SOFA and APACHE II scoring systems for predicting outcome of neurological patients admitted in a tertiary hospital intensive care unit.

Background: The field of neurology encompasses the study and treatment of disorders that affect the nervous system, and patients with neurological conditions often require specialized care, particularly in the ICU. Predictive scoring systems are measures of disease severity used to predict patient outcomes. The aim of this study was to compare the discriminative power of commonly used scoring systems, namely the sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) in the ICU of a tertiary care hospital. Methods: This retrospective study included patients with neurological disorders in the ICUs of Tribhuvan University Teaching Hospital from 1 January 2022 to 31 December 2022. Results: A total of 153 patients were included. The mean age of the patients was 54.76 ± 17.32 years with higher male predominance (60.78%). Ischaemic stroke was the most common neurological disorder. There were 58 patients (37.9%) who required mechanical ventilation and all-cause mortality was 20.9%. The mean SOFA score was significantly higher (P=0.002) in survivors, whereas the mean APACHE II did not show a significant difference (P=0.238). Receiver operating characteristic (ROC) analysis showed the area of curve (AUC) of SOFA score was 0.765 and of APACHE II was 0.722. Conclusions: SOFA score had comparatively higher discriminative power than APACHE II. Assessment of the performance of scoring systems in a specific ICU setting improves the sensitivity and applicability of the model to these settings.

Dyslipidemia and Obesity in Ischemic Stroke.

Background Dyslipidemia and obesity are both important risk factors for the first and recurrent ischemic strokes. Dyslipidemia is highly prevalent among Asian populations, and the prevalence of obesity is also noted to be progressively increasing in this population. This study was carried out to determine the prevalence of dyslipidemia and central obesity and their association with each other and various cardiovascular risk factors among patients who presented with an acute ischemic stroke to a tertiary care university hospital in Nepal. Methods This study is a secondary analysis done on data from a prospective observational study that was carried out on patients who were either acutely admitted to or visited the outpatient department of the hospital with a diagnosis of ischemic stroke. Dyslipidemia was defined according to the third report of the National Cholesterol Education Program expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. Obesity was defined as central obesity by measuring waist circumference. Data were collected by convenience sampling and analyzed by IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Significant variables were compared with logistic regression analysis. Other data were expressed as frequencies and percentages. Results Out of 145 patients, 77 were male (53.1%). The mean age of the patients was 60.15 years. Dyslipidemia and central obesity were present in 96.6% and 57.9% of the patients, respectively. The most common lipid abnormality was low-density lipoprotein cholesterol, present in 82.8% of the patients, followed by high triglycerides, present in 21.4% of them. Dyslipidemia was not associated with any vascular risk factors. Central obesity was significantly associated with female gender, diabetes, and low-density lipoprotein cholesterol in univariate analysis. However, in multivariate logistic regression analysis, it was significantly associated with only female gender (p=0.003) and diabetes (p=0.012). Conclusion Dyslipidemia and central obesity are very common in patients with ischemic stroke. Dyslipidemia is not associated with any vascular risk factors. However, central obesity is significantly associated with the female gender and diabetes.

Prevalence and Clinical Types of Tremor in Multiple Sclerosis and its Associated Disability: A Systematic Review.

Objective: To describe the state of literature regarding prevalence, clinical types of tremor in Multiple Sclerosis and associated disability. Background: Tremor has long been recognized as an important symptom of multiple sclerosis. This can be intention and postural tremor that affects the upper limbs. Patients with multiple sclerosis who experience tremor of any severity typically retire early or lose their jobs due to disability. Methods: This systematic review was performed up to September 9, 2022. Article selection was performed by searching the MEDLINE (PubMed) and EMBASE electronic bibliographic databases. The search strategy was not limited by study design but only for articles in the English language. Results: A total of nine full-text articles were included in the analysis. Six studies were cross-sectional studies; one each was a prospective observational study, a case-control study, a community-based cohort. The prevalence of tremor in the multiple sclerosis (MS) population among studies ranged widely, between 12.5% and 68.9%. The presence of severe tremor ranged from 3% to 33%. Younger age was a significant predictor of tremor in two studies. The most common tremor subtype was action tremor. Upper extremities were the most common site involved in the majority of our studies, followed by head and neck. Conclusions: Prevalence of tremor ranged from 12.5% to 68.9% in the MS population with severe tremor being an infrequent complication. Severity of tremor correlated with increasing disability. Upper limb action tremor was the most common with rare occurrences of resting and rubral tremor.

