Arg4810Lys mutation in RNF213 among Eastern Indian non-MMD ischemic stroke patients: a genotype-phenotype correlation.

INTRODUCTION: RNF213 mutations have been reported mostly in moyamoya disease (MMD) with varying frequencies across different ethnicities. However, its prevalence in non-MMD adult-onset ischemic stroke is still not well explored. AIMS AND OBJECTIVES: This present study thus aims to screen the most common RNF213 variant (Arg4810Lys, among East Asians) in the Eastern Indian non-MMD ischemic stroke patients and correlate it with long-term progression and prognosis of the patients. The subjects were analyzed for this variant using PCR-RFLP and confirmed using Sanger sequencing method. RESULT AND CONCLUSION: We have identified Arg4810Lys variant among eleven young-onset familial ischemic stroke patients in heterozygous manner. A positive correlation of the variant with positive family history (P = 0.001), earlier age at onset (P = 0.002), and history of recurrent stroke (P = 0.015) was observed. However, the carriers showed better cognitive performances in memory (P = 0.042) and executive function (P = 0.004). Therefore, we can conclude that Arg4810Lys/RNF213 - a pathogenic variant for young-onset familial ischemic stroke with higher incidence of recurrent events unlike in MMD cases, have no additional impact on cognition among Eastern Indians.

Genetic Variations and Altered Blood mRNA Level of Circadian Genes and BDNF as Risk Factors of Post-Stroke Cognitive Impairment Among Eastern Indians.

Post-stroke cognitive impairment (PSCI) is a clinical outcome in around 30% of post-stroke survivors. BDNF is a major gene in this regard. It is regulated by circadian rhythm. The circadian genes are correlated with stroke timings at molecular level. However, studies suggesting the role of these on susceptibility to PSCI are limited. We aim here to determine: (a) genetic risk variants in circadian clock genes, BDNF and (b) dysregulation in expression level of CLOCK, BMAL1, and BDNF that may be associated with PSCI. BDNF (rs6265G/A, rs56164415C/T), CLOCK (rs1801260T/C, rs4580704G/C), and CRY2 (rs2292912C/G) genes variants were genotyped among 119 post-stroke survivors and 292 controls from Eastern part of India. In addition, we analyzed their gene expression in Peripheral blood Mononuclear cells (PBMC) from 15 PSCI cases and 12 controls. The mRNA data for BDNF was further validated by its plasma level through ELISA (n = 38). Among the studied variants, only rs4580704/CLOCK showed an overall association with PSCI (P = 0.001) and lower Bengali Mini-Mental State Examination (BMSE) score. Its 'C' allele showed a correlation with attention deficiency. The language and memory impairments showed association with rs6265/BDNF, while the 'CC' genotype of rs2292912/CRY2 negatively influenced language and executive function. A significant decrease in gene expression for CLOCK and BDNF in PBMC (influenced by specific genotypes) of PSCI patients was observed than controls. Unlike Pro-BDNF, plasma-level mBDNF was also lower in them. Our results suggest the genetic variants in CLOCK, CRY2, and BDNF as risk factors for PSCI among eastern Indians. At the same time, a lowering expression of CLOCK and BDNF genes in PSCI patients than controls describes their transcriptional dysregulation as underlying mechanism for post-stroke cognitive decline.

Interdependence of metals and its binding proteins in Parkinson's disease for diagnosis.

Metalloproteins utilizes cellular metals which plays a crucial function in brain that linked with neurodegenerative disorders. Parkinson's disease (PD) is a neurodegenerative disorder that affects geriatric population world-wide. Twenty-four metal-binding protein networks were investigated to identify key regulating protein hubs in PD blood and brain. Amongst, aluminum, calcium, copper, iron, and magnesium protein hubs are the key regulators showing the ability to classify PD from control based on thirty-four classification algorithms. Analysis of these five metal proteins hubs showed involvement in environmental information processing, immune, neuronal, endocrine, aging, and signal transduction pathways. Furthermore, gene expression of functional protein in each hub showed significant upregulation of EFEMP2, MMP9, B2M, MEAF2A, and TARDBP in PD. Dysregulating hub proteins imprint the metal availability in a biological system. Hence, metal concentration in serum and cerebrospinal fluid were tested, which were altered and showed significant contribution towards gene expression of metal hub proteins along with the previously reported PD markers. In conclusion, analyzing the levels of serum metals along with the gene expression in PD opens up an ideal and feasible diagnostic intervention for PD. Hence, this will be a cost effective and rapid method for the detection of Parkinson's disease.

