Publications by authors named "Birinder Paul"

39 Publications

Unabridged Histoplasmosis Myositis: Unsolved Dissemination with Diagnostic Challenge.

Ann Indian Acad Neurol 2021 Mar-Apr;24(2):239-242. Epub 2020 Sep 2.

Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Histoplasmosis occurs predominantly in immunocompromised hosts and typically presents with mild constitutional symptoms, weight loss, weakness, fatigability, hepatosplenomegaly, and lymphadenopathy. The diagnosis is generally delayed and is based upon isolating the organism in blood cultures or by identifying intracellular organisms in tissues. Disseminated Histoplasmosis is well described in HIV patients but Histoplasmosis myositis is a rare manifestation and has not been reported in seronegative patients till date. We here address a case of a pharmacologically immunosuppressed patient with extensive Histoplasmosis myositis invading almost all the skeletal muscles of body (including plantar foot muscles) with no evidence of dissemination to other organ-systems. Clinical examination and investigations co-related with infiltrative muscle disease and skeletal muscle biopsy revealed . This patient illustrates a distinctive clinical presentation of fungal infection with subtle constitutional symptoms and isolated muscle weakness which added to the diagnostic challenge. Hence, differential diagnosis of fungal infection must always be considered as a cause of myopathy in any pharmacologically immunosuppressed patient.
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http://dx.doi.org/10.4103/aian.AIAN_511_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232465PMC
September 2020

Anxiety in Parkinson's Disease: Correlation with Depression and Quality of Life.

J Neurosci Rural Pract 2021 Apr 24;12(2):323-328. Epub 2021 Mar 24.

Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

 Anxiety is common in patients with Parkinson's disease (PD). Its prevalence ranges from 20 to 40% but despite that, the high prevalence anxiety in PD is often undiagnosed and untreated. This research was aimed to study the pattern of anxiety with regard to its prevalence and risk factors and to establish the association of anxiety with depression and quality of life (QOL) in patients with PD.  A total of 105 patients with PD were prospectively observed. Demographic and clinical variables were recorded and patients were assessed for anxiety (the Parkinson anxiety scale [PAS]), depression (geriatric depression scale [GDS]), and QOL (Parkinson's Disease Questionnaire-39 [PDQ-39]). Multiple forward logistic regression analysis was done for parameters showing association with anxiety. Pearson's correlation was used to calculate the strength of association of depression and QOL with anxiety.  Anxiety was present in 56 PD patients (53.3%). Episodic anxiety was noted in 50%, avoidance behavior in 35%, and persistent anxiety in 15% of these patients. There was significant association of anxiety with duration of disease ( = 0.001), severity ( < 0.005), levodopa equivalent dose (LED; = 0.001), and tremor phenotype of PD ( = 0.004). Anxiety coexisted with depression in 50 patients (79.4%), which was statistically significant in our cohort ( = 0.001). There was significant linear relationship between the PAS and PDQ-39.  Anxiety exerts a negative impact on the QOL as revealed by proportionately worsening PDQ-39 and PAS scores. Screening for anxiety will allow efficient delivery of support and treatment to patients with PD and their families.
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http://dx.doi.org/10.1055/s-0041-1722840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8110433PMC
April 2021

Systemic manifestations of COVID-19.

J Anaesthesiol Clin Pharmacol 2020 Oct-Dec;36(4):435-442. Epub 2020 Oct 26.

Department of Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Coronavirus disease 2019 (COVID-19), caused due to a novel coronavirus SARS-CoV-2, has swept across the planet and has become a public health emergency of international concern. Like other coronaviruses, it predominantly involves the respiratory system. However, several atypical manifestations of the disease have been reported worldwide in a short span of time. Almost all organ systems (cardiovascular, gastrointestinal, renal, hepatic, endocrine, and nervous system) have been reported to be involved. This review concisely summarizes the systemic effects of COVID-19, thus emphasizing that the disease can present in various forms and the healthcare workers need to be extra vigilant, approaching all patients with a high index of suspicion.
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http://dx.doi.org/10.4103/joacp.JOACP_359_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022059PMC
October 2020

Multiple Sclerosis Relapse Presenting as Sensorineural Hearing Loss.

Neurology 2021 04 2;96(16):767-768. Epub 2021 Mar 2.

From the Department of Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

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http://dx.doi.org/10.1212/WNL.0000000000011796DOI Listing
April 2021

Gender Differences in Impulse Control Disorders and Related Behaviors in Patients with Parkinson's Disease and its Impact on Quality of Life.

Ann Indian Acad Neurol 2020 Sep-Oct;23(5):632-637. Epub 2020 Dec 8.

Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Background: Dopaminergic medications administered to remedy motor symptoms in Parkinson's disease are associated with an enhanced risk for impulse control disorders (ICD) and related compulsive behaviors (ICD-RB). Thus, the present study focuses on investigating the gender difference in the prevalence of ICD-RBs in Indian PD patients on dopamine replacement therapy (DRT), its impact on quality of life and to identify ICDs relevant in Indian scenario apart from the criteria set in QUIP-RS.

Method: This was a hospital-based observational cross-sectional study in which Parkinson's disease patients attending neurology clinic were included. Complete details of anti-parkinsonian therapy along with demographic and clinical variables were recorded on a predesigned Performa. Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease (QUIP), which is a validated quick screening tool, was used to detect ICD-RBs. The relative frequency and comparative impact of ICD on health-related quality of life (QOL) was studied using validated PDQ-39 Questionnaire.

