development of symptomatic ASD requiring reoperation. Patient factors like degenerative disc disease, spondylosis, osteoporosis, and vitamin D deficiency were associated, urging further age-specific risk assessment and nonoperative intervention exploration.

A Curious Case of a Child With Recurrent Twisting Movements of Limbs.

Paroxysmal kinesigenic dyskinesia (PKD) is characterized by recurrent attacks of abnormal involuntary movements that are triggered by sudden movement, intention to move, or acceleration. A 10-year-old boy presented with paroxysmal, involuntary twisting movements of the left upper and lower limbs, precipitated by sudden body movements, lasting for 10-15 seconds and subsiding spontaneously. On examination, choreiform movements were observed, which were precipitated by sudden movements during some activities. The patient responded to carbamazepine with complete subsidence of the movements. The diagnosis of PKD was further confirmed by genetic testing. A high suspicion index helps in the prompt and early diagnosis of this rare entity.

Thrombotic and Thromboembolic Complications After Vaccination Against COVID-19: A Systematic Review.

Thromboembolic complications after the COVID-19 vaccination have been reported from all over the world. We aimed to identify the thrombotic and thromboembolic complications that can arise after receiving various types of COVID-19 vaccines, their frequency, and distinguishing characteristics. Articles published in Medline/PubMed, Scopus, EMBASE, Google Scholar, EBSCO, Web of Science, the Cochrane Library, the CDC database, the WHO database, ClinicalTrials.gov, and servers like medRxiv.org and bioRxiv.org, as well as the websites of several reporting authorities between December 1, 2019, and July 29, 2021, were searched. Studies were included if they reported any thromboembolic complications post-COVID-19 vaccination and excluded editorials, systematic reviews, meta-analyses, narrative reviews, and commentaries. Two reviewers independently extracted the data and conducted the quality assessment. Thromboembolic events and associated hemorrhagic complications after various types of COVID-19 vaccines, their frequency, and distinguishing characteristics were assessed. The protocol was registered at PROSPERO (ID-CRD42021257862). There were 59 articles, enrolling 202 patients. We also studied data from two nationwide registries and surveillance. The mean age of presentation was 47 ± 15.5 (mean ± SD) years, and 71.1% of the reported cases were females. The majority of events were with the AstraZeneca vaccine and with the first dose. Of these, 74.8% were venous thromboembolic events, 12.7% were arterial thromboembolic events, and the rest were hemorrhagic complications. The most common reported event was cerebral venous sinus thrombosis (65.8%), followed by pulmonary embolism, splanchnic vein thrombosis, deep vein thrombosis, and ischemic and hemorrhagic stroke. The majority had thrombocytopenia, high D-dimer, and anti-PF4 antibodies. The case fatality rate was 26.5%. In our study, 26/59 of the papers were of fair quality. The data from two nationwide registries and surveillance revealed 6347 venous and arterial thromboembolic events post-COVID-19 vaccinations. COVID-19 vaccinations have been linked to thrombotic and thromboembolic complications. However, the benefits far outweigh the risks. Clinicians should be aware of these complications because they may be fatal and because prompt identification and treatment can prevent fatalities.

Effect of Exercise on ß-Endorphin and Its Receptors in Myasthenia Gravis Patients.

