Impact of fibromyalgia severity on patients mood, sleep quality, and quality of life.

Objectives: Fibromyalgia syndrome (FMS) is characterized by persistent widespread pain which greatly impacts the quality of life (QOL). Pain not only limits patients' daily activities but also restricts their social activities further leading to depression, anxiety, and stress. The present cross-sectional study elucidated the association of sleep quality and mood with increasing symptom severity of fibromyalgia and its impact on the QOL of fibromyalgia patients. Materials and Methods: Hundred adult fibromyalgia patients diagnosed by the American College of Rheumatology 2010 criteria were evaluated for: sleep - using the Pittsburgh sleep quality index, QOL by SF-36, pain-visual analog scales (VASs) and global pain scale (GPS), mood-depression, anxiety, stress scale-21, somatic symptoms, anxiety and depression - by patients health questionnaire somatic, anxiety, and depressive symptom scales (PHQ-SADS), and FMS severity was evaluated using fibromyalgia impact questionnaire (FIQR). Results: The mean pain score was 6.80 ± 1.58 on VAS and 54.10 ± 14.33 on GPS. FIQR score was 50.62 ± 13.68, mean sleep quality was poor (9.30 ± 3.88), and depression, anxiety, and stress scores were increased (10.04 ± 4.59, 8.33 ± 4.48, and 10.75 ± 4.66). An increasing trend of depression, anxiety, stress, and somatoform symptoms was observed with an increase in the severity of FMS when patients were compared according to FMS severity scores. Sleep also deteriorated with increasing severity of FMS from 5.66 ± 1.92 in mild FMS to 12.0 ± 3.41 in highly severe FMS patients. The QOL too deteriorated in all the domains with increasing severity. Conclusion: With the increasing severity of fibromyalgia, not only does the pain increase but mood and sleep quality also deteriorate, which further impacts the QOL of FMS patients. Thus, comorbid mood derangements must also be screened and addressed for maximum benefit of the patients.

Exaggerated response to pattern reversal visual evoked potential among migraineurs.

OBJECTIVE: Visual evoked potential recording has reported ambiguous results among migraineurs, thus the present study explored the association of check-size and reversal rates on the latency and amplitude of pattern reversal VEP among migraineurs. METHOD AND MATERIAL: Monocular VEP responses for both eyes were recorded in 133 migraineurs and 111 controls. Checkerboard pattern with phase reversal frequency of 0.5, 1, 2 and 4 Hz and check-size of 16 × 16, 32 × 32, 64 × 64 and 128 × 128, i.e. spatial frequency of 0.475, 1.029, 2.056 and 4.112 cycle per degree (cpd) were used to record 100 responses each. Three-minutes gap was given after change of reversal frequency to a higher rate for next cycle of 4 check-size records. RESULT: A linear increase in latencies was observed with decreasing check-size in both groups, but migraineurs had significantly higher latencies at a given reversal rate. Amplitudes A1 and A2 were higher among migraineurs and amplitude A2 showed an inverted 'U' shaped trend with maximum amplitude at 32 × 32 check size (1.029 cpd) in both groups, with an exaggerated response among migraineurs. Check-size 32 × 32 i.e. spatial frequency of 1.029 behaves differently than other larger or smaller check-sizes. CONCLUSION: Variable VEP response for different visual stimuli may be due to differential activation of respective retinocortical pathways and cortical areas. The highest amplitude at modest check-size suggests a contributory role of foveal-parafoveal fibres in migraineurs. Exaggerated physiological response to visual stimuli may be responsible for higher amplitudes and prolonged latencies among migraineurs.

Exaggerated physiological VEP response as higher amplitudes and prolonged latencies, among migraineurs may be due to differential activation of respective retinocortical pathways and cortical areas.

Validation and Diagnostic Accuracy of Hindi Restless Legs Syndrome (RLS-H) Screening Tool.