Results: Out of 102 patients, at least one ICD or ICD-RB was present in 41.19% and ≥2 ICD-RBs were present in 15.59%. At least one ICD was present in 16.67%, any ICD-related compulsive behaviors was present in 34.31% patients. The most common was punding and compulsive medication use (12.75% each), followed by hobbyism (7.84%), compulsive eating (6.86%), pathological gambling (3.92%), and hypersexuality, walkabout, and compulsive shopping (2.94% each). ICDs not classified elsewhere such as trichotillomania were found 3 patients (2.94%). ICD-RBs showed a trend to be more frequent in women (44.82% women vs. 39.39% men). As compared with patients without ICD-RBs, those with ICD-RBs were found to have higher dose of LD and DA and higher Hoehn and Yahr stage. ICD-RBs have a negative impact on the quality of life of Parkinson's disease patients.

Conclusion: ICDs and ICD-RBs have been included in the behavioral spectrum of nonmotor symptoms in PD. PD patients are at increased risk of developing ICD-RBs which interfere with important activities and have obligation in ordinary life, leading to legal and psychological consequences with a great impact on QOL.
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http://dx.doi.org/10.4103/aian.AIAN_47_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887492PMC
December 2020

Assessment of knowledge gaps and perceptions about COVID-19 among health care workers and general public-national cross-sectional study.

J Anaesthesiol Clin Pharmacol 2020 Jul-Sep;36(3):337-344. Epub 2020 Jul 31.

Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Background And Aims: COVID-19 has impacted everyone's life and livelihood in one way or the other. Individual response to measures taken to control the rapid spread of this disease depend on their knowledge and perceptions. Hence, we proposed to evaluate responses about COVID-19 among the health care workers (HCWs) as well as general public participants (GPPs).

Material And Methods: This was a cross-sectional, observational survey conducted during the peak of the pandemic. The 35-items questionnaire was prepared using Google forms and distributed through e-mails and social media.

Results: The 1,026 responses comprised of 558 HCWs (54.4%) and 468 GPPs (45.6%). The most reliable source of information was TV news for 43% GPPs, whereas it was HCWs/Local health authorities for 36.8% HCWs. HCWs had sufficient knowledge regarding COVID-19, while it was relatively low among GPPs (average correct response 65% and 53%, respectively). Intra-group analysis with respect to age, sex, qualification, and socioeconomic status showed that knowledge about mode of transmission by airborne aerosols was significantly low with respect to qualification among GPPs while younger age group (<40 years) HCWs had significantly more knowledge about mode of transmission and asymptomatic carriers. Paranoia of contracting the infection was significantly higher in GPPs with upper and middle socioeconomic status and younger HCWs.

Conclusion: HCWs had moderate level of knowledge, whereas GPPs had low to moderate knowledge, with large scope of improvement in both groups. Continued education, both at professional and community level will not only be helpful but also necessary to improve knowledge, avert negative attitudes and control the devastating pandemic.
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http://dx.doi.org/10.4103/joacp.JOACP_326_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812952PMC
July 2020

Safety and Efficacy of Sovateltide (IRL-1620) in a Multicenter Randomized Controlled Clinical Trial in Patients with Acute Cerebral Ischemic Stroke.

CNS Drugs 2021 01 11;35(1):85-104. Epub 2021 Jan 11.

Nizam's Institute of Medical Sciences, Hyderabad, India.

Background: Sovateltide (IRL-1620, PMZ-1620), an endothelin-B receptor agonist, has been previously shown to increase cerebral blood flow, have anti-apoptotic activity and produce neurovascular remodeling when administered intravenously following acute cerebral ischemic stroke in rats. Its safety and tolerability were confirmed in healthy human volunteers (CTRI/2016/11/007509).

Objective: Our objective was to determine the safety, tolerability and efficacy of sovateltide as an addition to standard of care (SOC) in patients with acute cerebral ischemic stroke.

Methods: A prospective, multicentric, randomized, double-blind, placebo-controlled study was conducted to compare the safety (primary objective) and efficacy (secondary objective) of sovateltide in patients with acute cerebral ischemic stroke. Adult males or females aged 18-70 years who had experienced a radiologically confirmed ischemic stroke within the last 24 h were included in the study. Patients with intracranial hemorrhage and those receiving endovascular therapy were excluded. Patients randomized to the sovateltide group received three doses of sovateltide (each dose 0.3 µg/kg) administered as an intravenous bolus over 1 min at an interval of 3 ± 1 h on day 1, day 3 and day 6 (total dose of 0.9 µg/kg/day). Patients randomized to the placebo group received an equal volume of saline. Every patient in both groups received SOC for stroke. Efficacy was evaluated using neurological outcomes based on National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index (BI) scores from day 1 through day 90. Quality of life was measured using the EuroQoL-5 Dimensions (EQ-5D) and Stroke-Specific Quality of Life (SSQoL) at 60 and 90 days of follow-up.

