Publications by authors named "Birinder S Paul"

23 Publications

  • Page 1 of 1

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

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

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

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

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

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

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

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

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

Therapeutic plasma exchange in the treatment of myasthenia gravis.

Indian J Crit Care Med 2015 Jan;19(1):9-13

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

Aim: The aim of this study was to analyze the retrospective experience related to the indication, complication and outcome of Therapeutic Plasma Exchange (TPE) in Myasthenia gravis (MG). It is a well known autoimmune disease characterized by antibodies against the acetylcholine receptor (anti-ACHR) on the post synaptic surface of the motor end plate. Plasma exchange is the therapeutic modality well established in MG with a positive recommendation based on strong consensus of class III evidence.

Materials And Methods: A total of 35 patients of MG were submitted to a total of 41 cycles and 171 session of TPE. It was performed using a single volume plasma exchange with intermittent cell separator (Hemonetics) by Femoral or central line access and schedule preferably on alternate day interval. Immediate outcome was assessed shortly after each session and overall outcome at discharge.

Results: Total of 110 patients of MG who were admitted to our hospital during the study period of two years. 35 (31.8%) patients had TPE performed with mean age of 32 years (M:F = 2:1). The mean number of TPE session was 4.2 (SD±1.2), volume exchange was 2215 ml (SD±435); overall incidence of adverse reaction was 21.7%. All patients had immediate benefits of each TPE cycle. Good acceptance of procedure was observed in 78.3% of patients.

Conclusion: TPE may be considered as one of the treatment options especially in developing countries like ours as it is relatively less costly but as effective for myasthenic crisis as other modalities.
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http://dx.doi.org/10.4103/0972-5229.148631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296418PMC
January 2015

Snake bite and stroke: Our experience of two cases.

Indian J Crit Care Med 2014 Apr;18(4):257-8

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

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http://dx.doi.org/10.4103/0972-5229.130585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033865PMC
April 2014

Spectrum of neurological complications in HELLP syndrome.

Neurol India 2013 Sep-Oct;61(5):467-71

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

Background: Hemolysis (H), elevated liver enzymes (EL), and low platelets (LP), HELLP syndrome is the extended spectrum of severe preeclampsia and is associated with high mortality. A large proportion of mortality can be attributed to catastrophic central nervous system events.

Aims: The purpose of this study was to access the clinical manifestations, radiological abnormalities and outcome in patients of HELLP syndrome with neurological manifestations.

Setting: Obstetric unit and neurology intensive critical unit (ICU) of an academic medical center.

Study Design: Retrospective study.

Subjects And Methods: Case records of all obstetrical patients who were admitted between January 2012 and December 2012 were screened and data was collected from those patients who were diagnosed with HELLP syndrome with neurological complications. It was entered into a structured performa and analyzed using percentages .

Results: During the study period; 1,166 deliveries were conducted, 108 patients had pregnancy-induced hypertension (PIH); and of the 12 patients with HELLP, eight (66%) patients had neurological complications. The presenting neurological features were seizures (four), focal neurological deficits (two), and encephalopathy (two). Of the eight patients, in six patients neuroimaging showed features of posterior reversible encephalopathy syndrome (PRES), three of them had associated hemorrhage, and two patients had isolated intracranial hemorrhage. All except two were discharged home.

Conclusions: Neurological complications are not uncommon in patients with HELLP syndrome and a high index of suspicion is essential. Aggressive multidisciplinary approach is the key to reduce the morbidity and mortality.
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http://dx.doi.org/10.4103/0028-3886.121909DOI Listing
January 2014

Commentary.

J Neurosci Rural Pract 2013 Jul;4(3):331-2

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

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3821429PMC
July 2013

Sedation in neurological intensive care unit.

Ann Indian Acad Neurol 2013 Apr;16(2):194-202

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

Analgesia and sedation has been widely used in intensive care units where iatrogenic discomfort often complicates patient management. In neurological patients maximal comfort without diminishing patient responsiveness is desirable. In these patients successful management of sedation and analgesia incorporates a patient based approach that includes detection and management of predisposing and causative factors, including delirium, monitoring using sedation scales, proper medication selection, emphasis on analgesia based drugs and incorporation of protocols or algorithms. So, to optimize care clinician should be familiar with the pharmacokinetic and pharmacodynamic variables that can affect the safety and efficacy of analgesics and sedatives.
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http://dx.doi.org/10.4103/0972-2327.112465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3724073PMC
April 2013

Clinical predictors of mechanical ventilation in Guillain-Barré syndrome.

Neurol India 2012 Mar-Apr;60(2):150-3

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

Background: Patients with Guillain-Barré syndrome (GBS) require assisted ventilation frequently. However, no single factor can predict ventilator requirement.

Aims: To identify clinical variables which could predict the need for mechanical ventilation in GBS.

Settings And Design: Tertiary hospital-based retrospective and prospective study.

Materials And Methods: One hundred and thirty-eight GBS patients studied were divided into two groups ventilated (Group 1) and non-ventilated (Group 2). Parameters assessed included age, gender, associated illness(es), antecedent events, first symptom at onset, time from onset to bulbar involvement, confinement to bed and peak disability, upper limb power and reflexes at nadir, presence of facial weakness, neck muscle weakness and autonomic dysfunction.

Statistical Analysis: Multivariate predictors of ventilation were assessed using logistic regression analysis.

Results: There were 53 patients in Group 1 and 85 in Group 2. The mean age in the two groups was comparable. On bivariate analysis, simultaneous weakness of upper (UL) and lower (LL) limbs as the initial symptom (P<0.001); UL power less than Grade 3/5 at nadir (P<0.001); presence of neck and bulbar weakness (P<0.001); shorter duration from onset to bulbar weakness and confinement to bed (P=0.001) and bilateral facial involvement (P<0.01) were more frequently associated with the need for ventilation. Preserved reflexes in UL at nadir was significantly associated with absence of the need for mechanical ventilation (P<0.01). On multivariate analysis, factors independently associated with the need for mechanical ventilation included simultaneous motor weakness in UL and LL as the initial symptom (P=0.02), UL power<3/5 (Medical Research Council grade) at nadir (P=0.013) and presence of bulbar weakness (P<0.001). Preserved reflexes in the UL at nadir was independently associated with a lesser need for ventilation (P=0.001).

Conclusions: Comprehensive assessment of clinical features may predict the need for mechanical ventilation in patients of GBS.
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http://dx.doi.org/10.4103/0028-3886.96383DOI Listing
August 2012

Isaac's syndrome associated with myasthenia gravis and thymoma.

Indian J Med Sci 2010 Jul;64(7):320-4

Deparment of Neurology, Dayanad Medical College and Hospital, Ludhiana, Punjab, India.

A 65-year-old male developed fatigable weakness of ocular and bulbar muscle and positive anti-acetyl cholinesterase antibodies suggesting the diagnosis of myasthenia gravis. His condition responded to anticholinesterase and immunotherapy. However, 18 months later, he developed painful paresthesiae, muscle cramps with hyperhiderosis, and was diagnosed as having Isaac's syndrome (neuromyotonia, continuous muscle fibre activity). Computed tomography of the chest revealed a thymic mass, which was confirmed after surgery and histopathology as thymic cell carcinoma. The co-occurrence of myasthenia gravis and continuous muscle fiber activity should prompt the consideration of the occurrence of these disorders as one of the paraneoplastic manifestations, most often due to a thymic neoplasm. Both these conditions respond to treatment of underlying thymoma. This case is a very rare presentation worth reporting.
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http://dx.doi.org/10.4103/0019-5359.99866DOI Listing
July 2010
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