Publications by authors named "Jayantee Kalita"

222 Publications

NMR based CSF metabolomics in tuberculous meningitis: correlation with clinical and MRI findings.

Metab Brain Dis 2022 Jan 14. Epub 2022 Jan 14.

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India.

We report the potential role of H Nuclear Magnetic Resonance (NMR) based metabolomics in tuberculous meningitis (TBM). We also correlate the significant metabolites with clinical-radiological parameters. Forty-three patients with TBM were included, and their severity of meningitis was graded as stages I to III, and patients with positive Mycobacterium tuberculosis or its nucleic acid was considered as definite TBM. H NMR-based metabolomic study was performed on (CSF) samples, and the significant metabolites compared to healthy controls were identified. Outcome at three months was defined as death, poor and good based on the modified Rankin Scale. These metabolites were compared between definite and probable groups of TBM, and also correlated with MRI findings. About 11 metabolites were found to be significant for distinguishing TBM from the controls. In TBM, lactate, glutamate, alanine, arginine, 2-hydroxyisobutyrate, formate, and cis-aconitate were upregulated, and glucose, fructose, glutamine, and myo-inositol were downregulated compared to the controls. For differentiating TBM from the controls, the AUC of the ROC curve generated using these significant metabolites was 0.99, with a 95% confidence interval from 0.96 to 1, demonstrating that these metabolites were able to classify cases with good sensitivity and specificity. Lactate concentration in CSF correlated with hemoglobin, CSF glucose, and infarction. The outcome did not correlate with metabolomics parameters. NMR-based CSF metabolomics have a potential role in differentiating TBM from the controls.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11011-021-00860-yDOI Listing
January 2022

Renin, antidiuretic hormone (ADH), and ADH receptor levels in cerebral salt wasting associated with tuberculous meningitis.

Neurol Sci 2022 Jan 5. Epub 2022 Jan 5.

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow, Uttar Pradesh, India, 226014.

Background: To evaluate serum antidiuretic hormone (ADH), its receptors, and renin levels in cerebral salt wasting (CSW) in tuberculous meningitis (TBM).

Methods: Patients diagnosed with definite (n = 30) or probable TBM (n = 47) who developed hyponatremia (CSW, SIADH, or miscellaneous causes) were included. Sequential measurement of serum ADH, ADH-R, and renin activity by enzyme-linked immunosorbent assay was done and correlated with serum sodium level, urinary output, and fluid balance.

Results: Out of 79 TBM patients, CSW was observed in 36, SIADH in four, and miscellaneous hyponatremia in eight patients. CSW patients had a longer hospital stay (P < 0.001), lower GCS score (P < 0.007), higher MRC grade (P < 0.007), and a lower serum Na (P < 0.001) compared to non-CSW TBM patients. In severe CSW patients, serum ADH and ADH-R were correlated with hyponatremia and returned to baseline on correction; however, serum renin levels remained elevated. Serum ADH was related to hyponatremia but ADH-R and renin were not. ADH-R and renin levels did not significantly differ in CSW and SIADH.

Conclusion: CSW is the commonest cause of hyponatremia in TBM and correlates with disease severity. ADH is related to hyponatremia, but ADH receptor and renin are not.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10072-021-05681-6DOI Listing
January 2022

Recurrent Spontaneous Cerebrospinal Fluid Leaks at Multiple Levels.

Neurol India 2021 Nov-Dec;69(6):1828-1830

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Intracranial hypotension due to multiple spinal epidural cerebrospinal fluid (CSF) leak is rare and has multiple etiologies. These patients require epidural blood patches (EBP). We report a patient with recurrent paraplegia due to intracranial hypotension following recurrent epidural CSF leak. Cerebrospinal fluid leak was noted at D1, D10, D11, and L2 levels. Autologous epidural blood patch (EBP) at lower thoracic (3 ml) and lumbar region (4 ml) was performed. The patient developed paraplegia with sensory level at D2 for which 3 ml of EBP was done at D1 level after two months. Following EBP, the patient developed quadriplegia and root pain, which recovered in one month. The patient was free of symptoms for 18 months. Spinal epidural CSF leak should be suspected in patients with features of low pressure headache and recurrent paraplegia at multiple levels. Nuclear scintigraphy and CT myelography help in localizing the site of leak.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/0028-3886.333501DOI Listing
January 2022

A study of glutamate excitotoxicity in seizures related to tuberculous meningitis.

Epilepsy Res 2021 Dec 25;178:106789. Epub 2021 Oct 25.

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India; Department of Neurology, Director of Neuroscience and Head of Neurology Apolomedics Super Specialty Hospital Lucknow and Vivekananda Polyclinic & Institute of Medical Sciences, Lucknow, Uttar Pradesh 226007, India. Electronic address:

Background And Purpose: Glutamate is a neurotransmitter that regulates approximately half of the nervous system, along with the sensory system. Glutamate excitotoxicity is related to seizures but its role in TBM-related seizure has not been reported to our best knowledge. It is proposed to report plasma glutamate level and its receptors in TBM patients with seizures and correlate with the type of seizures, Magnetic Resonance Imaging (MRI) findings, and outcome.

Methods: TBM was diagnosed clinically with MRI as well as cerebrospinal fluid examination. TBM-related seizures have been categorized into early (< 1 month) or late (> 1 month) seizures. Six months outcome was defined using modified Rankin Scale as good (mRS ≤ 2) or poor (mRS > 2). Plasma glutamate was measured by ELISA, along with NR1, NR2A, and NR2B receptors using Real Time Polymerase Chain Reaction (RT-PCR) and have been correlated with seizure, MRI abnormalities, and outcome.