Results: A total of 40 patients with acute cerebral ischemic stroke were enrolled in this study, of whom 36 completed the 90-day follow-up. Patients received saline (n = 18; 11 male and 7 female) or sovateltide (n = 18; 15 male and 3 female) within 24 h of onset of stroke. The number of patients receiving investigational drug within 20 h of onset of stroke was 14/18 in the saline group and 10/18 in the sovateltide group. The baseline characteristics and SOC in both cohorts was similar. Sovateltide was well-tolerated, and all patients received complete treatment with no incidence of drug-related adverse events. Hemodynamic, biochemical or hematological parameters were not affected by sovateltide. Sovateltide treatment resulted in improved mRS and BI scores on day 6 compared with day 1 (p < 0.0001), an effect not seen in the saline group. Sovateltide increased the frequency of favorable outcomes at 3 months. An improvement of ≥ 2 points on the mRS was observed in 60 and 40% of patients in the sovateltide and saline groups, respectively (p = 0.0519; odds ratio [OR] 5.25). An improvement on the BI of ≥ 40 points was seen in 64 and 36% of the sovateltide and saline groups, respectively (p = 0.0112; OR 12.44). An improvement of ≥6 points on the NIHSS was seen in 56% of patients in the sovateltide group versus 43% in the saline group (p = 0.2714; OR 2.275). The number of patients with complete recovery (defined as an NIHSS score of 0 and a BI of 100) was significantly greater (p < 0.05) in the sovateltide group than in the saline group. An assessment of complete recovery using an mRS score of 0 did not show a statistically significant difference between the treatment groups. Sovateltide treatment resulted in improved quality of life as measured by the EQ-5D and SSQoL on day 90.

Conclusion: Sovateltide was safe and well-tolerated and resulted in improved neurological outcomes in patients with acute cerebral ischemic stroke 90 days post-treatment.

Trial Registration: The study is registered at CTRI/2017/11/010654 and NCT04046484.
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http://dx.doi.org/10.1007/s40263-020-00783-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872992PMC
January 2021

Clinical characteristics of epilepsy in resource-limited communities in Punjab, Northwest India.

Epilepsia Open 2020 Dec 1;5(4):582-595. Epub 2020 Nov 1.

NIHR University College London Hospitals Biomedical Research Centre UCL Queen Square Institute of Neurology London UK.

Objectives: To describe clinical characteristics of a community-based epilepsy cohort from resource-limited communities in Punjab, Northwest India.

Methods: The cohort was gathered following a two-stage screening survey. We cross-sectionally examined and followed up the cohort for one year. A panel of neurologists assigned seizure types, syndromes, and putative etiologies and categorized drug responsiveness.

Results: The cohort of 240 included 161 (67.1%) men, 109 (45.4%) illiterates and 149 (62.1%) unemployed. Current age was >18 years in 155 (64.6%) but age at epilepsy onset was <18 years in 173 (72.1%). Epilepsies due to structural and metabolic causes were diagnosed in 99 (41.3%), but syndromic assignments were not possible in 97 (40.4%). After one year, drug-resistant epilepsy was established in 74 (30.8%). Perinatal events (n = 35; 14.6%) followed by CNS infections (n = 32; 13.3%) and traumatic brain injury (n = 12; 5.0%) were common risk factors. Most of those with CNS infections (n = 19; 63.3%), perinatal antecedents (n = 23; 76.7%), and other acquired risk factors (n = 27; 90.0%) presented with epilepsy due to structural and metabolic causes. Perinatal events were the putative etiology for nearly 40.7% of generalized epilepsies due to structural and metabolic causes and 28.2% of all epilepsies with onset <10 years.

Significance: Existing classifications schemes should be better suited to field conditions in resource-limited communities in low- and middle-income countries. The finding of drug-resistant epilepsy in nearly at least a third in a community-based sample underscores an unmet need for enhancing services for this segment within healthcare systems. Perinatal events, CNS infections, and head injury account for a third of all epilepsies and hence preventative interventions focusing on these epilepsy risk factors should be stepped up.
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http://dx.doi.org/10.1002/epi4.12439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733663PMC
December 2020

Profile of cerebrovascular accidents in subjects with or without type 2 diabetes mellitus in intensive care units of tertiary care centre.

J Anaesthesiol Clin Pharmacol 2020 Apr-Jun;36(2):251-254. Epub 2020 Jun 15.

Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Background And Aims: Diabetes Mellitus (DM) is a modifiable and independent risk factor for stroke. As the clinical features, radiological profile, outcome and prognosis of the stroke in type 2 diabetic and non diabetic patients are significantly variable, we proposed to evaluate these variations of stroke in patients with or without Type 2 DM.

Material And Methods: A prospective study was conducted from January, 2011 to June, 2012 on in-hospital admitted diabetic and non diabetic patients presenting with stroke. Data was recorded on a predesigned Performa.

Results: A total of 150 cases were enrolled into the study. Out of these, 66% of patients had ischemic stroke and 34% of patients had hemorrhagic stroke. Type 2 diabetes mellitus was present in 52% patients. Ischemic stroke was significantly higher in diabetics than non diabetics ( = 0.007); however, hemorrhagic stroke was more in non diabetics. Mean age was significantly higher in diabetics ( = 0.04). CAD ( = 0.04), recurrent stroke ( = 0.006) had significant association with diabetes. Large vessel stroke was more common than small vessel stroke. Anterior circulation stroke was more common than posterior circulation stroke. There was significant improvement in morbidity and disability of the patients on follow up with treatment.

Conclusions: A greater incidence of anterior circulation ischemic stroke, and recurrent strokes occur in patients with DM.
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http://dx.doi.org/10.4103/joacp.JOACP_181_14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480310PMC
June 2020

Mortality implications and factors associated with nonengagement in a public epilepsy care initiative in a transient population.

Epilepsy Behav 2020 11 22;112:107438. Epub 2020 Sep 22.

NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3BG, United Kingdom; Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, United Kingdom; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede 2103 SW, Netherlands. Electronic address:

Background: Community-based, public care programs are a requisite to close the epilepsy treatment gap in disadvantaged communities in low- and middle-income countries (LMICs). Potential beneficiaries may, however, choose not to engage in these programs.

Aims: The aim of the study was to describe factors associated with and mortality consequences of nonacceptance of a public epilepsy care initiative.