Background Restless legs syndrome (RLS), a prevalent and treatable entity, has high impact on quality of life, requiring a better screening tool for its early detection. Thus, present study aimed to derive a Hindi RLS (RLS-H) screening tool for its use in Indian population. Materials and Methods RLS-H screening tool, derived by translating first four criteria of 2012 revised International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria in Hindi and was validated in 50 RLS and 50 non-RLS patients. This validated RLS-H tool was used to screen 1,066 patients attending neurology clinic for assessing its diagnostic accuracy. Internal consistency, discriminatory validity, and various diagnostic yields were calculated. IRLSSG was used as gold standard for final diagnosis of RLS. Results RLS-H screening tool had an internal consistency of 0.910. No correlation was found between RLS-H screening tool and Epworth sleepiness scale, Pittsburgh sleep quality index, or International Restless Legs Syndrome Study Group rating scale indicating satisfactory discriminant validity. Prevalence of RLS was 13.6%. The question (Q)1 had highest sensitivity (97.9%) and Q4 had highest specificity (92.66%). Thus, its combinations (Q1 + Q4) along with addition of Q2 or Q3 were compared for best combination of diagnostic accuracy. A minimum cutoff value of RLS-H screening tool was 2.5 for considering patients requiring detailed RLS evaluation. Conclusion RLS-H screening tool can be used as a screening tool for early detection of RLS among susceptible patients. Patients answering "yes" to more than two questions (cutoff = 2.5) or "yes" to Q1 and Q4 should be interviewed and assessed for RLS.

Paroxysmal Kinesigenic Dyskinesia Masquerading as Dissociative Disorder: A Case Report on Pseudo-Dissociation.

Movement disorders are common presentations to psychiatry and neurology clinics in general hospitals. Many a times, liaison between psychiatry and neurology helps in determining the exact etiology and diagnosis of rare movement disorders. Paroxysmal dyskinesia is a group of disorders caused by a genetic mutation. It is one of the rare presentations among dyskinetic disorders but often encountered by psychiatrists due to the psychogenic nature of episodes and apparently normal neurological findings in-between the episodes. Liaison work with a neurologist is of great importance rather than misdiagnosing them as a dissociative or psychogenic movement disorder. Unawareness of their presentation can lead to repeated consultations, unwarranted psychotherapies, and can create a sense of therapeutic nihilism among the treating psychiatrists. Predominantly four different variants are described in the literature under this group and new classification has been proposed recently. We encountered a case of paroxysmal kinesigenic dyskinesia with obstructive sleep apnea masquerading as a dissociative disorder.

Clinical profile and outcome of non-COVID strokes during pandemic and the pre pandemic period: COVID-Stroke Study Group (CSSG) India.

BACKGROUND: As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected. AIMS: The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019. METHODS: The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points. RESULTS: A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods. CONCLUSIONS: Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe.

Impact of sleep disturbances and autonomic dysfunction on the quality of life of patients with fibromyalgia.

OBJECTIVES: Fibromyalgia, a painful musculoskeletal disorder is associated with sleep disturbances as well as autonomic dysfunction. Pathophysiology of fibromyalgia is yet not clear and neuroanatomical proximity of sleep and autonomic centre prompts probable involvement of the two impacting the quality of life of fibromyalgia patients. Present study was done with the objective to explore the extent of sleep disturbances and/or autonomic dysfunction in fibromyalgia and asses their impact on quality of life of fibromyalgia patients. METHOD AND MATERIALS: Thirty consecutive fibromyalgia patients (diagnosed by ACR 2010) from out-patient department and 30 age-gender matched controls were enrolled after the ethical clearance. All participants were evaluated for: (1) sleep using Pittsburgh sleep quality index and medical outcomes study sleep scale-12 Revised, (2) Quality of life by 36 item short-form health survey-36v2TM and revised fibromyalgia impact questionnaire (only patients). Autonomic functions of patients were evaluated by standard cardiovascular autonomic function tests by Ewing's battery and heart rate variability (5-min) measurement. RESULTS: Fibromyalgia patients had increased sleep disturbances compared to controls (39.46 ± 11, 59.61 ± 2.31; p=0.0001) and very poor sleep quality (13.63 ± 4.15, 3.03 ± 1.56; p=0.0001) as well as quality of life (p=0.0001) which further deteriorated with increasing severity of fibromyalgia. Twelve patients had autonomic dysfunction but it was neither associated with sleep disturbances nor with quality of life. CONCLUSIONS: Mild to moderate grade fibromyalgia patients have significant sleep disturbance, poor sleep quality which remarkably impacts their quality of life. Autonomic dysfunction is not an early feature of disease. The study suggests that full spectrum of sleep disturbances and sleep quality should be explored in fibromyalgia syndrome (FMS) patients.