Results: A total of 29 (53.7%) patients developed seizures (early-09, late-20). Glutamate (P < 0.0001), NR1 (p ≤ 0.0001), NR2A (p ≤ 0.0001), and NR2B (p ≤ 0.0001) were higher than the controls. In TBM patients with seizures, plasma glutamate (p = 0.01), NR1 (p = 0.03) and NR2A (p = 0.001) were significantly higher than those without seizures. Plasma glutamate level and all three receptor genes expression were higher during seizures and improved on cessation of seizure compared to the baseline. These markers correlated well with MRI findings and determined the outcome. ROC curve was used to estimate the diagnostic accuracy of the markers. The result indicated that NR2A gene was the best predictor followed by glutamate and NR1 gene.

Conclusion: Our results highlight the role of glutamate and its receptors in TBM-related seizures and outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eplepsyres.2021.106789DOI Listing
December 2021

Predictors of fever response in tuberculous meningitis: A clinical, MRI and biomarker study.

Eur J Clin Invest 2022 Feb 2;52(2):e13701. Epub 2021 Nov 2.

Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

Background: Central nervous system (CNS) has a different immune surveillance system; therefore, fever at admission and timeline of fever response after antitubercular treatment (ATT) may follow a different course in CNS infection. We report the predictors of fever response in tuberculous meningitis (TBM) including the effect of tumour necrosis factor-α (TNF-α) in cerebrospinal fluid (CSF) and its gene expression at mRNA of peripheral blood mononuclear cells (PBMCs).

Methods: Fifty-seven patients with TBM were prospectively evaluated. Their clinical findings and severity of meningitis were recorded. The expression of TNF-α gene in PBMCs was quantified by real-time polymerase chain reaction and TNF-α concentration in CSF by cytokine bead array both in the patients and 14 matched controls.

Results: All the patients had history of fever for a median duration of 75 days. The admission temperature ranged between 37.2°C and 40°C and correlated with CSF cell counts (p < 0.05). Cranial MRI was abnormal in 54 (94.7%) and revealed exudates in 33(57.9%), hydrocephalus in 27(47.4%), infarction in 27(47.4%) and tuberculoma in 33(57.9%) patients. Fever subsided after a median duration of 18 (2 60) days of treatment. Twelve (21.8%) patients only became afebrile within 10 days. The expression of TNF-α gene correlated with CSF concentration of TNF-α (p = 0.02) and independently predicted duration of defervescence [adjusted hazard ratio 1.02 (95% CI 1.00-1.04; p = 0.01).

Conclusion: In the patients with TBM, defervescence takes longer time, and TNF-α gene expression predicts the duration of defervescence. Future studies are needed to evaluate the role of TNF-α-modifying drugs in TBM.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/eci.13701DOI Listing
February 2022

A Randomized Controlled Trial of High Rate rTMS Versus rTMS and Amitriptyline in Chronic Migraine.

Pain Physician 2021 09;24(6):E733-E741

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India.

Background: The patients with chronic migraine (CM) respond poorly to pharmacological agents including tricyclic antidepressants, beta-blockers, anticonvulsants, calcium channel blockers, flunarizine, and melatonin. The combination of 2 or more pharmacological agents has not shown better efficacy but increased side effects. High rate repetitive transcranial magnetic stimulation (rTMS) has been reported effective in episodic migraine and converts CM to episodic migraine. A combination of high rate rTMS with a pharmacological agent may be more effective compared to rTMS alone.

Objectives: We evaluate the efficacy and safety of 10 Hz rTMS compared to rTMS and amitriptyline in CM.

Study Design: Randomized controlled trial.

Setting: Tertiary care teaching institute in India.

Methods: Patients with CM as per International Classification of Headache Disorder third edition (ICHD-3) beta criteria were included whose age was between 18 years and 55 years. CM was defined if there were 15 headache days per month and at least 8 of these attacks having migraine characteristics for a period of more than 3 months. Patients with major psychiatric, other neurological or systemic disease, and those on migraine prophylaxis were excluded. The demographic details, frequency of headache attacks and headache days per month, migraine triggers, and associated symptoms were noted. The severity of headache was noted using a 0-10 Visual Analog Scale and the number of abortive drugs per month was noted. CM patients were randomly assigned to rTMS (group I) or rTMS and amitriptyline (group II). 10 Hz rTMS was applied using a figure of eight magnetic stimulation coil. The coil was placed over the left frontal cortex corresponding to the hot spot of the right abductor digiti minimi, which is approximately 7 cm lateral from the midline and 2 cm anterior to interaural line. The motor threshold was measured, and 70% of it was used for rTMS. Ten trains of 10 Hz rTMS, each train comprising of 60 pulses with an inter-train interval of 45 seconds were delivered in one session. Three such sessions were delivered on an alternate day and were repeated every month for 3 months. Amitriptyline was prescribed in a dose of 10mg, increased to 25mg after 2 weeks; thereafter increase in dose to 50 mg was optional. The primary outcome was > 50% reduction in headache days, and secondary outcomes were the reduction in severity of headache, abortive drug, and side effects.

Results: Forty-one patients were included in group I and 42 in group II, and their baseline characteristics were comparable. A higher proportion of group II patients had more than 50% reduction in headache days at 3 months (76.2 vs 31.7%; P < 0.001) compared to group I. More than 50% reduction in headache severity was also greater in group II compared to group I at 3 months (47.6% vs 19.5%; P = 0.01). Side effects were comparable, and none had to be withdrawn.

Limitations: A higher proportion of patients was shifted from group I to group II.

