BMI, HOMA-IR, and Fasting Blood Glucose Are Significant Predictors of Peripheral Nerve Dysfunction in Adult Overweight and Obese Nondiabetic Nepalese Individuals: A Study from Central Nepal.

Objective. Nondiabetic obese individuals have subclinical involvement of peripheral nerves. We report the factors predicting peripheral nerve function in overweight and obese nondiabetic Nepalese individuals. Methodology. In this cross-sectional study, we included 50 adult overweight and obese nondiabetic volunteers without features of peripheral neuropathy and 50 healthy volunteers to determine the normative nerve conduction data. In cases of abnormal function, the study population was classified on the basis of the number of nerves involved, namely, "<2" or "≥2." Multivariable logistic regression analysis was carried out to predict outcomes. Results. Fasting blood glucose (FBG) was the significant predictor of motor nerve dysfunction (P = 0.039, 95% confidence interval (CI) = 1.003-1.127). Homeostatic model assessment of insulin resistance (HOMA-IR) was the significant predictor (P = 0.019, 96% CI = 1.420-49.322) of sensory nerve dysfunction. Body mass index (BMI) was the significant predictor (P = 0.034, 95% CI = 1.018-1.577) in case of ≥2 mixed nerves' involvement. Conclusion. FBG, HOMA-IR, and BMI were significant predictors of peripheral nerve dysfunction in overweight and obese Nepalese individuals.

A study of seven day mortality in acute ischemic stroke in a teaching hospital in Chitwan.

BACKGROUND: Stroke mortality rate indicates a measure in hospital quality care. Most of the available data are from developed countries and are for late mortality. Only few studies on 7-day fatality, a recently implemented indicator of early stoke mortality, are reported. We attempted to identify the predictors of clinical outcome by 7th day in acute ischemic stroke. METHODS: This descriptive study included 100 consecutive cases of acute ischemic stroke admitted to Neurology center of a teaching hospital in Chitwan, Nepal. Common risk factors were identified. The cases were classified as per TOAST classification and severity at admission assessed using National Institutes of Health Stroke Scale. Univariate and multivariate analysis was used to analyze the data. RESULTS: Thirteen percent patients expired by 7th day. On univariate analysis severity of stroke, fever, atrial fibrillation, hypertension at admission and early neurological deterioration were related to early 7-day mortality where as age, gender, smoking, diabetes mellitus, coronary artery disease, early onset seizures, dyslipidemaia, and hematocrit were unrelated to early mortality. Multivariate analysis showed that only NIHS score was significantly correlated with early mortality. CONCLUSIONS: A mortality rate of 13 percent was noted by 7th day. A positive association was noted with stroke severity, early neurological deterioration, arterial fibrillation, hypertension and fever at onset.

Stroke mortality in intensive care unit from tertiary care neurological center.

INTRODUCTION: Stroke is the second most common cause of death and major cause of disability worldwide. About a quarter of stroke patients are dead within a month, about a third by six months, and a half by one year. Although the most substantial advance in stroke has been the routine management of patients in stroke care units, Intensive Care Unit has remained the choice for stroke patients' care in developing countries. This study explores the mortality of stroke patients in ICU setting in tertiary care neurological centre in a developing country. METHODS: We collected data of stroke patients admitted in our ICU from August 2009 to August 2010 and analyzed. RESULTS: Total 44 (10.25%) patients were admitted for acute stroke. Age ranged from 17-93 years. Low Glasgow Coma Scale (GCS), uncontrolled hypertension and aspiration pneumonia were common indications for admission in ICU. Total 23 (52.3%) patients had hemorrhagic stroke and 21 (47.7%) patients had ischemic stroke. Total 13 (29.54%) patients of stroke died within seven days, nine (69.23%) patients of hemorrhagic stroke died within six days, and four patients (30.76%) of ischemic stroke died within seven days and six (13.63%) patients left hospital against medical advice. All of these patients had ischemic stroke. CONCLUSIONS: Stroke mortality in ICU remains high despite of care in tertiary neurological center in resource poor settings. Stroke Care Unit, which would also help dissemination of knowledge of stroke management, is an option for improved outcome in developing countries.