A review of movement disorders in persons living with HIV.

BACKGROUND: The human immunodeficiency virus (HIV) causes movement disorders in persons living with HIV (PLH). OBJECTIVES AND METHODS: We conducted a systematic review on the spectrum of movement disorders in PLH using standard terms for each of the phenomenologies and HIV. RESULTS: Movement disorders in PLH were commonly attributed to opportunistic infections (OI), dopamine receptor blockade reactions, HIV-associated dementia (HAD), presented during seroconversion, developed due to drug reactions or antiretroviral therapy (ART) itself and lastly, movement disorders occurred as a consequence of the HIV-virus. Parkinsonism in ART naïve PLH was associated with shorter survival, however when Parkinsonism presented in PLH on ART, the syndrome was indistinguishable from Idiopathic Parkinson's disease and responded to therapy. Tremor was often postural due to HAD, drugs or OI. Generalized chorea was most frequent in HIV encephalopathy and toxoplasmosis gondii caused most cases of hemichorea. Ataxia was strongly associated with JCV infection, ART efavirenz toxicity or due to HIV itself. Dystonia was reported in HAD, secondary to drugs and atypical facial dystonias. Both cortical/subcortical and segmental/spinal origin myoclonus were noted mainly associated with HAD. In patients with HIV related opsoclonus-myoclonus-ataxia-syndrome, seroconversion illness was the commonest cause of followed by IRIS and CSF HIV viral escape phenomenon. CONCLUSIONS: Aetiology of movement disorders in PLH depend on the treatment state. Untreated, PLH are prone to develop OI and HAD and movement disorders. However, as the number of PLH on ART increase and survive longer, the frequency of ART and non-AIDS related complications are likely to increase.

Augmented reality-based training versus standard training in improvement of balance, mobility and fall risk: a systematic review and meta-analysis.

Augmented reality (AR) technology is being used recently in healthcare, especially for rehabilitation purposes, owing to its ability for repetition, rapid feedback, and motivation for patients. This systematic review and meta-analysis aims to compare the efficacy of AR-based interventions to conventional physical interventions in improving balance, mobility, and fall risk. Material and methods: PubMed, Google Scholar, Scopus, and the Cochrane Central Register of Controlled Trials were systematically searched from inception to January 2023. Randomized trials and observational cohort studies comparing the effects of AR-based exercises with conventional training in patients 18 years and older were included in the analysis. Studies using virtual reality, case reports and series, reviews, meta-analyses, letters, and editorials were excluded. Post-intervention data on the Berg Balance Scale (BBS) and Timed Up and Go (TUG) Test were extracted and studied. The fixed-effects inverse variance model was utilized to pool the extracted data. Results: Out of 438 articles, seven articles (199 participants) comparing AR-based exercise with the standard training were included in the systematic review. Six articles with sufficient data on the parameters were included in the meta-analysis. AR-based exercises resulted in a significantly higher BBS score than conventional exercise (Hedge's g=0.48, 95% CI=0.19-0.77, P<0.001). The BBS value was significantly higher in AR-based training of 8 weeks or more (Hedge's g=0.88, 95% CI=0.46-1.31) when compared with trainings conducted for less than 8 weeks (Hedge's g=0.11, 95% CI=-0.30 to 0.52), P=0.01). Likewise, the TUG Test score was found to be to be significantly lower in ARgroup than the controls (Hedge's g= -0.54, 95% CI=-0.85 to -0.23, P<0.01). Conclusion: In comparison to conventional methods, AR-based exercises had higher improvements in balance, mobility, and fall risk parameters. The use of AR technology in elderly patients can promote independence while preventing falls and associated morbidity and mortality. There is a need for a larger randomized controlled trial to provide a more accurate comparison on efficacy and safety of different modalities of training.