Conclusion: Combination of rTMS and amitriptyline is safe and more effective in CM compared to rTMS alone.
View Article and Find Full Text PDF

Download full-text PDF

Source
September 2021

Prediction models for mechanical ventilation and outcome in Guillain-Barré syndrome.

J Clin Neurosci 2021 Oct 14;92:131-135. Epub 2021 Aug 14.

Department of Neurology, AIIMS, Rishikesh, Uttarakhand, India.

Various prediction models have been formulated to predict the need for mechanical ventilation (MV). In this study, we compare the sensitivity and specificity of Erasmus GBS Respiratory Insufficiency Score (EGRIS) and Sharshar score with single breath count (SBC) at 2 Hz to assess their usefulness in predicting MV and functional outcome. The primary outcome was prediction of MV and relative usefulness of all three models based on sensitivity and specificity. The secondary outcome was functional recovery at 6 months using the cut off points for MV and functional outcome at 6months was assessed using Hughes scale and categorized as good (<2) and poor (≥2). The median age was 30 years, and 64 (69.6%) were males. The sensitivity and specificity of EGRIS score was 78.1% and 67.2%, Sharshar score was 75.0% and 64.1%, and SBC at 2 Hz was 78.1% and 75.0%. The area under the receiver operating curves was maximum for SBC at 2 Hz (0.86) compared to other models, although insignificant. EGRIS score < 5 had better functional recovery compared to those with score ≥ 5 (66% vs 34%, p = 0.001). Similarly, in Sharshar score, 23/59 (39%) with score ≥ 4 had good recovery compared to 36 (61%) with score < 4 (p = 0.01). All the three models have comparable predictive values for MV. Outcome prediction is the best with EGRIS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2021.07.060DOI Listing
October 2021

A Study of Diffusion Tensor Imaging in Hirayama Disease.

Neurol India 2021 Jul-Aug;69(4):889-893

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, Uttar Pradesh, India.

Background: Hirayama disease (HD) is a motor neuron disease and occasionally is associated with lower limb hyper-reflexia. Corticospinal tract dysfunction can be evaluated by diffusion tensor imaging (DTI), but there is paucity of study in HD.

Objective: We report corticospinal tract functions using DTI in the patients with HD and correlate with clinical findings.

Materials And Methods: The patients with HD diagnosed on the basis of clinical and electromyography findings were included. Their age, duration of illness, side of initial involvement, and progression were noted. Presence of lower limb hyper-reflexia, and cervical spine magnetic resonance imaging (MRI) findings were noted. Cranial MRI was done and DTI findings at internal capsule, cerebral peduncle, pons, and pyramid were noted.

Results: In total, 10 patients with HD and 5 matched controls were evaluated. The apparent diffusion coefficient (7.03 ± 0.27 vs 6.83 ± 0.36), fractional anisotropy (0.79 ± 0.04 vs 0.82 ± 0.05), axial diffusivity (5.08 ± 0.08 vs 5.04 ± 0.07), and radial diffusivity (3.79 ± 0.05 vs 3.76 ± 0.05) between HD patients and controls were not different in internal capsule. These values were also not significantly different in cerebral peduncle, pons, and pyramid. These values were also not significantly different between the severe and less severely affected sides. The fractional anisotropy did not correlate with lower limb hyper-reflexia (P = 1.00) and spinal cord atrophy (P = 0.60).

Conclusion: DTI study in HD patients did not reveal corticospinal tract involvement in brain.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/0028-3886.325338DOI Listing
September 2021

Cerebral Venous Sinus Thrombosis and Pachymeningitis in IgG4 Related Disease: Report of Two Cases and Review of Literature.

Ann Indian Acad Neurol 2021 May-Jun;24(3):432-436. Epub 2021 Jan 8.

Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/aian.AIAN_411_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370182PMC
January 2021

Neuropsychiatric Manifestations of Wilson Disease: Correlation with MRI and Glutamate Excitotoxicity.

Mol Neurobiol 2021 Nov 26;58(11):6020-6031. Epub 2021 Aug 26.

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, India.

This study aims to identify neuropsychiatric manifestations in neurological Wilson disease (NWD), and their correlation with MRI changes and glutamate excitotoxicity. Forty-three consecutive patients with NWD from a tertiary care teaching hospital were evaluated prospectively who fulfilled the inclusion criteria. The neuropsychiatric evaluation was done using Neuropsychiatric Inventory (NPI) battery that assesses 12 domains including delusion, hallucination, agitation/aggression, dysphoria/depression, anxiety, euphoria, apathy, disinhibition, irritability, aberrant motor activity, appetite change, and abnormal nighttime behavior. Cranial MRI was done using a 3 T machine, and locations of signal changes were noted including the total number of MRI lesions. Serum glutamate level was measured by a fluorescence microplate reader. Abnormal NPI in various domains and total NPI scores were correlated with MRI lesions, serum and urinary copper, and glutamate level. The median age of the patients was 16 years. Forty-one (48.8%) patients had cognitive impairment and 37 (86%) had movement disorder. Neurobehavioral abnormality was detected in all-commonest being agitation (90.7%) followed by appetite change (81.4%), elation (74.4%), irritability (69.8%), anxiety (67.4%), depression (65.1%), apathy (44.2%), night time abnormal behavior (32.6%), aberrant motor behavior (20.9%), delusions (16.3%), and hallucination (18.6%). The thalamic lesion was associated with depression, globus pallidus with depression and anxiety, caudate with anxiety and agitation, brainstem with irritability, and frontal cortex with apathy. Serum glutamate level was higher in NWD. NPI sum score correlated with MRI load and glutamate level. Varying severity of neurobehavioral abnormalities are common in the patients with NWD and correlate with the location of MRI lesion and glutamate level.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12035-021-02525-4DOI Listing
November 2021

A study of hyperhomocysteinemia in cerebral venous sinus thrombosis.