This is a prospective observational study evaluating the change in ß-endorphin (BE) and its receptors following exercise in patients with myasthenia gravis (MG) and their association with clinical improvement. Fifteen patients with mild to moderate MG, aged 16-70 years, who were able to do 6-Minute Walk Test (6-MWT) and had MG Quality of Life-15 (MGQoL-15) ≤ 45 without any contraindication for exercise were included. The patients walked 30 min daily for 3 months. The primary outcome at 3 months was > 50% improvement in MGQoL-15 from the baseline, and the secondary outcomes were MG Activities of Daily Living (MGADL), Hospital Anxiety and Depression Scale (HADS), number of steps, and distance covered on 6-MWT and adverse events. Plasma BE level, µ-opioid receptor (MOR), and δ-opioid receptor (DOR) were measured on admission and at 1 and 3 months. Twelve age- and gender-matched healthy controls who were not on regular exercise were included for comparison of BE, MOR, and DOR levels. Plasma BE level (P = 0.007) and DOR expression (P = 0.001) were lower in MG patients compared to the healthy controls. After 3 months of exercise, 6 patients improved. Plasma BE, MOR, and DOR levels increased in the first and decreased in the third month. MGQoL-15 (P < 0.001), HADS (P < 0.0001), number of steps (P < 0.007), distance (P = 0.030), and MGADL (P < 0.001) significantly improved compared to baseline. At 3 months, MGQoL-15 was associated with HADS score (P = 0.001), reduced depression (P = 0.013), MGADL (P = 0.035), and distance travelled on the 6-WMW test (P = 0.050). The improvement in depression was associated with higher BE level.

Mechanosynthesis and photophysics of colour-tunable photoluminescent group 13 metal complexes with sterically demanding salen and salophen ligands.

A series of four photoluminescent Al and In complexes were synthesised using an environmentally-benign mechanosynthesis strategy. Sterically crowded 3,5-di-tert-butyl functionalised salophen and salen ligands and their respective complexes have been synthesised in the solid-state and fully characterised. Subsequent photophysics and electrochemistry studies of the resulting complexes suggest that these new group 13 complexes can be viable alternatives to traditional photoluminescent complexes based on expensive and low abundant noble metals. The herein-reported strategy avoids the use of organic solvents and provides a process with low environmental impact and enhanced energy efficiency.

Association of Catechol-O-Methyltransferase Gene rs4680 Polymorphism and Levodopa Induced Dyskinesia in Parkinson's Disease: A Meta-Analysis and Systematic Review.

INTRODUCTION: Long-term levodopa therapy for Parkinson's disease (PD) can cause levodopa induced dyskinesia (LID). Genetic predisposition has a significant role to play in inter-individual heterogeneity in the clinical manifestation of LID. Despite accumulating evidence for the role of COMT gene polymorphism (rs4680) as a genetic basis for LID, to date results have been inconsistent. Early assessment of the Catechol-O-Methyltransferase (COMT) genotype might be helpful to stratify PD patients concerning their individual risk for LID. METHOD: In this meta-analysis, we have used 9 studies, which were selected through online databases. Statistical analysis was performed using R (v-3.6) software. 5 genetic models have been used in the present study: Allele model (A vs. G), Dominant model (AA+AG vs. GG), Homozygote model (AA vs. GG), Co-dominant/heterozygote model (AG vs. GG), and Recessive model (AA vs. AG + GG). RESULTS: The results indicated a significant association between COMT rs4680 (Val158Met) polymorphism and LID risk. The genotype AA of COMT rs4680 is a risk factor for LID in PD patients under the recessive model (AA vs GG+AG) in the random-effect model. Analysis based on ethnicity showed that COMT rs4680 SNP allele A is a risk factor for LID development in Asian PD patients, while GG genotype is a risk factor for LID development in non-Asian PD patients using different genetic models. CONCLUSION: The results of the present meta-analysis support that the COMT Val158Met polymorphism is a risk factor for the development of LID in PD patients having ethnic variations.

Assessment of Non-Motor Symptoms of Parkinson's Disease and Their Impact on the Quality of Life: An Observatiobnal Study.