Methods: In this cross-sectional study, we contacted 207 (36%) people out of 575 who screened positive for epilepsy during a population-based survey of 59,509 people. They were invited for neurological evaluation and care provision (including antiseizure medications (ASMs)) but chose not to engage. Structured questionnaires and qualitative interviews were conducted to determine reason for their nonengagement. Factors associated with nonengagement were evaluated by univariate and multivariate analysis. We conducted verbal autopsies for those who had died.

Results: Ten (5%) of the 207 individuals died since the initial screening; six with epilepsy-related causes. Of those who could be contacted (n = 48), 40 (19%) were confirmed to have epilepsy. Nonengaging individuals were likely to be older (odds ratio (OR): 1.02; 95% confidence interval (CI), 1.01, 1.11), locals (OR: 4.32; 95% CI, 1.55, 12.03), and earn less than US$ 78/month (OR: 3.6; 95% CI, 1.62, 8.06). Reasons for not engaging included a belief that epilepsy is inconsequential, loss of daily wages owing to healthcare facility visit and physical infirmity.

Conclusions: Nonacceptance of a community-based public epilepsy care initiative is associated with high premature mortality, mostly attributed to epilepsy-related causes. Older age, ethnic status, and economic deprivation are factors associated with nonacceptance, though the underlying reasons may be varied.
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http://dx.doi.org/10.1016/j.yebeh.2020.107438DOI Listing
November 2020

2019-NCoV: What Every Neurologist Should Know?

Ann Indian Acad Neurol 2020 Apr 17;23(Suppl 1):S28-S32. Epub 2020 Apr 17.

Department of Neurology, Dayanand Medical College, Ludhiana, Punjab, India.

The 2019 novel Corona Virus pandemic beginning from Wuhan, China primarily affects the respiratory tract but its has impacted clinical practice across a range of specialities including neurology. We review the bearing of the 2019 NCoV infection on neurological practice. Neurological manifestations are less common than respiratory manifestations, yet conspicuous, affecting nearly over a third of hospitalized individuals. These may be classified in to early - headache, dizziness, hyposmia and hypogeusia and late - encephalopathy. Rarely but surely, a very small proportion of infected individuals might present with stroke. Certain neurological conditions, including cerebrovascular disease in both China and Italy and dementia in Italy predispose to infection and more severe manifestations, requiring intensive care unit admission. There is no convincing evidence that the manifestations, course and outcome of various neurological disorders is impacted by 2019 nCoV infection. Concerns of an increased risk of febrile seizures offset by a reduced frequency of infection in the paediatric age group. Individuals with multiple sclerosis might potentially experience both true and pseudorelapses. Besides a direct effect, 2019 nCoV has tremendously affected neurological care by disrupting the continuity of care and the availability of neurological medicines worldwide. Neurologists should respond to this challenge by developing and sustaining innovative methods of providing care as well as alerting the society at large to adopt measures to contain the spread of 2019 nCoV.
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http://dx.doi.org/10.4103/aian.AIAN_210_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213032PMC
April 2020

Prevalence of Malnutrition in Parkinson's Disease and Correlation with Gastrointestinal Symptoms.

Ann Indian Acad Neurol 2019 Oct-Dec;22(4):447-452. Epub 2019 Oct 25.

Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Background: Parkinson's disease (PD) patients are at a higher risk of malnutrition with the overall prevalence estimated to be 3%-60%, but there are limited data in India regarding nutritional assessment of PD.

Aim: This study aims to assess nutritional status of PD patients and correlate the disease factors and gastrointestinal tract (GIT) symptoms with nutritional status.

Materials And Methods: The PD cohort was assessed for demographic factors, nutritional assessment was done by Mini-Nutritional Assessment (MNA) Scale, and GI symptoms were assessed by validated scales. Age- and gender-matched cohort controls were randomly selected to correlate the GIT symptoms influencing nutritional status. The study population was divided into two groups according to the MNA score; Group I malnourished/at risk of malnutrition (score <23.5) or Group II normal nutrition (>23.5). The two subgroups were then compared.

Results: We assessed 75 patients of PD and 35 age- and gender-matched controls. According to anthropometric criteria, 23% of the PD population was underweight, and according to biochemical assessment, 17.3% had hypoalbuminemia along with anemia. According to MNA scale, 12% were malnourished and 45.3% were at risk of malnutrition. Hence, a total of 57.3% patients in Group I (with abnormal nutrition) as compared to 14% of the controls were at risk of malnutrition while none was found to be malnourished. In our study, GIT symptoms, such as sialorrhea and dysphagia was reported by 29.3% each and constipation by 41.3% patients. While comparing GI symptoms within the two MNA groups, there was statistically significant relationship of all GI manifestations, sialorrhea ( = 0.041), dysphagia ( = 0.00081), and constipation ( = 0.0042) with malnutrition. There was no statistical significant difference between groups for age ( = 0.54), gender ( = 0.903), and duration of disease ( = 0.743).

Conclusions: The data suggest that about 45% of PD patients are at risk of malnourishment. MNA Score is a validated nutritional assessment tool and anthropometric or biochemical measures alone cannot identify all the malnourished population. PD patients at risk of malnutrition or malnourished do have symptoms of dysphagia, sialorrhea, and constipation as compared to PD patients with normal nutrition.
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http://dx.doi.org/10.4103/aian.AIAN_349_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6839331PMC
October 2019

Educational achievement, employment, marriage, and driving in adults with childhood-onset epilepsy.

Epilepsy Behav 2019 08 25;97:149-153. Epub 2019 Jun 25.