Indian J Med Res 2020 Dec;152(6):584-594

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Background & Objectives: Vegetarianism may result in low vitamin B12 and acquired hyperhomocysteinemia leading to thrombotic conditions such as cerebral venous sinus thrombosis (CVST). The clinico-radiological presentation and outcome of patients with hyperhomocysteinemia may be different from those without, but there is a paucity of information. This study was undertaken to find out the relationship of homocysteine (Hcy) with vitamin B12, folic acid and methyltetrahydrofolate reductase (MTHFR) mutation in the patients with CVST, and compare clinico-radiological severity and outcome of patients with and without hyperhomocysteinemia.

Methods: Ninety-six CVST patients in whom Hcy level was measured, were included, and their risk factors and neurological, magnetic resonance (MR) imaging and MR venography findings were noted. They were evaluated for prothrombotic conditions including Hcy, vitamin B12, folic acid and MTHFR 677C→T mutation. Three month outcome was categorized as death, poor and good.

Results: Seventy three per cent patients had risk factors; hyperhomocysteinemia in 52.1 per cent, protein S deficiency in 47.8 per cent, protein C deficiency in 19.4 per cent, MTHFR 677C→T mutation in 30.7 per cent, antinuclear antibody 11 per cent, and Factor V Leiden mutation in two per cent each. Thirty two per cent patients with hyperhomocysteinemia had no other thrombotic cause, and 22 per cent of them had either vitamin B12 and or folic acid deficiency only. The patients with hyperhomocysteinemia more frequently had vitamin B12 deficiency (70 vs. 13%), MTHFR 677C→T mutation (47.5 vs. 9.1%) and superior sagittal sinus thrombosis (78 vs. 56.5%) than normal Hcy group. The clinico-radiological severity and outcome were similar.

Interpretation & Conclusions: Hyperhomocysteinemia was an important correctable risk factor of CVST in patients from northern India, and majority of them had either low vitamin B12 level or MTHFR mutation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/ijmr.IJMR_2125_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8224164PMC
December 2020

Impact of anticoagulation status on recanalization and outcome of cerebral venous thrombosis.

J Clin Neurosci 2021 Jul 29;89:43-50. Epub 2021 Apr 29.

Apollo Medics Super-specialty Hospitals and Senior consultant neurologist, Vivekanand Polyclinic, and Institute of Medical science, Lucknow 226001, India.

Effective anticoagulation status may determine the recanalization and outcome of cerebral venous thrombosis (CVT). We report impact of anticoagulation status on recanalization and outcome of CVT. This is a retrospective study on 126 patients with CVT diagnosed on magnetic resonance venography (MRV). Their clinical features and risk factors were noted. The data were retrieved from a prospectively maintained registry, and international normalized ratio (INR) was noted after discharge till 3 months. All the patients were on acenocoumarol. Based on INR value, patients were categorized as Group A (effective anticoagulation INR within the therapeutic range or above) and Group B (ineffective anticoagulation INR > 50% below the therapeutic range). A repeat MRV at 3 months was done for recanalization. Outcome at 3 months was evaluated using modified Rankin Scale (mRS), and categorized as good (mRS ≤ 2) and poor (mRS 2 or more) 101(80.2%) patients were in group A and 25(19.8%) in group B. Their demographic, risk factors, magnetic resonance imaging (MRI) and MRV findings were comparable. On repeat MRV, recanalization occurred in 22/24(91.7%); 15(88%) in group A and 7(100%) in group B. Recanalization was independent of coagulation status. Seven (5.6%) patients died and 107(84.9%) had good outcome; 85(84.2%) in group A and 22(88%) in group B. Kaplan Meier analysis also did not reveal survival or good outcome benefits between the groups. In CVT, outcome and recanalization at 3 months are not dependent on coagulation status. Further prospective studies are needed regarding duration of anticoagulant and its impact on recanalization and outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2021.04.016DOI Listing
July 2021

Feasibility and usefulness of tele-follow-up in the patients with tuberculous meningitis.

Trans R Soc Trop Med Hyg 2021 10;115(10):1153-1159

Department of Neurology, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh 226007, India.

Background: Tuberculous meningitis (TBM) is the most severe form of tuberculosis and these patients need close follow-up because of a high frequency of complications. The coronavirus disease 2019 pandemic and lockdown resulted in an interruption in physical follow-up. In this situation, tele-follow-up may be helpful. We report the feasibility and usefulness of a telephonic follow-up in patients with TBM.

Methods: Patients with TBM managed by us from January 2017 to March 2020 were included from the TBM registry. Their presenting symptoms, and clinical and investigation findings were noted. We contacted these patients telephonically and their clinical status was obtained using a questionnaire. Based on the telephonic information, outcomes were categorized as death, poor or good. Patients with the new medical problems were advised as to relevant investigations and the reports were obtained through WhatsApp for prescribing treatment.

Results: The telephone numbers of 103 of 144 (71.5%) patients were viable. Twenty-seven (26.2%) patients died, 15 (19.7%) had a poor outcome and 61 (80.2%) had a good outcome. Twenty-five (32.9%) patients had new medical problems: 18 TBM related and 7 TBM unrelated. The medical problems of 23 patients could be managed telephonically and only 3 (4%) patients needed a physical visit. Sixty-five (85.5%) patients happily answered the questionnaire and willing responders needed a treatment modification more frequently than the reluctant responders (p=0.008). Patients on active antitubercular treatment needed treatment modification more frequently (80% vs 21.3%).