Diagnostic accuracy of composite autonomic symptom scale 31 (COMPASS-31) in early detection of autonomic dysfunction in type 2 diabetes mellitus.

PURPOSE: Diabetic autonomic neuropathy (DAN) is a common and disabling complication of diabetes, with cardiac autonomic neuropathy (CAN) being a major cause of mortality and morbidity. Standard autonomic function tests (AFT) are cumbersome and time consuming to conduct in OPD setting. OBJECTIVE: To evaluate the diagnostic accuracy of composite autonomic symptom scale 31 (COMPASS-31) as a screening test for DAN. PATIENTS AND METHODS: A cross-sectional study which enrolled 60 type 2 diabetes individuals was conducted at a tertiary care center. Autonomic functions were evaluated by COMPASS-31 questionnaire as well as by standard Ewing's battery of tests; short-term heart rate variability; sympathetic skin response along with nerve conduction studies. RESULTS: Thirty males and 24 females completed the study. Forty-nine (89%) participants had CAN, of which, 9 (17%) had definite CAN. Peripheral neuropathy was present in 20 (37%). COMPASS-31 scores showed no difference between "No CAN" and "Early CAN". "Definite CAN" individuals differed significantly from "No and Early CAN" on COMPASS-31 scores and its gastrointestinal sub-domain. Receiver operating characteristic between "Definite CAN" and "No and Early CAN" showed fair accuracy with AUC of 0.731 (95% CI 0.561-0.901), sensitivity 77.8%, specificity 71.7% at a cut-off of 28.67 of COMPASS-31 score. Gastrointestinal sub-domain, at a cut-off score of 5.8, had 77.8% sensitivity, 60% specificity, and AUC was 0.748 (95% CI 0.603-0.894). CONCLUSION: COMPASS-31, a self-administered tool, requiring less time, qualifies as an acceptable screening tool, especially for definite CAN. However, individuals scoring low on COMPASS-31 are still required to be evaluated by Ewing's battery to differentiate between "Early CAN" and "No CAN".

Factors associated with delayed diagnosis of migraine: A hospital-based cross-sectional study.

CONTEXT: Migraine is common debilitating disorders, affecting 10 to 20% of the world's population. However, proper diagnosis is delayed due to many factors. AIMS: To determine various factors associated with delayed diagnosis of migraine. SETTINGS AND DESIGN: Hospital-based cross-sectional study. MATERIALS AND METHODS: Patients attending Neurology OPD of AIIMS Bhopal and satisfying diagnostic criteria of the International Headache Society (ICHD-3ß) for migraine were selected for study. MIDAS, MINI, and ROME-III were used. First diagnosis was considered as "Appropriate" if patients were previously diagnosed as "migraine" or getting treatment for it; otherwise labeled as "Inappropriate." STATISTICAL ANALYSIS: Associations were tested by Chi-square, t-test, or Mann-Whitney test. Logistic regression analysis was used for identifying independent factors associated with inappropriate diagnosis. RESULTS: Hundred patients (female = 77) of migraine were included. Mean age (SD) was 32.42 (10.74). Diagnosis was "inappropriate" in 65 patients. Number of inappropriate diagnosis/appropriate diagnosis was 10/40 (25%) by neurologists; 35/39 (89.3%) by physicians; 18/18 (100%) by ophthalmologists. Factors associated with "Inappropriate Diagnosis" were "Neurologist vs Other Doctors" {10 (25%) vs 55 (91.7%), P < 0.001}; throbbing vs other types of headache {51 (60.7%) vs 14 (87%), P = 0.047}; and temporal vs other sites {9 (42.9%) vs 56 (70.9%), P = 0.017}. Patients with "Inappropriate Diagnosis" had to expend more money {7000 (4,500; 12,500) vs 4000 (1000, 6000), P < 0.01; median (interquartile range) all in INR}. Other clinical parameters including vertigo, cervical pain, anxiety, depression, and functional gastrointestinal symptoms were not associated with delayed diagnosis. CONCLUSION: Delayed diagnosis and misdiagnosis is very frequent in migraine, leading to financial burden to patients. Management of common disorders like migraine should be addressed in undergraduate medical teaching curriculum.