PARK2 and PARK7 Gene Polymorphisms as Risk Factors Associated with Serum Element Concentrations and Clinical Symptoms of Parkinson's Disease.

Besides clinical and imaging techniques, there is a lack of molecular makers for the diagnosis of Parkinson's disease (PD). There is an immense need to develop biomarkers associated with the phenotypes which may be valuable for individualized treatment. Single-nucleotide polymorphisms (PARK2: Ser167Asn (G>A) and Val380Leu (G>C); PARK7: IVS4 + 46G>A and IVS4 + 30T>G) in PD-related genes were examined to elucidate its relationship with concentration of serum elements and clinical symptoms of PD. A total of 214 PD patients and 213 controls from Indian population were genotyped using PCR and DNA sequencing methods. The serum element concentrations were detected and clinical symptoms were determined based on UPDRS scale and recorded at the time of sample collection. The IVS4 + 30T>G, Ser167Asn (G>A) and Val380Leu (G>C) polymorphisms appeared to alter element concentrations in PD. The patients with Ser167Asn polymorphism showed significant association with copper, iron and zinc that reinforces the role of A allele as a factor for change in the concentrations of elements, than those patients with G allele. In particular, patients with A allele of Ser167Asn have risk of having high serum iron concentration (OR 11.55, 95% CI 5.59-23.85), which are associated with dementia and postural imbalance. Similar results were observed for Val380Leu (G>C) and IVS4 + 30T>G polymorphisms which suggest their role in element concentration and neurological symptoms. Overall, our study demonstrates the influence of polymorphisms of PD genes on element concentrations and clinical symptoms. Results of this study may be taken into account when considering the contributing factors for PD symptoms.

Epidemiology of dementia and its burden in the city of Kolkata, India.

OBJECTIVES: Increase in aging population is expected to lead to increasing prevalence of dementia in India. In this study, we aimed to determine prevalence, incidence, and mortality of dementia and its subtypes and assess dementia burden in terms of disability-adjusted life years (DALY). METHODS: A community study was conducted over 5 years (2003-2008) in Kolkata, India, on 100,802 (males 53,209) randomly selected subjects to assess prevalence and capture data on incident cases and deaths. Standard case definitions were used. The data were used to estimate years of life lost (YLL) due to premature mortality, years of life lived with disability (YLD), and DALY, based on Global Burden of Disease 2010 approach. RESULTS: During 2003-2004, there were 103 (men 55) cases of dementia. The prevalence was 1.53% (age adjusted 1.12%) at age ≥65 years. In those ≥55 years age, average annual incidence rate of dementia was 72.57 per 100,000. All-cause standardized mortality ratio in dementia cases was 4.74 (men 6.19, women 3.03). The burden of dementia in 2007-2008 revealed that overall YLL was 47.13 per 100,000 and YLD ranged from 1.87 to 16.95 per 100,000 depending on the clinical severity of dementia. The overall DALY lost per 100,000 due to dementia for the year 2007-2008 was 74.19. CONCLUSIONS: This community study revealed a low prevalence and incidence of dementia with consequent low DALY-derived burden of illness compared with many industrialized nations. YLL formed major component of DALY indicating premature mortality to be an outcome of dementia burden. Copyright © 2016 John Wiley & Sons, Ltd.

Metallomic Biomarkers in Cerebrospinal fluid and Serum in patients with Parkinson's disease in Indian population.

Parkinson's disease (PD) is a neurodegenerative disease with the absence of markers for diagnosis. Several studies on PD reported the elements imbalance in biofluids as biomarkers. However, their results remained inconclusive. This study integrates metallomics, multivariate and artificial neural network (ANN) to understand element variations in CSF and serum of PD patients from the largest cohort of Indian population to solve the inconsistent results of previous studies. Also, this study is aimed to (1) ascertain a common element signature between CSF and serum. (2) Assess cross sectional element variation with clinical symptoms. (3) Develop ANN models for rapid diagnosis. A metallomic profile of 110 CSF and 530 serum samples showed significant variations in 10 elements of CSF and six in serum of patients compared to controls. Consistent variations in elements pattern were noticed for Calcium, Magnesium and Iron in both the fluids of PD, which provides feasible diagnosis from serum. Furthermore, implementing multivariate analyses showed clear classification between normal and PD in both the fluids. Also, ANN provides 99% accuracy in detection of disease from CSF and serum. Overall, our analyses demonstrate that elements profile in biofluids of PD will be useful in development of diagnostic markers for PD.

Knowledge, attitude, and practice in relation to stroke: A community-based study from Kolkata, West Bengal, India.