Conclusions: Tele-follow-up is feasible in 96% of TBM patients and is beneficial, cost effective and overcomes the barrier of distance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/trstmh/trab069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8194613PMC
October 2021

Rest or 30-Min Walk as Exercise Intervention (RESTOREX) in Myasthenia Gravis: A Randomized Controlled Trial.

Eur Neurol 2021 9;84(3):168-174. Epub 2021 Apr 9.

Department of Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Introduction: There is a lack of evidence about the usefulness of exercise or rest in myasthenia gravis (MG). This study is aimed to evaluate the efficacy and safety of exercise or rest in MG.

Methods: In a single-center open-labeled randomized controlled trial, the patients with mild to moderate MG were randomized to 30-min walk or rest in addition to the standard treatment. The primary endpoint was 50% improvement in the MG Quality of Life (MG-QOL15), and secondary endpoints were change in the Myasthenic Muscle Score (MMS), MG Activities of Daily Living (MGADL), grip strength, dose of acetylcholine esterase inhibitor and prednisone, 6-min walk test (6MWT), decrement in trapezius on the low-rate repetitive nerve stimulation test, and adverse events. The outcomes were defined at 3 months, by >50% improvement in these outcome parameters.

Results: Forty patients with MG were randomized to the exercise or rest arm. The 2 arms were matched for demographic and clinical parameters. The patients in the exercise arm had significantly better QOL evidenced by MG-QOL15 (p = 0.02). The secondary endpoints, distance covered in 6MWT (p = 0.007), were also better in the exercise arm without any adverse event.

Conclusion: Regular exercise for 30 min in mild and moderate MG improves quality of life and walking distance compared to rest and is safe.

Clinical Trial Registration: The clinical trial registration number is CTRI/2019/11/021869.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000513668DOI Listing
April 2021

Mechanism, spectrum, consequences and management of hyponatremia in tuberculous meningitis.

Wellcome Open Res 2019 29;4:189. Epub 2021 Mar 29.

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

Hyponatremia is the commonest electrolyte abnormality in hospitalized patients and is associated with poor outcome. Hyponatremia is categorized on the basis of serum sodium into severe (< 120 mEq/L), moderate (120-129 mEq/L) and mild (130-134mEq/L) groups. Serum sodium has an important role in maintaining serum osmolality, which is maintained by the action of antidiuretic hormone (ADH) secreted from the posterior pituitary, and natriuretic peptides such as atrial natriuretic peptide and brain natriuretic peptide. These peptides act on kidney tubules via the renin angiotensin aldosterone system. Hyponatremia <120mEq/L or a rapid decline in serum sodium can result in neurological manifestations, ranging from confusion to coma and seizure. Cerebral salt wasting (CSW) and syndrome of inappropriate secretion of ADH (SIADH) are important causes of hyponatremia in tuberculosis meningitis (TBM). CSW is more common than SIADH. The differentiation between CSW and SIADH is important because treatment of one may be detrimental for the other; evidence of hypovolemia in CSW and euvolemia or hypervolemia in SIADH is used for differentiation. In addition, evidence of dehydration, polyuria, negative fluid balance as assessed by intake output chart, weight loss, laboratory evidence and sometimes central venous pressure are helpful in the diagnosis of these disorders. Volume contraction in CSW may be more protracted than hyponatremia and may contribute to border zone infarctions in TBM. Hyponatremia should be promptly and carefully treated by saline and oral salt, while 3% saline should be used in severe hyponatremia with coma and seizure. In refractory patients with hyponatremia, fludrocortisone helps in early normalization of serum sodium without affecting polyuria or functional outcome. In SIADH, V2 receptor antagonist conivaptan or tolvaptan may be used if the patient is not responding to fluid restriction. Fluid restriction in SIADH has not been found to be beneficial in TBM and should be avoided.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12688/wellcomeopenres.15502.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372311.2PMC
March 2021

Is Palinopsia in Migraineurs a Phenomenon of Impaired Habituation of Visual Cortical Neurons?

Clin EEG Neurosci 2021 Mar 1:1550059421991707. Epub 2021 Mar 1.

30093Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Palinopsia in migraine has been reported recently, which may be due to the dysexcitability of visual cortical neurons. In this cross-sectional study, we report the correlation of neuronal dysexcitability with palinopsia using pattern shift visual evoked potential (PSVEP) in 91 migraineurs and 25 healthy controls. The presence of palinopsia was evaluated using a novel objective method, and revealed more frequent palinopsia in the migraineurs compared to the controls (53 of 91 [58.2%] vs 3 of 25 [12%];  < .001). Five consecutive blocks of PSVEP were recorded for the evaluation of sensitization and impaired habituation. Amplitudes of N75 and P100 in block 1 were considered for sensitization. Impaired habituation of N75 and P100 was considered if any amplitudes in blocks 2 to 5 were higher than block 1. Impaired habituation was more frequent in migraineurs compared with the controls, and was more marked in wave N75 (81.3% vs 32%;  < .001) than wave P100 (63.7% vs 44%;  = .12). Impaired habituations of wave N75 (81.7% vs 58.9%;  = .008) and wave P100 (71.7% vs 46.4%;  = .008) were more frequent in those with palinopsia compared with those without. There was a lack of suppression of P100 amplitude in block 3 in the palinopsia group compared to the controls. The duration of palinopsia correlated with the extent of impaired habituation of N75. It can be concluded that the impaired habituation of PSVEP waveforms is a biomarker of palinopsia in migraine.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1550059421991707DOI Listing
March 2021

Is cerebral salt wasting related to sympathetic dysregulation in tuberculous meningitis?