Stroke patterns and outcomes during the second wave of COVID-19 pandemic: a cross-sectional study.

The coronavirus disease 2019 (COVID-19) pandemic has affected the number of stroke activations, admission of patients with various types of strokes, the rate and timely administration of reperfusion therapy, and all types of time-based stroke-related quality assessment metrics. In this study, we describe the different types of strokes, different delays in seeking and completing treatment occurring during the second wave of the COVID-19 pandemic, and predictors of outcome at 3 months follow-up. Materials and methods: This is a single-centered prospective cross-sectional study carried out from May 2021 to November 2021, enrolling patients with stroke. Data collected were demographic characteristics, stroke types and their outcomes, and different types of prehospital delays. Results: A total of 64 participants were included in the study with a mean age of 60.25±15.31 years. Ischemic stroke was more common than hemorrhagic stroke. The median time of arrival to the emergency room of our center was 24 h. The most common cause of prehospital delay was found to be delays in arranging vehicles. The median duration of hospital stays [odds ratio (OR)=0.72, P<0.05] and baseline NIHSS (National Institute of Health Stroke Scale) score (OR=0.72, P<0.05) were found to be a predictor of good outcomes at 3 months follow-up on binary logistic regression. Conclusion: The factors that cause the delayed transfer to the hospital and onset of treatment should be addressed. Patient counseling about the likely prognosis can be done after evaluating the probable outcome based on the NIHSS score and median duration of hospital stay. Nevertheless, mechanisms should be developed to reduce the prehospital delay at the ground level as well as at the policy level.

Painful tonic spasms in a patient with neuromyelitis optica spectrum disorder: A case report.

Painful tonic spasms initially described in association with multiple sclerosis are actually more common in patients with neuromyelitis optica spectrum disorder. Characterized by fierce pain and tonic posture of limbs, painful tonic spasms are common in patients during the recovery phase after the first episode of myelitis. A 68-year-old man presented with painful tonic spasm after 2 months of diagnosis of neuromyelitis optica spectrum disorder. Eventual use of eslicarbazepine resulted in significant control of spasms. Early recognition of painful tonic spasms and appropriate therapeutic medications can significantly decrease the impact it can have on the quality of life among neuromyelitis optica spectrum disorder patients.

MRI of the brain mimicking autoimmune encephalitis in Sjögren syndrome with chorea: a case report.

Neurologic manifestations in primary Sjögren syndrome (SS) range in prevalence from 8 to 49%, and most of the studies suggest a prevalence of 20%. The incidence of SS patients developing movement disorders is about 2%. Case presentation: The authors herein report a case of a 40-year-old lady with MRI of the brain mimicking autoimmune encephalitis in SS who presented with chorea. Her MRI findings revealed T2 and FLAIR (fluid-attenuated inversion recovery) high signal intensity areas in bilateral middle cerebellar peduncles, dorsal pons, dorsal midbrain, hypothalami, and medial temporal lobes. Clinical discussion: There is still no evidence to support the definite use of MRI in characterizing the central nervous system involvement in primary SS, especially due to overlapping findings with age and cerebrovascular disease. Multiple areas of increased signal intensity in periventricular and subcortical white matter in FLAIR and T2-weighted image is commonly seen in primary SS patients. Conclusion: It is crucial to consider autoimmune diseases like SS as a cause of chorea in adults, even in those whose imaging findings are suggestive of autoimmune encephalitis.

Wallerian degeneration in the brain after organophosphorus poisoning: a case report.