Department of Neurology, Dayanand Medical College and Hospital, Ludhiana - 141001, India. Electronic address:

Background: People with epilepsy (PWE) beginning in childhood often experience psychological and social hold-ups in addition to seizures. The hold-ups relate to education, employment, driving, and marriage.

Objective: The objective of this study was to document the impact of long-standing, childhood-onset epilepsy on sociopersonal accomplishments of adults pertaining to education, employment, marriage, and driving.

Methods: A prospective, questionnaire-based survey was undertaken in a hospital-based sample of PWE and their unaffected (by epilepsy) older siblings within the immediate/extended family unit.

Results: People with epilepsy were significantly more likely to abandon formal education after primary (6; 2.4% compared to none in controls) or secondary (69; 31.1% compared with controls 58; 26.1%) school, less likely to be currently married (97; 43.7%) when compared with their elder siblings (158; 71.2%) (P = 0.0001), and less likely to be currently employed (103; 46.4%) (P = 0.0001) or driving (111; 50%) (P = 0.0001) compared with the older same-gender siblings (employed: 148; 66.7%; driving: 165; 74.3%). In multivariate models, having epilepsy and age were associated with employment status, whereas age and education and employment status were associated with both marriage and driving.

Conclusion: Notwithstanding the influence of a number of socioeconomic and epilepsy-related variables, childhood-onset epilepsy stands apart in exerting a huge negative impact on educational achievement, employability, marital status, and driving in adulthood.
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http://dx.doi.org/10.1016/j.yebeh.2019.05.019DOI Listing
August 2019

Eight-and-a-half syndrome: A rare neuro-ophthalmologic syndrome of pontine infarction.

Neurol India 2019 Mar-Apr;67(2):611-612

Department of Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

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http://dx.doi.org/10.4103/0028-3886.257993DOI Listing
December 2019

Parkinson's Disease in Intensive Care Unit: An Observational Study of Frequencies, Causes, and Outcomes.

Ann Indian Acad Neurol 2019 Jan-Mar;22(1):79-83

Department of Pharmacology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Objective: To analyze the frequency, causes, and outcomes of admission to the Intensive Care Unit (ICU) among Parkinson's disease (PD) population so that preventive measures can be developed.

Methods: We prospectively observed patients with diagnosis of PD admitted to ICU from January 2014 to December 2016. Based on etiology for hospital admission, they were divided into two groups - related to PD (further divided into direct or indirect) or not associated with PD at all. Etiology for hospitalization was determined from history and investigational data. The primary outcome was death or discharge from the hospital. Factors contributing to ICU admission were analyzed by comparing these patients with a cohort of 50 PD patients admitted to the neurology ward during the same study period. All values were expressed as mean (standard deviation) and percentages using SPSS version 16.0.

Results: Fifty-three (36%) out of a total of 146 patients required ICU admission. Most common causes leading to admission in decreasing order of frequency were fever (34%), delirium (16%), falls (12%), encephalopathy (8%), gastrointestinal emergencies (6%); while direct disease-related severe dyskinesias were seen only in two patients (4%). 13.7% needed mechanical ventilation and mean duration of ventilation was 5.94 days with mortality rate of 20%. Significant factors predicting ICU admission, and thus, poor outcomes were age >65 years, history of previous admission within the last 12 months, delirium, and hypoalbuminemia. There was no significant association between the incidence of ICU admission and duration of disease or severity of the disease.

Conclusions: Poor outcome in PD patients is due to systemic causes, hence multidisciplinary teamwork may improve outcome in these patients.
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http://dx.doi.org/10.4103/aian.AIAN_44_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327702PMC
January 2019

Therapeutic Efficacy of Plasma Exchange in Neuromyelitis Optica.

Ann Indian Acad Neurol 2018 Apr-Jun;21(2):140-143

Department of Immunohaematology and Blood Transfusion, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Background: Neuromyelitis optica (NMO) is an inflammatory demyelinating disease that selectively affects the optic nerves and spinal cord and generally follows a relapsing course. Therapeutic plasma exchange (TPE) appears to be effective in patients with central nervous system inflammatory demyelinating disease who do not respond to first-line corticosteroid treatment.

Objective: We represent a retrospective review of the use of TPE in the treatment of an acute attack of NMO in five patients who failed to respond to initial immunomodulatory treatment.

Materials And Methods: We evaluated the effect of TPE on the degree of recovery from NMO. It was performed using a single volume plasma exchange with intermittent cell separator (Hemonetics Mobile Collection System plus) by femoral or central line access and scheduled preferably on alternate-day intervals from 8 to 10 days. Both subjective and objective clinical response to TPE was estimated, and final assessment of response was made at the time of the last TPE in the series.

Results: All patients were severely disabled before the initiation of TPE and they were female; with the mean age of these patients was 52.5 years (range = 36-69 years), the median age of NMO diagnosis was 49.4 years (range = 35-65 years), and the median duration of disease was 2.6 years (range = 0-5 years). Out of five patients, three had a history of bilateral optic neuritis, and all patients were anti-against protein aquaporin-4antibody positive. Totally 24 TPE procedures were performed on five patients, the mean time of start of TPE in the acute attack was 18.6 days. Patients were severely disabled at the initiation of TPE (range = expanded disability status scale 6.5-9), and improvement was observed early in the course of TPE treatment in most patients.

