Publications by authors named "Man Mohan Mehndiratta"

57 Publications

Neurological disorders in India: past, present, and next steps.

Lancet Glob Health 2021 08 14;9(8):e1043-e1044. Epub 2021 Jul 14.

Department of Neurology, Janakpuri Super Speciality Hospital, New Delhi, India.

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http://dx.doi.org/10.1016/S2214-109X(21)00214-XDOI Listing
August 2021

Clinical management of chronic inflammatory demyelinating polyneuropathy (CIDP) in Europe and India: An exploratory study.

J Neurol Sci 2021 08 21;427:117507. Epub 2021 May 21.

Department of Neurology, Faculty of Medicine and University Hospital of Cologne, Germany. Electronic address:

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disorder causing inflammatory demyelination of peripheral nerves and consecutive disability. Diagnostic criteria and treatments are well established, but it is unknown how clinical practice may differ in different geographical regions. In this multicentre study, clinical management of CIDP was compared in 44 patients from Germany, India and Norway regarding diagnostic and therapeutic procedures. All centres used EFNS/PNS diagnostic criteria for CIDP but diagnostic workup varied regarding screening for infectious diseases, genetic testing and nerve biopsy. Intravenous immunoglobulin and prednisolone were the most common therapies in all centres with differences in indication and dosage. Patients from the Indian cohort were the most severely affected with less diverse therapeutic approaches, whereas psychological strain did not differ significantly from the two other cohorts. Our exploratory study discloses an unaddressed issue in management of CIDP that should be further investigated to optimise standard of care for CIDP worldwide.
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http://dx.doi.org/10.1016/j.jns.2021.117507DOI Listing
August 2021

Corona of Webinars: Therapeutic and toxic effects.

Ann Indian Acad Neurol 2021 Jan-Feb;24(1):101-103. Epub 2020 Jun 22.

Department of Pathology, Janakpuri Superspeciality Hospital, Janakpuri, New Delhi, India.

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http://dx.doi.org/10.4103/aian.AIAN_426_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061503PMC
June 2020

Sonographic pattern of median nerve enlargement in Hansen's neuropathy.

Acta Neurol Scand 2021 Aug 26;144(2):155-160. Epub 2021 Apr 26.

Karnataka Medical Research Foundation, Bangalore, India.

Objectives: Median nerve enlargement in leprosy seems to be more proximal than in carpal tunnel syndrome (CTS), but this feature has not been studied systematically. The aim of the study was to compare the sites of median nerve enlargement in patients with leprosy with that of patients with CTS.

Materials And Methods: Transverse sections of the median nerve were recorded from wrist to the mid-forearm (at distal wrist crease and at 2-cm: M1, 4-cm: M2, 6-cm: M3, 8-cm: M4 and 10-cm: M5, proximal to the distal wrist crease in the forearm) in patients with leprosy, CTS and healthy subjects using high-resolution ultrasound.

Results: Twenty-six patients each with leprosy and CTS were compared with healthy controls. Patients with leprosy included 6 (23.1%), 7 (26.9%), 7 (26.9%) and 6 (23.1%) patients with borderline tuberculoid, borderline-borderline, borderline lepromatous and lepromatous leprosy, respectively. Cross-sectional area (CSA) of median nerve was increased in all patients with leprosy as compared to healthy controls at all points of measurement. CSA was higher among patients with leprosy as compared to CTS at all points except at the wrist. In patients with leprosy, the maximal enlargement was noted 2-cm (M1) proximal to the wrist crease with gradual tapering of the CSA proximally (p < .05). In contrast, in patients with CTS the median nerve was maximally enlarged at the distal wrist crease (p<.05).

Conclusions: Median nerve enlargement 2-cm proximal to the distal wrist crease distinguishes leprosy from CTS. This important discriminating sign can be used at point-of-care to identify patients with leprosy.
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http://dx.doi.org/10.1111/ane.13432DOI Listing
August 2021

Stroke Care during the COVID-19 Pandemic: International Expert Panel Review.

Cerebrovasc Dis 2021 23;50(3):245-261. Epub 2021 Mar 23.

Department of Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte, Germany.

Background: Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions.

Summary: The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.
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http://dx.doi.org/10.1159/000514155DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8089455PMC
June 2021

Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study.

Inj Prev 2020 10 24;26(Supp 1):i125-i153. Epub 2020 Aug 24.

Department of Pharmacy, Adigrat University, Adigrat, Ethiopia.

Background: While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria.

Methods: In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced.

Results: GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes.

Conclusions: GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.
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http://dx.doi.org/10.1136/injuryprev-2019-043531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571362PMC
October 2020

IgG4-Related Disease with Selective Testicular Involvement- A Rare Entity: Case Report with Review of Literature.