BACKGROUND: The rising incidence of stroke in India indicates the importance of evaluating the existing knowledge, attitude, and practice (KAP) in the community, which is essential for stroke control. OBJECTIVE: To explore and compare stroke-related KAP among participants from stroke-affected families (SAFs) and nonstroke-affected families (NSFs). DESIGN: Using stratified random sampling, a three-phase house-to-house survey was conducted in Kolkata, West Bengal, India. First, field investigators screened subjects of stroke; second, the neurologist confirmed positive cases; and third, under supervision of the neuropsychologist, a validated questionnaire on KAP was administered to participants from SAFs and age-matched NSAFs from the same neighborhood. RESULTS: The KAP questionnaire was administered to 282 participants each from both groups. Knowledge about stroke prevailed in 97% participants and was significantly higher in the SAF group. Both SAF and NSAF groups had better knowledge about prominent symptoms of stroke (loss of consciousness and paralysis) and admitted it as emergency situation requiring hospitalization and that it was potentially preventable. Those persons belonging to the SAF group, however, had lesser knowledge of the risk factors such as diabetes (P < 0.001), smoking (P < 0.014), alcoholism (P < .0.0001), family history (P < .0.0001) and mild stroke symptoms such as headache, (P < 0.001), vomiting (P < 0.001), and fits (P 0.003) as compared to the NSAF group. CONCLUSIONS: Persons from both SAF and non-SAF groups are aware about stroke but possess lesser knowledge about the many symptoms of stroke and risk factors, indicating the necessity of enhancement of existence knowledge on symptoms for better diagnosis and of risk factors for better prevention.

Fifty years of stroke researches in India.

Currently, the stroke incidence in India is much higher than Western industrialized countries. Large vessel intracranial atherosclerosis is the commonest cause of ischemic stroke in India. The common risk factors, that is, hypertension, diabetes, smoking, and dyslipidemia are quite prevalent and inadequately controlled; mainly because of poor public awareness and inadequate infrastructure. Only a small number of ischemic stroke cases are able to have the benefit of thrombolytic therapy. Benefits from stem cell therapy in established stroke cases are under evaluation. Presently, prevention of stroke is the best option considering the Indian scenario through control and/or avoiding risk factors of stroke. Interventional studies are an important need for this scenario.

Correlates of functional outcome among stroke survivors in a developing country--a prospective community-based study from India.

Stroke survivors (SS) are rising with higher incidence of stroke in developing countries. In addition to physical impairment, other factors such as cognition, social interaction, and depression determine the functional outcome after stroke. Considering the paucity of data from developing countries, we planned to determine the change in various functional parameters among SS. This community-based prospective study was carried out in Kolkata, India among 283 SS between 2006 and 2010. Functional outcome was assessed at baseline and at 3 annual follow-up visits using validated tools. A stepwise regression analysis was performed with demographic and stroke-related covariates against various measures of functional outcome. Result showed that mean Barthel Index score at baseline was 76.4 ± 30.8. Bengali version of mental status examination and Geriatric Depression Scale scores trended down over time with a negative regression coefficient of -.2061 (standard error [SE], .0937) and -.4488 (SE, .2145). Other outcomes did not change. Female gender, depression, and cognitive dysfunction had an unfavorable impact, whereas education correlated positively. In conclusions female gender and neuropsychiatric disturbances showed poor functional outcome compared with education, which correlates with better outcome. This information will be helpful for patients in developing countries for planning stroke rehabilitation.

Dementia and cognitive impairment in patients with Parkinson's disease from India: a 7-year prospective study.

Depression and cognitive impairment are frequent manifestations in Parkinson's disease (PD). Although a few longitudinal studies have reported on depression and dementia in PD, there is a yet a lack of such studies in India. This 7-year longitudinal study is a hospital-based prospective case (n = 250)-control (n = 280) study. In all, 36.8% had PD with no cognitive impairment (PD-Normal), 27.2% of the patients with PD were affected by dementia (PDD), and 36% of the remaining patients with PD had mild cognitive impairment (PD-MCI) at baseline. After 7 years of evaluation, 32 new patients, 12 patients from the PD-MCI group and 9 patients from the PD-Normal group, were diagnosed with dementia. The 7-year prevalence rate for dementia was estimated to be 49.28%. In the Indian population, an early onset of dementia is noted among patients with PD, with the age of onset being less than 55 years. Patients with early-onset PDD showed depression symptoms that differed significantly from the controls of the same age-group. There was a major difference in verbal fluency, word list recall, constructional praxis and recall, word list recognition, abridged Boston Naming Test, word list memory with repetition, and Mini-Mental State Examination between PD-MCI and PDD groups. Hallucinations before baseline (odds ratio [OR] = 4.427, 95% confidence interval [CI] = 2.122-9.373), akinetic/tremor dominancy (OR = 0.380, 95%CI = 0.149-0.953), and asymmetrical disease onset (OR = 0.3285, 95%CI = 0.1576-0.685) can be considered as risk factors for patients with dementia. Patients with early-onset PD might be more prone to complex depression and dementia. As the disease progresses, akinetic-dominant PD, early hallucinations, and asymmetrical disease onset are the potential risk factors for the development of dementia in patients with PD.