Conclusion: The present study provides clinical support for the importance of TPE in refractory acute attack in NMO. However, with new diagnostic technologies and increasing clinical awareness, we may see a more improved ways of TPE in these patients in the future; hence, TPE is more effective modality of treatment as it also removed the antibodies.
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http://dx.doi.org/10.4103/aian.AIAN_330_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6073968PMC
August 2018

Stroke profile and outcome between urban and rural regions of Northwest India: Data from Ludhiana population-based stroke registry.

Eur Stroke J 2017 Dec 27;2(4):377-384. Epub 2017 Jul 27.

Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, India.

Introduction: The objective of this study is to compare the clinical profile, risk factors, type and outcome of stroke patients in urban and rural areas of Punjab, India.

Methods: The primary data source was from the Ludhiana urban population-based stroke registry. The data of first-ever stroke patients with age ≥18 years were collected using WHO stepwise approach from all hospitals, general practitioners, physiotherapy and scan centres between 26 March 2011 and 25 March 2013.

Results: A total of 4989 patients were included and out of 4989 patients, 3469 (69%) were from urban areas. Haemorrhagic stroke was seen more in rural as compared to urban regions (urban 1104 (32%) versus rural 552 (36%); p = 0.01). There were significant differences seen in stroke risk factors; hypertension (urban 1923 (84%) versus rural 926 (89%); p = 0.001) and hyperlipidaemia (urban 397 (18%) versus rural 234 (23%); p = 0.001) between two groups. In the multivariable analysis the rural patients were more likely to be younger (age < 40 years) (OR: 1.82; 95% CI: 1.24-2.68; p = 0.002), Sikhs (OR: 2.57; 95% CI: 1.26-5.22; p = 0.009), farmers (OR: 9.41; 95% CI: 5.36-16.50; p < 0.001), housewives (OR: 2.71; 95% CI: 1.45-5.06; p = 0.002), and consumed alcohol (OR: 1.57; 95% CI: 1.19-2.06; p = 0.001) as compared to urban patients. In addition, use of imaging was higher in rural patients (OR: 1.99; 95% CI: 1.06-3.74; p = 0.03) as compared to urban patients.

Discussion And Conclusion: In this large cohort of patients, rural and urban differences were seen in risk factors and type of stroke. Stroke prevention strategies need to take into consideration these factors including regional sociocultural practices.
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http://dx.doi.org/10.1177/2396987317724052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453185PMC
December 2017

Clinical Features, Risk Factors, and Short-term Outcome of Ischemic Stroke, in Patients with Atrial Fibrillation: Data from a Population-based Study.

Ann Indian Acad Neurol 2017 Jul-Sep;20(3):289-293

Department of Neurology, Christian Medical College, Ludhiana, India.

Objectives: Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder associated with stroke. This study was done to describe risk factors, clinical features, and short-term outcomes of stroke patients with AF.

Materials And Methods: This study was a part of the Indian Council of Medical Research funded "Ludhiana urban population based Stroke Registry." Data were collected using WHO STEPS stroke method. All patients ≥18 years of age, who developed ischemic stroke between March 26, 2011, and March 25, 2013, were included in this study. Data about demographic details, clinical features, and risk factors were collected. The outcome was assessed at 28 days using modified Rankin scale (mRs) (good outcome: mRS ≤2; poor outcome >2). The statistical measures calculated were descriptive statistics, Chi-square test, Fischer's exact test, and independent -test.

Results: Of the total 7199 patients enrolled in the registry, data of 1942 patients who fulfilled inclusion criteria were analyzed, and AF was seen in 203 (10%) patients. AF patients were older (AF 62 ± 14 vs. non-AF 60 ± 15 years, = 0.01), had more hypertension (AF 176 [87%] vs. non-AF 1396 [80%], = 0.03), hyperlipidemia (AF 60 [32%] vs. non-AF 345 [21%], = 0.001), coronary artery disease (AF 60 [30%] vs. non-AF 195 [11%], < 0.0001), and carotid stenosis (AF 14 [7%] vs. non-AF 57 (3%), = 0.02). They had worse outcome (mRS >2; AF 90 [50%] vs. non-AF 555 [37%], = 0.001).

Conclusions: Ten percent of stroke patients had AF. They were older, had multiple risk factors and worse outcome. There was no gender difference in this large cohort.
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http://dx.doi.org/10.4103/aian.AIAN_16_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5586127PMC
September 2017

Dengue fever presenting as cauda equina syndrome.

BMJ Case Rep 2017 Jul 24;2017. Epub 2017 Jul 24.

Department of Radiology, Dayanand Medical College and Hospital, Ludhiana, India.

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http://dx.doi.org/10.1136/bcr-2017-221251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624003PMC
July 2017

Unseen face of varicella-zoster infection in adults.

Indian J Crit Care Med 2016 Dec;20(12):731-734

Department of Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Varicella infection is common in children caused by varicella-zoster virus (VZV). VZV is known to cause cerebral arterial vasculopathy and antibody-mediated hypercoagulable state leading to thrombotic complications in children. Such complications in adults are very rare. We report three cases that represent the unseen face of primary varicella infection in adults. Simultaneous involvement of cortical venous sinus thrombosis and deep vein thrombosis leading to clot in right atrium and pulmonary embolism in first case; cortical venous sinus thrombosis in second case; and deep vein thrombosis in third case. Early diagnosis and management can help prevent associated morbidity and mortality.
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http://dx.doi.org/10.4103/0972-5229.195713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5225775PMC
December 2016

Assessment of fatigue in Parkinson's disease: Indian perspective.

Ann Indian Acad Neurol 2016 Oct-Dec;19(4):451-455

Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Context: Fatigue is one of the most frequent nonmotor manifestations in Parkinson's disease (PD), having a major effect on quality of life but is not reported in Indian patients.