Neuropsychiatric co-morbidities in non-demented Parkinson's disease.

OBJECTIVE: To evaluate neuropsychiatric co-morbidities (depression, psychosis and anxiety) in non-demented patients with Parkinson's disease (PD). BACKGROUND: Non-motor symptoms like neuropsychiatric co-morbidities are common in Parkinson's disease and may predate motor symptoms. Currently there is scarcity of data regarding neuropsychiatry manifestations in Indian patients with PD. METHODS: In this cross-sectional study consecutive 126 non-demented patients with PD (MMSE ≥25) were enrolled. They were assessed using Unified Parkinson's disease rating scale (UPDRS), Hoehn & Yahr (H&Y) stage, Schwab and England (S&E) scale of activity of daily life. Mini-international neuropsychiatric interview (MINI) was used for diagnosis of depression, psychosis and anxiety. Beck's depression inventory (BDI), Brief psychiatric rating scale (BSRS) and Hamilton rating scale for anxiety (HAM-A) scales were used for assessment of severity of depression, psychosis and anxiety respectively. RESULTS: Mean age and duration of disease was 57.9 ± 10.9 years and 7.3 ± 3.6 years respectively. At least one of the neuropsychiatric co-morbidity was present in 64% patients. Depression, suicidal risk, psychosis and anxiety were present in 43.7%, 31%, 23.8% and 35.7% respectively. Visual hallucinations (20.6%) were most frequent, followed by tactile (13.5%), auditory (7.2%) and olfactory hallucinations (1.6%). Patients with depression had higher motor disability (UPDRS-motor score 33.1 ± 14.0 vs 27.3 ± 13.3; and UPDRS-total 50.7 ± 21.8 vs 41.0 ± 20.3, all p values <0.05). Patients with psychosis were older (63.6 ± 8.0 years vs 56.1 ± 11.1 years, p < 0.05) and had longer duration of illness (8.6 ± 3.4 years vs 6.9 ± 3.5, p < 0.05). CONCLUSIONS: About two third patients with Parkinson's disease have associated neuropsychiatric co-morbidities. Depression was more frequent in patients with higher disability and psychosis with longer duration of disease and older age. These co-morbidities need to be addressed during management of patients with PD.

Use of corticosteroids and other adjunct therapies for acute bacterial meningitis in adults.

Acute bacterial meningitis is associated with high morbidity and mortality despite the availability of effective antibiotics. The inflammatory response induced by bacterial products in the subarachnoid space is responsible for neuronal injury. The use of adjuvant therapy in acute bacterial meningitis draws its rationale from the notion of arresting the inflammatory cascade at an early stage of the disease to improve clinical outcome. Corticosteroids have been studied extensively in these patients and seems effective in selective groups of patients, particularly those with pneumococcal meningitis. Glycerol appears harmful in adults with acute bacterial meningitis. Experimental models suggest promising role of newer anti-inflammatory drugs such as antioxidants, inhibitors of Tumor Necrosis Factor-α, poly-ADP-ribose inhibitors, caspase inhibitors, brain-derived neurotrophic factor etc.; however clinical trials are still lacking for these novel potential targets in acute bacterial meningitis. This review focuses on corticosteroids with comments on the role of other potential adjuvant therapy in adults with acute bacterial meningitis.