Background: During the past decade the view of Parkinson's disease (PD) as a motor disorder has changed significantly and currently it is recognized as a multisystem disorder with diverse non-motor symptoms (NMS). Aims: The present study aimed to evaluate and characterize the NMS and study their impact on quality of life (QoL) in a PD patient cohort. Material and Methods: This was a cross-sectional study where 92 PD patients fulfilling the UK Parkinson's disease society brain bank criteria were enrolled from a movement disorder clinic. All patients were evaluated using unified Parkinson's disease rating scale, non-motor symptoms scale (NMSS) for the non-motor symptoms, and Parkinson's disease questionnaire-39 (PDQ-39) for the QoL. The impact of NMS on QoL was assessed statistically. Results: A total of 92 patients were enrolled with a mean age of 55.40 ± 7.37 years, mean age of onset of disease 51.62 ± 6.38 years, and mean disease duration of 3.78 ± 1.54 years. Type of disease was akinetic rigid variant in 29.3% (n = 27), tremor predominant type in 36.9%(n = 34), and mixed type in 33.6% (n = 31). Mean Hoehn and Yahr stage was 2.12 ± 0.54. In the NMSS, most common symptom was sleep and fatigue (83%), followed by urinary tract symptoms (63%), mood and cognition (51%), cardiovascular symptoms and falls (43%), gastrointestinal tract symptoms (38%), and sexual function (33%). Univariate analyses showed that all NMS domains had a significant correlation with PDQ-39 with P < 001. Conclusion: Our study shows that NMS in PDare fairly common and significantly impact the QoL.

Does gender difference matter in cerebral venous thrombosis?

Female specific risk factors (FSRFs) in cerebral venous thrombosis (CVT) may have difference in clinical, imaging and outcome parameters compared to those females with additional risk factors and males. We compare the clinical, MRI and outcome between male and female patients with CVT. We also compare female patients with and without female specific risk factors. 172 patients were included from a prospectively maintained CVT registry. The diagnosis was confirmed on magnetic resonance venography (MRV). Clinical details, risk factors, MRI and MRV findings were noted. The risk factors in the females were categorized as 1) Isolated FSRF (oral contraceptive, pregnancy, puerperium), 2) FSRF in addition to other risk factor, 3) non FSRF only, and 4) no risk factor groups. Outcome at 6 months was assessed using modified Rankin Scale (mRS) as death, poor (mRS 3-5) and good (mRS ≤ 2). There were 80 (46.5%) females; 24 (30%) had FSRFs and 18 (75%) of whom also had other risk factors leaving only 6(25%) females with isolated FSRF. The frequency of other prothrombotic risk factors, and clinical and imaging findings were similar in males and females except more frequent hyperhomocysteinemia in males (59% vs 41%; P = 0.036) and altered sensorium in females (66% vs 40%; P = 0.001). 17(9.9%) patients died, 12(7%) had poor and 143(83.1%) had good outcome, which were similar in both the gender, and in the females with and without FSRF. Isolated FSRF is rare in CVT, and there is no gender difference in terms of non FSRFs, clinico-radiological severity and outcome.

Generalized Morphea Coincident With Aplastic Anemia: A Case Report.

Morphea is a rare skin condition characterized by erythematous or violaceous lesions as well as sclerotic plaques. Patients with morphea frequently have other autoimmune disorders. Contributing factors are thought to be autoimmunity and an increase in extracellular matrix production. A case of a 45-year-old male patient with progressive restriction of both shoulder movements and patchy discoloration over the abdomen, neck, back, forearms, and bilateral axillae is discussed in this article. Examination revealed multiple shiny hyperpigmented to hypopigmented indurated plaques, and some lesions showed erythematous to violaceous borders, fine scales, and woody induration. The neurological examination was normal. Skin biopsy showed a sparse superficial perivascular lymphohistiocytic infiltrate with thickening of collagen bundles that were hyalinized in the reticular dermis, which was consistent with superficial morphea. Hematological tests showed pancytopenia and bone marrow aspiration revealed hypocellular marrow, which was consistent with aplastic anemia. The patient was diagnosed with generalized morphea with aplastic anemia. The patient was referred to a transplant center for further treatment, but, unfortunately, he died of sepsis while waiting for his transplant. Our case may indicate a possible link between aplastic anemia and generalized morphea. Due to a possible similar underlying mechanism of pathogenesis, treatment of aplastic anemia may be effective in morphea also. Aplastic anemia must be detected early to reduce complications and mortality in patients.

A Randomized Controlled Trial of High Rate rTMS Versus rTMS and Amitriptyline in Chronic Migraine.