The type, quantity, and potency of the organophosphorus compound (OPC) taken determine the symptoms of OPC poisoning as well as their severity. The exact etiology for organophosphorus (OP) poisoning delay neuropathy regulating Wallerian degeneration is still unknown. Case Presentation: We report here a rare case of a 25-year-old lady with Wallerian degeneration in the brain found in an MRI in a patient after OPC ingestion. MRI of the brain, in our case, shows Wallerian degeneration of the corona radiata, internal capsule, and midbrain. Clinical Discussion: Some OPCs can lead to OP-induced delayed neuropathy, a form of delayed neurotoxicity in humans (OPIDN). The distal axonopathy's (in OPIDN) morphological pattern resembles Wallerian degeneration, which happens in vitro following nerve damage. Although delayed Wallerian degeneration from organophosphate poisoning often affects the peripheral nervous system, it can also affect the central nervous system. Rehabilitation therapy combined with appropriate nursing care has been demonstrated to improve the disease. Conclusion: Central nervous system involvement after OP poisoning is rare, and MRI of the brain and spinal cord can document evidence of Wallerian degeneration after OP poisoning.

Guillain-Barré syndrome complicating early pregnancy: a case report from Nepal.

Guillain-Barré syndrome (GBS) is an immunological demyelinating disorder characterized by progressive, ascending flaccid weakness, usually resulting after infection or some immune stimulation. Its occurrence during pregnancy is rare and due to attribution of its symptoms to pregnancy, diagnosis might be delayed. Case Presentation: A 39-year-old G4P3L2A0 woman at 13 weeks 6 days period of gestation presented with acute, symmetrical, ascending type of flaccid quadriparesis leading to slurring of speech, swallowing difficulty, and eventually respiratory failure. With the diagnosis of GBS, she was admitted to the intensive care unit, five sessions of plasma exchange were done along with physiotherapy and her symptoms started improving. After discharge she was on regular antenatal care visits and eventually, she delivered a healthy baby at term with an uneventful labor event and postpartum period. Clinical Discussion: There is a huge maternal-fetal risk of respiratory failure, aspiration pneumonia, preterm delivery, possible use of forceps or vacuum, and operative interference due to GBS in pregnancy, whose causative agents are similar to that of the general population. The swinging pattern of risk of GBS in pregnancy might be due to immunological changes with predominant Th2 response seen in pregnancy. Treatment measures are similar as in the general population with initial symptomatic care and administration of disease-specific therapy later which consists of intravenous immunoglobulin and/or plasmapheresis. Conclusion: A well-timed diagnosis of GBS in pregnancy might allow successful management with the help of intensive monitoring with or without immunotherapy.

Pontine and bilateral cerebellar lesion in osmotic demyelination syndrome associated with uncontrolled type II diabetes mellitus: a case report.

Osmotic demyelination syndrome (ODS) as a result of the hyperosmolar hyperglycemic state is rare and can present with variable neurological manifestation due to lysis of myelin sheath. Case presentation: A 44-year diabetic male presented with complaints of sudden onset, progressive bilateral weakness in lower limbs, and slurring of speech for the past 1.5 months. Cerebellar examination showed a bilaterally impaired finger nose test, dysdiadochokinesia, impaired heel shin test, and an impaired tandem gait. MRI brain (T2 and fluid-attenuated inversion recovery sequences) showed high signal intensity in the central pons and bilateral cerebellum. With a diagnosis of ODS with poorly controlled diabetes, he was treated with insulin, metformin, and supportive measures following which his symptoms subsided gradually. Clinical discussion: A rapid correction of hyponatremia is considered the most common cause of ODS. Variations in plasma glucose levels, a rare cause of ODS, can cause an abrupt osmolality change causing pontine and extrapontine myelinolysis. Prevention of rapid correction of hyponatremia and rapid changes in plasma osmolality in vulnerable patients is the mainstay of treatment. Conclusions: Clinical features, imaging studies, and monitoring of serum osmolality, serum glucose, and electrolytes aid in diagnosis and favorable outcomes for the patient.

Epidemiological and clinical characteristics of central nervous system infections in a tertiary center: A retrospective study.