Aims: To evaluate the frequency of fatigue in a cohort of PD population and its correlation with disease.

Settings And Design: Fatigue Severity Scale (FSS) was translated and validated in local vernacular language. All patients of PD visiting neurology outpatient department of a tertiary care hospital.

Subjects And Methods: A total of 150 patients were screened, and 104 were included in this study. They were divided into - Group I with fatigue (score of >4 in each item) and Group II without fatigue.

Statistical Analysis: Data were analyzed by SPSS software version 20.0. Spearman correlation was used to evaluate the convergent validity of the FSS-Ind score with PD-related variables. The principal components analysis was applied to detect the domain structure of the FSS.

Results: Of the total 104 patients, 68 (65.3%) patients experienced fatigue. The duration of disease was significantly more ( = 0.021) in Group I (4.39 ± 3.8 years) than in the Group II (3.13 ± 1.6 years). The severity of disease also showed a positive correlation with fatigue with 50.9% patients in H and Y stage >3 experiencing fatigue. 69.1% patients of tremor phenotype experienced fatigue as compared to 32.3% of rigid phenotype. There was no relation of fatigue with age, gender, H and Y stage, levodopa equivalent dose and mean Unified PD Rating Scale motor III score.

Conclusions: Translated version of the FSS, FSS-Ind has high internal consistency and validity which supports its application as an effective tool in detecting fatigue in patients with PD. Fatigue in PD was related to duration and phenotype of the disease.
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http://dx.doi.org/10.4103/0972-2327.194419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5144464PMC
December 2016

The dilemma of arranged marriages in people with epilepsy. An expert group appraisal.

Epilepsy Behav 2016 08 8;61:242-247. Epub 2016 Jul 8.

Samvedana Epilepsy Group, Pune, India.

Introduction: Matrimony remains a challenging psychosocial problem confronting people with epilepsy (PWE). People with epilepsy are less likely to marry; however, their marital prospects are most seriously compromised in arranged marriages.

Aims: The aim of this study was to document marital prospects and outcomes in PWE going through arranged marriage and to propose optimal practices for counseling PWE contemplating arranged marriage.

Methods: A MEDLINE search and literature review were conducted, followed by a cross-disciplinary meeting of experts to generate consensus.

Results: People with epilepsy experience high levels of felt and enacted stigma in arranged marriages, but the repercussions are heavily biased against women. Hiding epilepsy is common during marital negotiations but may be associated with poor medication adherence, reduced physician visits, and poor marital outcome. Although divorce rates are generally insubstantial in PWE, divorce rates appear to be higher in PWE undergoing arranged marriages. In these marriages, hiding epilepsy during marital negotiations is a risk factor for divorce.

Conclusions: In communities in which arranged marriages are common, physicians caring for PWE are best-equipped to counsel them about their marital prospects. Marital plans and aspirations should be discussed with the family of the person with epilepsy in a timely and proactive manner. The benefits of disclosing epilepsy during marital negotiations should be underscored.
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http://dx.doi.org/10.1016/j.yebeh.2016.05.034DOI Listing
August 2016

Acute subdural hematoma secondary to cerebral venous sinus thrombosis: Case report and review of literature.

Asian J Neurosurg 2016 Apr-Jun;11(2):177

Department of Neurosurgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Cerebral venous sinus thrombosis is a rare type of stroke primarily affecting young women. Diagnosis is generally delayed or overlooked due to a wide spectrum of clinical symptoms. Subdural hematoma secondary to cerebral venous sinus thrombosis is very rare. We report a case of 40-year-old female with cerebral venous sinus thrombosis who presented to us with an acute subdural hematoma and subarachnoid hemorrhage besides venous infarct. Management of such patients is complicated due to the rarity of the condition and contraindication for the use of anticoagulation. We conducted a thorough literature search through PubMed and could find only nine cases of spontaneous subdural hematoma secondary to cerebral venous sinus thrombosis.
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http://dx.doi.org/10.4103/1793-5482.175632DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802952PMC
April 2016

Incidence, short-term outcome, and spatial distribution of stroke patients in Ludhiana, India.

Neurology 2016 Feb 6;86(5):425-33. Epub 2016 Jan 6.

From the Stroke Unit (J.D.P., P.K., S.J.V., P.M., G.M., A. Sharma), Department of Neurology, Christian Medical College and Hospital; Department of Neurology (G. Singh, R.B., B.S.P., M. Singla), Dayanand Medical College and Hospital; Departments of Community Medicine (S. Singh, C.J.S.) and Neurosurgery (S.S.G., S.S.J.), Christian Medical College; Arora Neuro Center (O.P.A.); Deep Hospital (A.K.D.); Sobti Neuro and Super Specialty Hospital (M.K.S.); Guru Teg Bahadur Charitable Hospital (H.S.); Shree Raghunath Hospital (M.K.); Deepak Hospital (T.N.S., T.A.); Mediciti Hospital (A. Saxena, G. Sachdeva); Delta Heart Center (J.S.G., R.S.B.); Heart Beat Diagnostic Center (A.G.); Ace Healthways (S.S.B.); Kuka Diagnostic Center (S.S.P.); Civil Hospital (G. Singh); ESIC Hospital (P.S.); Geology, Water Resources and Geoinformatic Division (P.K.L.), Punjab Remote Sensing Center, Ludhiana; and Non Communicable Diseases Division (M. Sharma), Indian Council of Medical Research, New Delhi.

Objective: To estimate the incidence, short-term outcome, and spatial distribution of stroke patients and to evaluate the completeness of case ascertainment in Ludhiana.