BACKGROUND: The patients with chronic migraine (CM) respond poorly to pharmacological agents including tricyclic antidepressants, beta-blockers, anticonvulsants, calcium channel blockers, flunarizine, and melatonin. The combination of 2 or more pharmacological agents has not shown better efficacy but increased side effects. High rate repetitive transcranial magnetic stimulation (rTMS) has been reported effective in episodic migraine and converts CM to episodic migraine. A combination of high rate rTMS with a pharmacological agent may be more effective compared to rTMS alone. OBJECTIVES: We evaluate the efficacy and safety of 10 Hz rTMS compared to rTMS and amitriptyline in CM. STUDY DESIGN: Randomized controlled trial. SETTING: Tertiary care teaching institute in India. METHODS: Patients with CM as per International Classification of Headache Disorder third edition (ICHD-3) beta criteria were included whose age was between 18 years and 55 years. CM was defined if there were 15 headache days per month and at least 8 of these attacks having migraine characteristics for a period of more than 3 months. Patients with major psychiatric, other neurological or systemic disease, and those on migraine prophylaxis were excluded. The demographic details, frequency of headache attacks and headache days per month, migraine triggers, and associated symptoms were noted. The severity of headache was noted using a 0-10 Visual Analog Scale and the number of abortive drugs per month was noted. CM patients were randomly assigned to rTMS (group I) or rTMS and amitriptyline (group II). 10 Hz rTMS was applied using a figure of eight magnetic stimulation coil. The coil was placed over the left frontal cortex corresponding to the hot spot of the right abductor digiti minimi, which is approximately 7 cm lateral from the midline and 2 cm anterior to interaural line. The motor threshold was measured, and 70% of it was used for rTMS. Ten trains of 10 Hz rTMS, each train comprising of 60 pulses with an inter-train interval of 45 seconds were delivered in one session. Three such sessions were delivered on an alternate day and were repeated every month for 3 months. Amitriptyline was prescribed in a dose of 10mg, increased to 25mg after 2 weeks; thereafter increase in dose to 50 mg was optional. The primary outcome was > 50% reduction in headache days, and secondary outcomes were the reduction in severity of headache, abortive drug, and side effects. RESULTS: Forty-one patients were included in group I and 42 in group II, and their baseline characteristics were comparable. A higher proportion of group II patients had more than 50% reduction in headache days at 3 months (76.2 vs 31.7%; P < 0.001) compared to group I. More than 50% reduction in headache severity was also greater in group II compared to group I at 3 months (47.6% vs 19.5%; P = 0.01). Side effects were comparable, and none had to be withdrawn. LIMITATIONS: A higher proportion of patients was shifted from group I to group II. CONCLUSION: Combination of rTMS and amitriptyline is safe and more effective in CM compared to rTMS alone.

Rest or 30-Min Walk as Exercise Intervention (RESTOREX) in Myasthenia Gravis: A Randomized Controlled Trial.

INTRODUCTION: There is a lack of evidence about the usefulness of exercise or rest in myasthenia gravis (MG). This study is aimed to evaluate the efficacy and safety of exercise or rest in MG. METHODS: In a single-center open-labeled randomized controlled trial, the patients with mild to moderate MG were randomized to 30-min walk or rest in addition to the standard treatment. The primary endpoint was 50% improvement in the MG Quality of Life (MG-QOL15), and secondary endpoints were change in the Myasthenic Muscle Score (MMS), MG Activities of Daily Living (MGADL), grip strength, dose of acetylcholine esterase inhibitor and prednisone, 6-min walk test (6MWT), decrement in trapezius on the low-rate repetitive nerve stimulation test, and adverse events. The outcomes were defined at 3 months, by >50% improvement in these outcome parameters. RESULTS: Forty patients with MG were randomized to the exercise or rest arm. The 2 arms were matched for demographic and clinical parameters. The patients in the exercise arm had significantly better QOL evidenced by MG-QOL15 (p = 0.02). The secondary endpoints, distance covered in 6MWT (p = 0.007), were also better in the exercise arm without any adverse event. CONCLUSION: Regular exercise for 30 min in mild and moderate MG improves quality of life and walking distance compared to rest and is safe. CLINICAL TRIAL REGISTRATION: The clinical trial registration number is CTRI/2019/11/021869.