Neurosci Lett 2021 03 29;747:135671. Epub 2021 Jan 29.

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India. Electronic address:

Background: Cerebral Salt wasting (CSW) is common in Tuberculous Meningitis (TBM) and is suggested to be due to sympathetic dysregulation of renal blood supply but has not been proven.

Objective: To evaluate plasma Catecholamines in TBM patients with CSW and correlate with the markers of stress.

Materials And Methods: The diagnosis of TBM was based on clinical, CSF and MRI criteria. Catecholamines level was measured by LC-MS on admission, at the time of hyponatremia and on correction of hyponatremia. Catecholamine levels were correlated with clinical and laboratory markers of stress, hyponatremia and severity of CSW using pre-defined criteria.

Results: There were 24 patients with TBM (12 with CSW) and 12 controls. The median age of patients was 31 (18-75) years and 12 (50 %) were females. TBM patients with CSW had significantly higher levels of catecholamines compared to controls (p < 0.001). TBM patients with CSW had higher levels of norepinephrine than those without CSW (p = 0.034). Sequential studies revealed that dopamine and epinephrine increased at the time of hyponatremia and declined on its correction. Severity of TBM was related to dopamine (p = 0.04) and severity of CSW was related to epinephrine (p = 0.016).

Conclusion: CSW in TBM seems to be related to catecholamine dysregulation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.neulet.2021.135671DOI Listing
March 2021

Prolonged coma in scrub typhus: consider non-convulsive status epilepticus.

Trans R Soc Trop Med Hyg 2021 09;115(9):1091-1093

Currently working in Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Uttar Pradesh-221005, India.

Background: Scrub typhus is prevalent in the Tsutsugamushi belt and may manifest with meningoencephalitis and seizures. We report a patient with scrub typhus who had non-convulsive status epilepticus (NCSE).

Methods: A 50-y-old female with fever and altered sensorium for 5 d was diagnosed as scrub typhus based on serum IgM ELISA. She was on mechanical ventilation and received doxycycline and ceftriaxone, but did not improve until the third day of admission.

Results: An EEG revealed >2.5 Hz generalised epileptiform discharges, which were suppressed by intravenous lorazepam suggesting NCSE. Following valproate and levetiracetam, she became conscious and had a full recovery.

Conclusion: A scrub typhus patient recovers even after prolonged NCSE.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/trstmh/trab007DOI Listing
September 2021

Impact of COVID-19 pandemic and lockdown in a cohort of myasthenia gravis patients in India.

Clin Neurol Neurosurg 2021 03 13;202:106488. Epub 2021 Jan 13.

Department of Neurology, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226007, India.

Objective: Myasthenia gravis (MG) is characterized by fluctuating muscle weakness due to immune mediated damage of acetylcholine receptor (AchR). COVID-19 infection, mental stress and non-availability of drugs following lockdown may worsen myasthenic symptoms. We report the impact of COVID 19, and lockdown on the physical and mental health, and quality of sleep in a cohort of MG.

Methods: Thirty-eight MG patients were telephonically interviewed 2months after the declaration of lockdown in India. The difficulty in procuring drugs, complications, and worsening in the MG Foundation of America (MGFA) stage were noted. The patients were enquired about MG Quality of Life 15 (MGQOL15), MG Activity of Daily Living (MGADL), Hospital Anxiety and Depression Scale (HADS) and Pittsburgh Sleep Quality Index (PSQI) using a prefixed questionnaire. Their pre-COVID parameters were retrieved from our earlier trial data, which was completed 4months back. The scores of the above mentioned parameters before and after COVID were compared.

Results: Their median age was 45 years, and the median duration of treatment for MG was 4.5years. Eleven (28.9 %) patients were hypertensive and 3(7.9 %) diabetic. All were on prednisolone and 18(47.4 %) received azathioprine. None developed COVID, but three had other infections. Two patients needed hospitalization because of wrong medication in one and severe anxiety-insomnia in another. Following COVID19 and lockdown, MG patients had worsening in MGQOL15, MGADL, HADS and PSQI scores. Pittsburgh Sleep Quality Index score correlated with MGQOL15 and dose of acetylcholine esterase inhibitors.

Conclusion: COVID-19 and lockdown were associated with anxiety, depression, poor MGQOL and sleep especially in severe MG patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clineuro.2021.106488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803624PMC
March 2021

Insomnia matters in myasthenia gravis.

Sleep Med 2021 03 30;79:221-222. Epub 2020 Dec 30.

Department of Neurology, Vivekananda Polyclinic & Institute of Medical Sciences, Lucknow, 226014, India.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.sleep.2020.12.031DOI Listing
March 2021

Phonophobia and brainstem excitability in migraine.

Eur J Neurosci 2021 03 30;53(6):1988-1997. Epub 2020 Dec 30.

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Phonophobia in migraineurs may be due to lower hearing threshold (HT) and higher brainstem neuronal excitability. We report the correlation of phonophobia in migraineurs with HT, brain stem auditory evoked potential (BAEP) findings, and auditory triggers. Sixty-one migraineurs and 101 controls were included for HT, of whom 59 migraineurs and 31 controls had BAEP studies. Clinical details, migraine triggers, and headache frequency were noted. Hearing threshold was measured, and amplitudes of waves I to V of BAEP studies were measured. Migraineurs had lower HT compared with controls (41.61 ± 5.25 versus 45.39 ± 6.26 dB; p < 0.001) especially in chronic migraine (40.24 ± 4.81; p < 0.001). Hearing threshold correlated with headache frequency (p < 0.05) and auditory, visual, and tactile (p < 0.05) triggers. Hearing threshold was lower during headache (p < 0.001). Wave II, III, and IV amplitudes of BAEP were higher in migraineurs than the controls. Wave II (p < 0.05) and III (p < 0.05) amplitudes correlated with HT. Migraineurs have lower HT, especially in those having chronic migraine, ictal HT recording, and multiple sensory triggers. Higher amplitudes of BAEP waves in migraineurs and their relationship with the frequency of headache and HT suggest the sensitization of brainstem auditory neurons.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ejn.15078DOI Listing
March 2021

Standard versus sequential anti-tubercular treatment in patients with tuberculous meningitis: a randomized controlled trial.