Background and Aims: Central nervous system (CNS) infection is one of the most common causes of morbidity, mortality, and hospital admission worldwide. The natural history of CNS infection is quite fatal. Early diagnosis and treatment have been proven to have a crucial role in patients' survival. The aim of this study was to identify the epidemiological and clinical patterns of patients diagnosed with CNS infections. Methods: This study is a retrospective study conducted in a tertiary level hospital in Nepal in which patient diagnosed with CNS infections (September 2019 to 2021) were included. Data were collected and analyzed in SPSS. Results: The mean age of the 95 patients included in the study was 45.18 ± 19.56. Meningoencephalitis (n = 44, 46.30%) was the most common infection diagnosed. Patients belonging to the age group 30-60 years had a higher frequency of focal neurological deficit, and other classical clinical features. All the patients who died during the treatment had associated comorbidities but no concurrent infections. Altered sensorium, fever, and headache were the common presenting symptoms in all the recovered patients. Conclusion: To ensure optimum disease outcome, early diagnosis and prompt management are crucial. For this, recognizing the local disease patterns in terms of disease distribution, commonly implicated aetiologies, presenting symptoms, and prognostic factors is of utmost importance.

Stiff person syndrome in a Nepalese man with uncontrolled diabetes mellitus and ketonuria: A rare case report.

Stiff Person Syndrome (SPS), a progressive Central Nervous System disorder is accompanied by progressive muscle rigidity, hyperreflexia, and spasms mainly in truncal and proximal leg muscles mainly associated with autoimmune disorders. Here, we report a rare case of SPS in a middle-aged Nepalese man with uncontrolled diabetes mellitus and ketonuria.

Chorea hyperglycemia basal ganglia syndrome: A case report from Nepal.

A rare case of chorea hyperglycemic basal ganglia syndrome in a 56-year-old woman who presented with left-sided hemichorea in the setting of uncontrolled, non-ketotic, type II diabetes mellitus is reported. Early blood glucose control could lead to complete resolution of symptoms. Despite an excellent prognosis, delayed recognition and management can lead to prolong disability due to movement disorder.

Multicentre registration of wake-up stroke in China (MCRWUSC): a protocol for a prospective, multicentre, registry-based cohort study.

INTRODUCTION: Wake-up stroke (WUS) is a type of acute ischaemic stroke (AIS) that occurs during sleep with unknown time of symptom onset. The best treatment is usually not suitable for WUS, as thrombolysis is usually provided to patients who had a symptomatic AIS within a definite 4.5 hours, and WUS remains a therapeutic quandary. Efforts to explore the onset time characteristics of patients who had a WUS and the risk factors affecting poor prognosis support a role for providing new insights by performing multicentre cohort study. METHODS AND ANALYSIS: This multicentre, nationwide prospective registry will include 21 comprehensive stroke centres, with a goal of recruiting 550 patients who had a WUS in China. In this study, clinical data including patient's clinical characteristics, stroke onset time, imaging findings, therapeutic interventions and prognosis (the National Institutes of Health Stroke Scale Score and the modified Rankin Scale Score at different time points) will be used to develop prediction models for stroke onset time and prognostic evaluation using the fast-processing of ischemic stroke software. The purpose of this study is to identify risk factors influencing prognosis, to investigate the relationship between the time when the symptoms are found and the actual onset time and to establish an artificial intelligence-based model to predict the prognosis of patients who had a WUS. ETHICS AND DISSEMINATION: This study is approved by the ethics committee of Shanghai Pudong Hospital (Shanghai, China) and rest of all participating centres. The findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: ChiCTR2100049133.

Occurrence of osmotic demyelination syndrome in diabetes mellitus: A case report and literature review of various etiologies for osmotic demyelination syndrome.

Osmotic demyelination syndrome is a rare condition reported mainly in the case of rapid correction of hyponatremia, but it can occur even in the case of complicated diabetes mellitus either during rapid correction of hyperglycemia or anytime during the complicated diabetes mellitus. We report a case of complicated diabetes mellitus developing osmotic demyelination syndrome. The patient had presented with altered sensorium and seizure, which was initially diagnosed as hyperglycemia, but during his treatment, the magnetic resonance imaging of brain revealed central pontine myelinolysis. Our search on the causes of osmotic demyelination syndrome other than rapid correction of hyponatremia has revealed several other causes like autoimmune liver disease, Sjogren's syndrome and non-Hodgkin's lymphoma in addition to diabetes mellitus.