Congestive myelopathy (Foix-Alajouanine Syndrome) due to intradural arteriovenous fistula of the filum terminale fed by anterior spinal artery: Case report and review of literature.

Spinal arteriovenous fistulas are rare entities. They often present with congestive myelopathy but are infrequently diagnosed as the cause of the patients' symptoms. Only one such case has been described previously in Indian literature. We describe one such case who presented to us after a gap of 3 years since symptom onset and following a failed laminectomy where the cause was later diagnosed to be an intradural fistula in the filum terminale fed by the anterior spinal artery and review the available literature.

Depression among stroke survivors: a community-based, prospective study from Kolkata, India.

OBJECTIVE: Post-stroke depression (PSD) is a disabling entity among stroke survivors (SS). Longitudinal studies on PSD, essential to determine its prognosis, are lacking from developing countries. This prospective study was undertaken to assess the prevalence, natural history, and correlates of depression among SS in an Indian community. METHODS: From a community based stroke registry, SS were assessed annually for cognition, disability, and depression using Bengali validated scales. PSD was diagnosed if score on geriatric depression scale was greater than or equal to 21. Complex sample strategy was considered when calculating prevalence of post stroke depression. An age- and sex-matched case-control study was undertaken to determine the odds of depression in SS. RESULTS: Prevalence of PSD was 36.98% (95% confidence interval [CI]: 31.89%-42.06%) among 241 patients assessed at baseline. About 17% developed depression annually and a similar proportion had spontaneous improvement. Peak rate of PSD was beyond 3 months and continued up to 18 months after stroke. Compared to the non-depressed group, PSD subjects were significantly older, had higher age at first stroke, less education, lower socioeconomic status, and greater cognitive impairment and disability. Education had a protective role. Mortality in PSD was nearly twice that in non-depressed patients, though not significant statistically (hazard ratio: 1.84; 95% CI: 0.90-3.77). Compared with controls, odds ratio of PSD was 19.95 (95% CI: 10.09-39.47). CONCLUSIONS: Approximately one-third of SS develop PSD, similar to developed countries. Prevalence remains stable annually. Delayed peak of PSD suggested later realization of underlying disability. Predictors of PSD have been described and higher literacy was protective in this study.

Disease burden of stroke in Kolkata, India: derivation of disability-adjusted life years by a direct method.

BACKGROUND/AIMS: The disability-adjusted life year (DALY) is a new time-based measure of disease burden incorporating both disability and mortality. Our study aims to determine the DALYs lost due to stroke using a direct methodology and the implications. METHODS: A population-based, house-to-house, 2-stage, prospective study on stroke was conducted over 7 years in Kolkata, India, on 100,802 randomly selected subjects to capture the incident cases of first-ever stroke and those with fatal stroke. The data were utilized to estimate years of life lost due to premature mortality (YLLs), years lived with disability (YLDs) and DALYs lost. RESULTS: Over 7 years, there were 763 incident cases of first-ever stroke; of these, 320 had a fatal stroke within 30 days and 443 were stroke survivors. The overall DALYs lost due to stroke were computed as 795.57 per 100,000 person-years (730.43 in men and 552.86 in women). The overall YLL and YLD values were 593.14 and 202.43 per 100,000 person-years, respectively. The YLLs comprised 74.5% of the total DALYs. CONCLUSIONS: This is the first study in India where DALYs lost due to stroke were derived by a direct method. High YLL values demand urgent measures for controlling premature stroke death.

Cognitive dysfunction in stroke survivors: a community-based prospective study from Kolkata, India.