Vertical gaze palsy with skew deviation.

With the advancement of neuroradiology, clinical localization followed by radiology, had made neurology more interesting. Vertical gage palsy as presentation cerebrovascular disease is not so common. Vertical gaze palsy usually localizes the lesion to dorsal mid brain. A 56 years male patient presented with sudden onset vertigo, diplopia, transient loss of consciousness and sways toward right side while walking. Clinical examination showed vertical gaze palsy with skew deviation along with swaying towards rt. during walk. MRI brain showed - infarct involving dorsal midbrain at superior colliculus level and medial thalamus.

Acute intermittent porphyria with SIADH and fluctuating dysautonomia.

Three cases of acute intermittent porphyria are reported. While in first case severe pain in abdomen with intermittent exacerbation was the only presentation, the second patient presented as accelerated hypertension and acute abdominal crises in whom the clinical course was characterized by development of deep coma due to inappropriate secretion of antidiuretic hormone before she made complete recovery. The third patient, initially manifested as acute encephalitic syndrome. After initial improvement, she developed features of acute intermittent porphyria i.e. acute abdomen, neuropsychiatric symptoms, and rapidly progressing acute motor neuropathy leading to respiratory and bulbar paralysis. In addition, she developed severe and fluctuating dysautonomia leading to cardiac arrest and fatal termination. The importance of early diagnosis, recognition of autonomic disturbances, prompt treatment and counseling for avoidance of precipitating factors is stressed.

Association of seizure, facial dysmorphism, congenital umbilical hernia and undescended testes.

With the advances in neurogenetics association of epilepsy and intellectual disability with chromosomal abnormalities are being increasingly recognized. While onset of seizures with mental retardation at an early age indicate chromosomal abnormality, combination of characteristics facial dysmorphism and congenital abnormalities gives a clue of a particular syndrome. In addition MRI findings may help in confirming the diagnosis. A nine years old boy is presented where early onset seizure, mental retardation, delayed development of speech, presence of facial dysmorphism,, umbilical hernia and undescended testes suggested possibility of chromosomal 6q deletion disorder. Important deletion disorders are discussed and importance of clinical examination is stressed.

Eye twist and tongue twist: a rare neurological syndrome.

A 27-year-old man presented with diplopia without features of raised intracranial pressure. He had left sixth cranial nerve (CN) palsy. Initial investigations in the form of blood tests, cerebrospinal fluid (CSF) opening pressure including CSF analysis and CT head were normal. He represented with paraparesis after 3 weeks. Examination revealed sixth CN palsy (eye twist) and new left-sided twelfth CN palsy (tongue twist), and hence Godtfredsen syndrome was diagnosed. MRI showed vertebral and clivus metastases. He showed partial response to high dose steroid. The statement 'sixth CN palsy may be a false localising sign' in neurology, should be followed by '....it can also be a true initial sign of clivus mass.'

C-reactive protein and early mortality in acute ischemic stroke.

BACKGROUND: There is growing evidence that inflammation plays an important role in atherogenesis. Several studies have shown that C-reactive protein (CRP), an inflammatory marker, is associated with stroke severity and outcome. But limited studies are there which show the relationship of CRP with early mortality i.e within seven days. OBJECTIVE: To study the association of CRP within 24 hours after acute ischemic stroke onset with severity during admission, types of ischemic stroke and outcome. METHODS: This cross sectional study was done including 100 consecutive cases of acute ischemic stroke admitted to Neurology center of College of Medical Sciences, Bharatpur (Chitwan), Nepal. The cases were classified as per TOAST classification and severity at admission assessed using National Institutes of Health Stroke Scale. C-reactive protein (CRP) level was estimated by latex particle agglutination test. RESULT: Thirteen percent patients expired by 7th day. In the expired group, CRP was positive in 15.3 percent, 15.3 percent and 61.5 percent in patients with lacunar, cardioembolic and large artery atherosclerotic infarction respectively (p 0.19). CRP was positive in all 7 patients (53.8%) who had expired with severe NIHS scale (p 0.004). CONCLUSION: High CRP level is associated with stroke severity at admission and is an independent predictor of early seven day mortality after ischemic stroke.