Methods: This population-based prospective cohort study was conducted in Ludhiana, Punjab, Northwest India. All first-ever stroke patients (≥18 years) were included between March 2010 and March 2013 using WHO Stepwise Approach Surveillance methodology from the city. Stroke patient data were obtained from hospitals, scan centers, and general practitioners, and details of deaths from the Municipal Corporation.

Results: Out of 7,199 stroke patients recruited, 3,441 were included in final analysis. The mean age was 59 ± 15 years. The annual incidence rate was 140/100,000 (95% confidence interval [CI] 133-147) and age-adjusted incidence rate was 130/100,000 (95% CI 123-137). The annual incidence rate for stroke in the young (18-49 years) was 46/100,000 (95% CI 41-51). The case fatality at 28 days was 22%. Patients above 60 years of age (p = 0.03) and patients who were managed in public hospitals had poor survival (p = 0.01). Hot spots for cumulative incidence were seen in central and southern parts of the city, and hot spots for poor outcome were seen in the outskirts of the city.

Conclusions: The incidence rates are similar to other studies from India. Stroke patient survival is poor in public hospitals. The finding of spatial analysis is of public health significance for stroke prevention and strengthening of stroke services.
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http://dx.doi.org/10.1212/WNL.0000000000002335DOI Listing
February 2016

Endovascular treatment for acute pulmonary embolism in neurological patient.

Int J Health Sci (Qassim) 2015 Jul;9(3):339-41

Associate Intensivist, Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana.

Among the spectrum of venous thrombo-embolic disease, acute pulmonary embolism accounts for the most life threatening manifestations with mortality exceeding 50%. It can affect many patient populations across various disciplines, hence immediate attention and aggressive treatment is crucial. With the advancement of technologies, various catheter-based devices are available to treat massive or submassive PE. In this paper we report two patients of acute pulmonary embolism with neurological issues where the life threatening emergency was successfully managed by utilizing endovascular directed thrombolytic reperfusion therapy.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4633197PMC
July 2015

Decompressive craniectomy in malignant middle cerebral artery infarct: An institutional experience.

Asian J Neurosurg 2015 Jul-Sep;10(3):203-6

Department of Neurosurgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.

Introduction: Decompressive craniectomy as a surgical treatment for brain edema has been performed for many years and for several different pathophysiologies, including malignant middle cerebral artery (MCA) infarct. The purpose of this article was to share author's experience with decompressive craniectomy in malignant MCA infarct with special emphasis on patients older than 60 years and those operated outside 48 h after onset of stroke.

Materials And Methods: Totally, 53 patients who underwent decompressive craniectomy after malignant MCA infarction between January 2012 and May 2014 at tertiary care hospital were analyzed for preoperative clinical condition, timing of surgery, cause of infarction, and location and extension of infarction. The outcome was assessed in terms of mortality and scores like modified Rankin scale (mRS).

Results: Totally, 53 patients aged between 22 and 80 years (mean age was 54.92 ± 11.8 years) were analyzed in this study. Approximately, 60% patients were older than 60 years. Approximately, 74% patients operated within 48 h (25 patients) had mRS 0-3 at discharge while 56% patients operated after 48 h had mRS 0-3 at discharge which is not significant statistically. 78% patients aged below 60 years had mRS 0-3 at discharge while only 38% patients aged above 60 years had mRS 0-3 at discharge which was statistically significant (P < 0.008).

Conclusion: Decompressive craniectomy has reduced morbidity and mortality especially in people aged below 60 years and those operated within 48 h of malignant MCA stroke though those operated outside 48 h of stroke also fare well neurologically, there is no reason these patients should be denied surgery.
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http://dx.doi.org/10.4103/1793-5482.161191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553732PMC
September 2015

Catheter-based therapy for acute pulmonary embolism: Lifesaving in a clinical dilemma!

Indian J Crit Care Med 2015 Jun;19(6):370-1

Head of Department of Critical Care Medicine, Dayanand Medical College, Ludhiana, Punjab, India.

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http://dx.doi.org/10.4103/0972-5229.158297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478687PMC
June 2015

Establishment of population-based stroke registry in Ludhiana city, northwest India: feasibility and methodology.

Neuroepidemiology 2015 5;44(2):69-77. Epub 2015 Mar 5.

Department of Neurology, Stroke Unit, Christian Medical College and Hospital, Ludhiana, India.

Background/aims: The Indian Council of Medical Research (ICMR) initiated the Task Force Project to evaluate the feasibility of conducting a population-based stroke registry in Ludhiana city, Punjab, Northwest India.

Methods: All first-ever, stroke patients over 18 years from the city of Ludhiana were included in the study from March 26th 2010 to March 25th 2011. Stroke information was collected based on the WHO STEPS approach from the participating hospitals, scan centres and doctors. Modified Rankin Scale (mRS) was administered by telephonic interview at 28 days after stroke. The information on stroke deaths was obtained from the Municipal Corporation (MC) office.

Results: A total of 905 first-ever stroke patients were documented. After excluding duplicate cases and patients from outside the city, 493 patients were included. The practical issues identified in data collection from these centres were reluctance to take informed consent, lack of willingness to share the data, difficulty to identify key persons from each centre, retrieving medical records from public hospitals and poor documentation of deaths in MC office.

Conclusion: Population-based stroke registry was feasible in an urban population with the above methodology. The issues related to feasibility were identified and necessary changes were made for the main phase of the registry.
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http://dx.doi.org/10.1159/000371520DOI Listing
January 2016
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