Safety and efficacy of endovascular thrombectomy in patients with severe cerebral venous thrombosis: A meta-analysis.

Background: Cerebral venous thrombosis (CVT) is a rare thrombotic condition which is traditionally treated with anti-coagulation therapy. Subsets of patients with severe CVT have been treated with endovascular thrombectomy (EVT). Despite the high estimated mortality associated with severe CVT, there has been only one randomized control trial done regarding safety and efficacy of EVT in severe CVT compared to standard medical management. Evidence in this area is lacking. Objective: The aim of this systematic review is to analyze all existing literature and generate robust information regarding the role of EVT in the management of patients with severe CVT. Methods: This systematic review and meta-analysis followed PRISMA guideline. PubMed, Embase, Google Scholar, and CNKI were searched for eligible studies from 2007 to 2021. Safety and efficacy of EVT were evaluated by meta-analyzing recanalization status, the good functional outcome at follow-up, recurrent CVT, new hematoma. A pooled proportion with a 95% confidence interval was derived from a meta-analysis of various outcomes (CI). Results: A total of 33 studies comprising 610 patients treated with EVT were included for analysis which comprised one randomized control trial, one prospective study and 31 retrospective studies. Based on pooled data, 85% of patients had good functional outcome, 62% had complete recanalization, 5% had all-cause mortality, and 3% had catheter related complications. The efficacy outcomes in this analysis had a significant heterogeneity and a subgroup analysis was also done to explain these findings. The minimum time of follow up was 3 months and varied EVT techniques were used across the studies. Conclusion: This meta-analysis suggests EVT may be safe and efficacious in treating patients with severe CVT. Registration: Our protocol was registered with PROSPERO: International prospective register of systematic reviews with the registration number CRD42021254760.

Guillain-Barre Syndrome following lower segment caesarean section under spinal anesthesia: A case report.

Symptoms of Guillain-Barre Syndrome (GBS) may be mistaken for typical puerperal changes, delaying diagnosis. Surgery and anesthesia may be triggers for GBS with an overall increase in pro-inflammatory cytokines in the postpartum period. We report a unique case of GBS in the postpartum period who made a good recovery with supportive measures.

Levetiracetam versus Oxcarbazepine as monotherapy in newly diagnosed focal epilepsy: A systematic review and meta-analysis.

OBJECTIVE: To compare the efficacy and safety of Levetiracetam (LEV) and Oxcarbazepine (OXC) as monotherapy for the treatment of newly diagnosed focal epilepsy. METHODS: We searched PubMed, Cochrane Library, EMBASE, and Google Scholar from January 1, 2000 to May 11, 2022, with no language restrictions along with The ClinicalTrials.gov website and the WHO International Controlled Trials Registry platforms. We pooled the risk ratio (RR) and corresponding 95% confidence interval (95% CI) for the efficacy and safety outcomes. The quality of included trials was assessed using the Cochrane Collaboration's tool. RESULTS: Two RCTs included a total of 574 newly diagnosed focal epilepsy patients (the LEV group [282 patients] and the OXC group [292 patients]). LEV group when compared with the OXC group had no significant difference in the pooled estimate of seizure freedom at week 24. (RR: 0.81; 95% CI: 0.62-1.05, p = .11). Similarly, there was no significant difference in the pooled estimate of withdrawal due to adverse events (AEs) (RR: 0.87; 95% CI: 0.34-2.23, p = .77). The commonly reported AEs in both trials were dizziness, headache, rash, somnolence, and nasopharyngitis with zero medication-related death and few serious AEs. CONCLUSIONS: LEV is noninferior to OXC in terms of seizure freedom at week 24 and treatment withdrawal rate due to AEs among adults but long-term treatment data is still missing. Future multicentric double-blinded RCTs and real-world studies are of great need.