The frequency of cognitive dysfunction among community stroke survivors (SS) is not known in India. This prospective study investigated the prevalence of poststroke mild cognitive impairment (psMCI) and poststroke dementia (psDem), the annual progression rate to dementia, and pertinent risk factors in a sample population of SS in Kolkata, India between September 2006 and July 2010. From a community-based stroke registry, 281 SS were assessed at baseline year after excluding attrition due to various causes. Validated cognitive tools were applied by trained field workers under supervision of a neuropsychologist. The assessment was repeated annually for consecutive three years. The mean follow-up period was 1.89 years (range, 1-3 years). The period prevalence rate of psDem was 13.88% (95% confidence interval [CI], 9.91%-18.90%) at baseline, and the average annual progression rate to dementia was 3.53% (95% CI, 2.09%-5.58%). Compared with subjects without dementia, those with psDem were significantly older at first-ever stroke and more likely to have cortical atrophy. The period prevalence rate of psMCI was 6.05% (95% CI, 1.45%-13.64%) at baseline, and 10.6% (95% CI, 4.57%-20.88%) of these subjects converted to psDem annually. Survival analysis of psDem patients showed a greater risk of death in psDem SS as compared to nondemented SS (hazard ratio, 2.65; 95% CI, 1.72-6.15). Our data suggest that the overall prevalence of psDem is higher than that of psMCI, possibly related to nonexclusion of prestroke dementia, but that the average annual progression rate of SS to psDem and that of psMCI to psDem are comparable. Older age at first-ever stroke and cortical atrophy are associated with increased risk for dementia among SS.

Refractory epilepsy.

Refractory Epilepsy (R.E.) is a condition where all antiepileptic drugs (AEDs) fail to provide adequate seizure control. To diagnose R.E., false cases of refractoriness need to be carefully excluded. There are several predictors of refractoriness. The treatment options in R.E. are resective surgery, ketogenic diet and vagal nerve stimulation. The roles of newer AEDs are also promising. The future therapeutic possibilities include deep brain stimulation, AED containing polymers, stem cells and gene therapy.

Evaluating intra-genetic variants of DJ-1 among Parkinson's disease patients of eastern India.

OBJECTIVES: Mutations in the DJ-1 gene have been described in autosomal recessive Parkinson's disease (PD) of European ancestry, Ashkenazi Jews, and Afro-Caribbean patients. Up to date, there is a lack of information about the prevalence of DJ-1 mutations among Indian PD patients. MATERIALS AND METHODS: In this study, we examined for DJ-1 mutations in Eastern Indian PD patients. Exons (no. 2-7) and intron boundaries of the DJ-1 gene were screened in 300 individuals (PD, 150; controls, 150) by direct sequencing. RESULTS: A total of six intronic variants (IVS4+30T>G, IVS4+45G>A, IVS4+46G>A, IVS4-98G>A, IVS5+31G>A and IVS5+69G>C) were detected including one novel intronic change (IVS5+69G>C). Clinical features of the two patients exhibiting IVS5+69G>C (novel change) were compared and both were found to have early onset PD. IVS4+30T>G, IVS4+45G>A, and IVS4+46G>A were found to be present equally both in the patient and control cohorts. We did not find any DJ-1 mutations in our study. CONCLUSION: Our results suggest that, unlike Parkin, pathogenic DJ-1 mutations seem to be restricted in certain populations and are unlikely to be of clinical importance in the eastern part of India.

Environmental and familial risk factors of Parkinsons disease: case-control study.

BACKGROUND: While the cause of Parkinson's disease (PD) remains unknown, evidence suggests certain environmental factors, such as well water drinking, herbicides, pesticides exposure and neurotoxins, may trigger the chain of oxidative reactions culminating in the death of dopaminergic neurons in substantia nigra to cause Parkinsonism. To investigate the possible impact of environmental risk factors for idiopathic PD, a case-control study was performed in the Eastern India. METHODS: During the period from January 1st, 2006 and December 10th, 2009, 175 PD patients (140 men, 35 women) and 350 non-Parkinson age-sex matched controls were included in the study. Subjects were given a structured neurological examination and completed an administered questionnaire which elicited detailed information on demographic data, pesticides, herbicides family history, occupation, dietary and smoking habits. RESULTS: The multivariate analysis revealed that family history of PD, pesticide exposure, exposure to toxins other than pesticides and herbicides, rural living and previous history of depression were associated with increased risk of PD, whereas, smoking appeared to be a protective factor. Well water drinking for at least five years, though a significant risk factor on univariate analysis (OR = 4.5, 95% CI = 2.1-9.9), could not be proved significant in multivariate analysis. Head trauma, vegetarian dietary habit, occupation involving physical exertion and exposure to domestic pets were not as significant risk factors. CONCLUSION: Results of our study support the hypothesis of multifactorial etiology of PD with environmental factors acting on a genetically susceptible host.