Prolonged coma in scrub typhus: consider non-convulsive status epilepticus.

BACKGROUND: Scrub typhus is prevalent in the Tsutsugamushi belt and may manifest with meningoencephalitis and seizures. We report a patient with scrub typhus who had non-convulsive status epilepticus (NCSE). METHODS: A 50-y-old female with fever and altered sensorium for 5 d was diagnosed as scrub typhus based on serum IgM ELISA. She was on mechanical ventilation and received doxycycline and ceftriaxone, but did not improve until the third day of admission. RESULTS: An EEG revealed >2.5 Hz generalised epileptiform discharges, which were suppressed by intravenous lorazepam suggesting NCSE. Following valproate and levetiracetam, she became conscious and had a full recovery. CONCLUSION: A scrub typhus patient recovers even after prolonged NCSE.

N-Bridged Acyclic Trimeric Poly-Cyclodiphosphazanes: Highly Tuneable Cyclodiphosphazane Building Blocks.

We have synthesized a completely new family of acyclic trimeric cyclodiphosphazane compounds comprising NH, Ni Pr, Nt Bu and NPh bridging groups. In addition, the first NH-bridged acyclic dimeric cyclophosphazane has been produced. The trimeric species display highly tuneable characteristics so that the distance between the terminal N(H)R moieties can be readily modulated by the steric bulk present in the bridging groups (ranging from ≈6 to ≈10 Å). Moreover, these species exhibit pronounced topological changes when a weak non-bonding NH⋅⋅⋅π aryl interaction is introduced. Finally, the NH-bridged chloride binding affinities have been calculated and benchmarked along with the existing experimental data available for monomeric cyclodiphosphazanes. Our results underscore these species as promising hydrogen bond donors for supramolecular host-guest applications.

Significance of recanalization of sinuses and resolution of parenchymal lesion in cerebral venous sinus thrombosis.

In cerebral venous sinus thrombosis (CVST), the degree of recanalization may determine resolution of parenchymal lesion and clinical outcome. The aim of our study was to evaluate the relationship of recanalization with resolution of MRI lesion and clinical outcome. The patients with CVST diagnosed on the basis of magnetic resonance venography (MRV) were included prospectively. Risk factors, clinical features, and MRI and MRV findings were noted. MRI and MRV were repeated at 6 months and the change in parenchymal lesion and grade of recanalization (I, II, III) were noted. Patients were evaluated clinically at three and six months. Complete recovery was considered if modified Rankin Scale (mRS) score was 0. Thirty-three CVST patients were included, 12 (36.4%) of whom were females. Recanalization occurred in 29 (87.9%), which was complete (grade III) in 6 (21%). Sigmoid sinus (52%) recanalized more frequently. Resolution of parenchymal lesion on repeat MRI occurred in 13.3% (4/30) patients, and they had no sequelae. Degree of recanalization was not related to resolution of neurological sequelae, MRI lesion at follow up and burden of thrombosis at baseline. Varying degree of recanalization occurred in 87.9% patients with CVST, and resolution of parenchymal lesion occurred in 13.3%. Clinical outcome however was not related to recanalization.

Inclusion of Mechanical Ventilation in Severity Staging of Tuberculous Meningitis Improves Outcome Prediction.