Trans R Soc Trop Med Hyg 2021 01;115(1):94-102

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India.

Background: To compare the safety and efficacy of sequential anti-tubercular treatment (ATT) regimen with the standard regimen in tuberculous meningitis (TBM).

Methods: This single-centre, open-label, parallel group randomized controlled trial was conducted from May 2017 to June 2019 in India. Treatment-naïve patients with TBM fulfilling the inclusion criteria were randomized to four drug ATT regimens (rifampicin, isoniazid, ethambutol and pyrazinamide) administered either simultaneously (standard arm) or one after another (sequential arm) in a 1 : 1 ratio. The primary endpoint was drug-induced hepatitis (DIH) and the secondary endpoints were in-hospital death and disability at 3 and 6 months using a modified Rankin Scale.

Results: A total of 97 patients with TBM were recruited; 15 did not meet the inclusion criteria and 2 refused to participate. The median age of the patients was 26 y (range 15-75) and 37 (46.2%) were males. The patients in the sequential arm had fewer cases of DIH (20% vs 42.5%; p=0.03). The patients in the sequential arm had lower in-hospital mortality (2.5% vs 17.5%; p=0.025) and better 6-month outcomes (25.0% vs 50.0%; p=0.02) compared with the standard arm.

Conclusions: Sequential ATT was associated with a lower frequency of DIH, lower in-hospital mortality and better 6-month outcome.

Trial Registration: Clinical Trials Registry of India (ctri.nic.in) identifier: REF/2016/09/012214/CTRI/2017/10/010072.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/trstmh/traa144DOI Listing
January 2021

Starry Sky In Disseminated Tuberculosis.

Am J Med 2021 05 2;134(5):603-605. Epub 2020 Nov 2.

Department of Neurology, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjmed.2020.09.050DOI Listing
May 2021

Myasthenic crisis due to anxiety and insomnia during COVID -19 pandemic.

Sleep Med 2020 11 9;75:532-533. Epub 2020 Aug 9.

Department of Neurology, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226007, India.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.sleep.2020.08.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415338PMC
November 2020

Movement Disorder in Wilson Disease: Correlation with MRI and Biomarkers of Cell Injury.

J Mol Neurosci 2021 Feb 13;71(2):338-346. Epub 2020 Jul 13.

Department of Radiology, Sanjay Gandhi Post Graduate Medical Sciences, Lucknow, 226014, India.

To report the phenomenology of movement disorder (MD) in neurological Wilson disease (NWD), and correlate these with MRI, and biomarkers of oxidative stress, excitotoxicity, and inflammation. Eighty-two patients were included, and their phenomenology of MD was categorized. The severity of dystonia was assessed using the Burke-Fahn-Marsden score, and chorea, athetosis, myoclonus, and tremor on a 0-4 scale. The MRI changes were noted. Serum glutamate, cytokines, and oxidative stress markers were measured. Movement disorders were noted in 78/82 (95.1%) patients and included dystonia in 69 (84.1%), chorea in 31 (37.8%), tremor in 24 (29.3%), parkinsonism in 19 (23.2%), athetosis in 13 (15.9%), and myoclonus in 9 (11.0%) patients. Dystonia was more frequently observed in the patients with thalamic (76.8 vs 23.2%), globus pallidus (72.0 vs 28.0%), putamen (69.5 vs 30.5%), caudate (68.3 vs 31.7%) and brainstem (61.0 vs 39.0%) involvement, and tremor with cerebellar involvement (37.5 vs 5.2%). The median age of onset of neurological symptoms was 12 (5-50) years. WD patients had higher levels of malondialdehyde (MDA), glutamate, and cytokines (IL-6, IL-8, IL-10, and TNFα) and lower levels of glutathione and total antioxidant capacity (TAC) compared with the controls. Serum glutamate, IL-6, IL-8, and plasma MDA levels were increased with increasing neurological severity, while glutathione and TAC levels decreased. The severity of dystonia related to the number of MRI lesions. MD is the commonest neurological symptoms in WD. Oxidative stress, glutamate, and cytokine levels are increased in WD and correlate with neurological severity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12031-020-01654-0DOI Listing
February 2021

Noninvasive Ventilation in Myasthenia Gravis.

Neurol India 2020 May-Jun;68(3):648-651

Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Background: Myasthenic crisis (MC) is mainly managed by invasive ventilation (IV) which is associated with prolonged intubation and ventilation and respiratory complication.

Aim: To report the characteristics of patients who can be managed by noninvasive ventilation (NIV) and also predictors of NIV in myasthenia gravis (MG).

Patients And Methods: In a retrospective study at tertiary care hospital in India during 2013-2015, patients with MG were evaluated. MG was diagnosed by clinical, repetitive nerve stimulation, and acetylcholine receptor antibodies. Patients were intubated based on arterial blood gas criteria. Demographic variables, Myasthenia Gravis Foundation of America (MGFA) score, and clinical examination were done. NIV success was defined if patient did not need mechanical ventilation (MV) in the management or for 72 h after extubation and was considered unsuccessful if patients required MV during this period.