Patients with tuberculous meningitis (TBM) in any stage of the British Medical Research Council (BMRC) scale, if requiring mechanical ventilation (MV), are likely to have a poor outcome. We report the usefulness of BMRC, BMRC-MV, and BMRC-hydrocephalus (BMRC-HC) staging, and Haydarpasa Meningitis Severity Index (HAMSI) scoring in predicting the outcome of TBM. One hundred ninety-seven TBM patients were analyzed from a prospectively maintained TBM registry. The severity of meningitis was categorized using BMRC (stages I-III), BMRC-MV (I-IV [MV patients were grouped as stage IV]), and BMRC-HC (I-IV [BMRC stage III patients with hydrocephalus were grouped as stage IV]). Haydarpasa Meningitis Severity Index scoring was categorized as < 6 and ≥ 6. The outcome was defined at 6 months using the modified Rankin Scale (mRS) as death, poor (mRS score > 2), or good (mRS score ≤ 2). Forty-nine (25%) patients died. BMRC-mechanical ventilation stage IV had the highest predictive value for defining death, with a sensitivity of 88% and a specificity of 86%. About 81.7% of surviving patients had a good outcome at 6 months. BMRC-mechanical ventilation stages I-III had the highest predictive value for defining good outcome, with a sensitivity of 93% and a specificity of 61%. In TBM, BMRC-MV staging has the best predictive value for defining death and disability.

A study of hyperhomocysteinemia in cerebral venous sinus thrombosis.

BACKGROUND & OBJECTIVES: Vegetarianism may result in low vitamin B12 and acquired hyperhomocysteinemia leading to thrombotic conditions such as cerebral venous sinus thrombosis (CVST). The clinico-radiological presentation and outcome of patients with hyperhomocysteinemia may be different from those without, but there is a paucity of information. This study was undertaken to find out the relationship of homocysteine (Hcy) with vitamin B12, folic acid and methyltetrahydrofolate reductase (MTHFR) mutation in the patients with CVST, and compare clinico-radiological severity and outcome of patients with and without hyperhomocysteinemia. METHODS: Ninety-six CVST patients in whom Hcy level was measured, were included, and their risk factors and neurological, magnetic resonance (MR) imaging and MR venography findings were noted. They were evaluated for prothrombotic conditions including Hcy, vitamin B12, folic acid and MTHFR 677C→T mutation. Three month outcome was categorized as death, poor and good. RESULTS: Seventy three per cent patients had risk factors; hyperhomocysteinemia in 52.1 per cent, protein S deficiency in 47.8 per cent, protein C deficiency in 19.4 per cent, MTHFR 677C→T mutation in 30.7 per cent, antinuclear antibody 11 per cent, and Factor V Leiden mutation in two per cent each. Thirty two per cent patients with hyperhomocysteinemia had no other thrombotic cause, and 22 per cent of them had either vitamin B12 and or folic acid deficiency only. The patients with hyperhomocysteinemia more frequently had vitamin B12 deficiency (70 vs. 13%), MTHFR 677C→T mutation (47.5 vs. 9.1%) and superior sagittal sinus thrombosis (78 vs. 56.5%) than normal Hcy group. The clinico-radiological severity and outcome were similar. INTERPRETATION & CONCLUSIONS: Hyperhomocysteinemia was an important correctable risk factor of CVST in patients from northern India, and majority of them had either low vitamin B12 level or MTHFR mutation.

A study of comorbidities in myasthenia gravis.

Management of myasthenia gravis (MG) in the presence of comorbidities may be difficult. We report the effect of comorbidities in the outcome of MG. The patients with MG during 1991-2016 were included and evaluated including their demographic variables, clinical findings, Myasthenia Gravis Foundation of America (MGFA) score. The patients were categorized into early onset (≤ 40 years) and late onset (> 40 years) MG. The comorbidities (autoimmune and miscellaneous) and iatrogenic complications were compared between early and late onset, and in good and poor outcome groups. Out of 81 patients with MG, 48 patients had early and 33 late onset. In 71 (88%) patients, comorbidities were present and were autoimmune in 8 (10%) and miscellaneous in all the patients (88%). Iatrogenic complications were present in 54 (67%) patients. Thymectomy was done in 19 patients; 16 had thymoma and 3 thymic hyperplasia. Myasthenic crisis occurred in 28 patients; 5 (18%) had autoimmune and all had miscellaneous comorbidities. The patients with poor outcome had ≥ 2 comorbidities, myasthenic crisis, leukocytosis, elevated serum bilirubin and creatinine, and increased number of hospital admissions (P < 0.05). Myasthenia gravis is associated with comorbidities in majority of patients especially in late onset group, and more than two comorbidities are related to poor outcome.