Results: Twenty three out of 68 MG patients had MC, 16 patients were given NIV, and 16 IV. Median intensive care unit stay was 18 (4-94) days. Predictors of crisis were infection, bulbar weakness, MGFA > 2b, and history of crisis. NIV was the only respiratory support in 7 patients and reintubation was prevented in 3 patients. NIV failed in 9 patients. Comparison of NIV success and failure did not reveal any difference.

Conclusion: With NIV, intubation was prevented in 7 and reintubation in 3 patients. NIV has lower incidence of complications. NIV should be tried in patients with impending MC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/0028-3886.289001DOI Listing
June 2021

Inclusion of Mechanical Ventilation in Severity Staging of Tuberculous Meningitis Improves Outcome Prediction.

Am J Trop Med Hyg 2020 08 21;103(2):689-695. Epub 2020 May 21.

Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Patients with tuberculous meningitis (TBM) in any stage of the British Medical Research Council (BMRC) scale, if requiring mechanical ventilation (MV), are likely to have a poor outcome. We report the usefulness of BMRC, BMRC-MV, and BMRC-hydrocephalus (BMRC-HC) staging, and Haydarpasa Meningitis Severity Index (HAMSI) scoring in predicting the outcome of TBM. One hundred ninety-seven TBM patients were analyzed from a prospectively maintained TBM registry. The severity of meningitis was categorized using BMRC (stages I-III), BMRC-MV (I-IV [MV patients were grouped as stage IV]), and BMRC-HC (I-IV [BMRC stage III patients with hydrocephalus were grouped as stage IV]). Haydarpasa Meningitis Severity Index scoring was categorized as < 6 and ≥ 6. The outcome was defined at 6 months using the modified Rankin Scale (mRS) as death, poor (mRS score > 2), or good (mRS score ≤ 2). Forty-nine (25%) patients died. BMRC-mechanical ventilation stage IV had the highest predictive value for defining death, with a sensitivity of 88% and a specificity of 86%. About 81.7% of surviving patients had a good outcome at 6 months. BMRC-mechanical ventilation stages I-III had the highest predictive value for defining good outcome, with a sensitivity of 93% and a specificity of 61%. In TBM, BMRC-MV staging has the best predictive value for defining death and disability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4269/ajtmh.20-0077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410456PMC
August 2020

Significance of recanalization of sinuses and resolution of parenchymal lesion in cerebral venous sinus thrombosis.

J Clin Neurosci 2020 Jul 27;77:175-180. Epub 2020 Apr 27.

Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India.

In cerebral venous sinus thrombosis (CVST), the degree of recanalization may determine resolution of parenchymal lesion and clinical outcome. The aim of our study was to evaluate the relationship of recanalization with resolution of MRI lesion and clinical outcome. The patients with CVST diagnosed on the basis of magnetic resonance venography (MRV) were included prospectively. Risk factors, clinical features, and MRI and MRV findings were noted. MRI and MRV were repeated at 6 months and the change in parenchymal lesion and grade of recanalization (I, II, III) were noted. Patients were evaluated clinically at three and six months. Complete recovery was considered if modified Rankin Scale (mRS) score was 0. Thirty-three CVST patients were included, 12 (36.4%) of whom were females. Recanalization occurred in 29 (87.9%), which was complete (grade III) in 6 (21%). Sigmoid sinus (52%) recanalized more frequently. Resolution of parenchymal lesion on repeat MRI occurred in 13.3% (4/30) patients, and they had no sequelae. Degree of recanalization was not related to resolution of neurological sequelae, MRI lesion at follow up and burden of thrombosis at baseline. Varying degree of recanalization occurred in 87.9% patients with CVST, and resolution of parenchymal lesion occurred in 13.3%. Clinical outcome however was not related to recanalization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2020.04.112DOI Listing
July 2020

Oxidative stress and ER stress may contribute to drug-induced hepatitis in tuberculous meningitis.

J Neurol Sci 2020 Jul 11;414:116825. Epub 2020 Apr 11.

Department of Biostatistics & Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Background: Study of oxidative stress and endoplasmic reticulum (ER) stress markers in drug induced hepatitis (DIH) associated with tuberculous meningitis (TBM) has not been done. Such a study may provide information on the role of stress in DIH.

Objective: To report the role of oxidative stress and ER stress in DIH associated with TBM and their effect on outcome of patients.

Method: Demographic and clinical information about TBM patients including stage of TBM, duration of illness, Magnetic Resonance Imaging (MRI) findings, laboratory markers, oxidative and ER stress markers were recorded. These markers were compared in patients with and without DIH. Survival analysis between DIH and no DIH patients was done using Kaplan - Meier analysis and the predictors of outcome were evaluated using Cox regression analysis.

Results: Out of 92 patients with TBM, 36 (39.1%) developed DIH. There was significant alteration in oxidative stress and ER stress markers compared to baseline and following recovery from DIH. At the time of discharge 58.3% patients with DIH had poor outcome (mRS >2). Kaplan-Meier analysis of survival revealed that the proportion of the patient's survival was significantly higher in non DIH group as compared to DIH group (89.3% vs. 61.1%, p = .006).

Conclusion: Oxidative stress and ER stress are related with the severity of TBM, its outcome and mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jns.2020.116825DOI Listing
July 2020

Vitamin B12 deficiency presenting as acute febrile encephalopathy and retinopathy.

Postgrad Med J 2021 Mar 26;97(1145):141-142. Epub 2020 Mar 26.

Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/postgradmedj-2020-137520DOI Listing
March 2021
-->