Turk Patoloji Derg 2021 ;37(1):78-83

Department of Pathology, Janakpuri Super Speciality Hospital Society, NEW DELHI, INDIA.

Immunoglobin-G4 related disease (IgG4-RD) is an auto-immune inflammatory condition where patients present with a tumour-like mass that shows infiltration by plasma cell and subsequent fibrosis. It is a systemic condition that primarily involves the salivary glands, pancreas, kidneys, aorta, and retroperitoneum amongst other organs. Testicular involvement is a rare occurrence in this disease entity. A 55-year old male patient presented with the complaints of pain and swelling in the right scrotal region. Right-sided orchidectomy was carried out which on histopathology showed features suggestive of IgG4-RD which was later confirmed on immunohistochemistry. Whole body MRI revealed that no other organ was involved in the disease process in this patient. IgG4-RD has a variable clinical course and considerable overlap with its differentials. Imaging studies and serum IgG4 levels are neither confirmatory nor customarily diagnostic in every case. The only confirmatory diagnostic investigation is histopathological examination, which shows infiltration of IgG4+ plasma cells and fibrosis in the involved tissue. Whenever a mass-forming lesion with typical histomorphological features is encountered with involvement of multiple organs/anatomic sites, IgG4-related disease should be considered among the differentials, and clinicians of all disciplines should be familiar with this disease entity.
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http://dx.doi.org/10.5146/tjpath.2020.01493DOI Listing
October 2021

Morbidity and mortality from road injuries: results from the Global Burden of Disease Study 2017.

Inj Prev 2020 10 8;26(Supp 1):i46-i56. Epub 2020 Jan 8.

Department of Public Health, Mizan-Tepi University, Teppi, Ethiopia.

Background: The global burden of road injuries is known to follow complex geographical, temporal and demographic patterns. While health loss from road injuries is a major topic of global importance, there has been no recent comprehensive assessment that includes estimates for every age group, sex and country over recent years.

Methods: We used results from the Global Burden of Disease (GBD) 2017 study to report incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years for all locations in the GBD 2017 hierarchy from 1990 to 2017 for road injuries. Second, we measured mortality-to-incidence ratios by location. Third, we assessed the distribution of the natures of injury (eg, traumatic brain injury) that result from each road injury.

Results: Globally, 1 243 068 (95% uncertainty interval 1 191 889 to 1 276 940) people died from road injuries in 2017 out of 54 192 330 (47 381 583 to 61 645 891) new cases of road injuries. Age-standardised incidence rates of road injuries increased between 1990 and 2017, while mortality rates decreased. Regionally, age-standardised mortality rates decreased in all but two regions, South Asia and Southern Latin America, where rates did not change significantly. Nine of 21 GBD regions experienced significant increases in age-standardised incidence rates, while 10 experienced significant decreases and two experienced no significant change.

Conclusions: While road injury mortality has improved in recent decades, there are worsening rates of incidence and significant geographical heterogeneity. These findings indicate that more research is needed to better understand how road injuries can be prevented.
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http://dx.doi.org/10.1136/injuryprev-2019-043302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571357PMC
October 2020

Burden of injury along the development spectrum: associations between the Socio-demographic Index and disability-adjusted life year estimates from the Global Burden of Disease Study 2017.

Inj Prev 2020 10 8;26(Supp 1):i12-i26. Epub 2020 Jan 8.

School of Public Health, Auckland University of Technology, Auckland, New Zealand.

Background: The epidemiological transition of non-communicable diseases replacing infectious diseases as the main contributors to disease burden has been well documented in global health literature. Less focus, however, has been given to the relationship between sociodemographic changes and injury. The aim of this study was to examine the association between disability-adjusted life years (DALYs) from injury for 195 countries and territories at different levels along the development spectrum between 1990 and 2017 based on the Global Burden of Disease (GBD) 2017 estimates.

Methods: Injury mortality was estimated using the GBD mortality database, corrections for garbage coding and CODEm-the cause of death ensemble modelling tool. Morbidity estimation was based on surveys and inpatient and outpatient data sets for 30 cause-of-injury with 47 nature-of-injury categories each. The Socio-demographic Index (SDI) is a composite indicator that includes lagged income per capita, average educational attainment over age 15 years and total fertility rate.

Results: For many causes of injury, age-standardised DALY rates declined with increasing SDI, although road injury, interpersonal violence and self-harm did not follow this pattern. Particularly for self-harm opposing patterns were observed in regions with similar SDI levels. For road injuries, this effect was less pronounced.

Conclusions: The overall global pattern is that of declining injury burden with increasing SDI. However, not all injuries follow this pattern, which suggests multiple underlying mechanisms influencing injury DALYs. There is a need for a detailed understanding of these patterns to help to inform national and global efforts to address injury-related health outcomes across the development spectrum.
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http://dx.doi.org/10.1136/injuryprev-2019-043296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571356PMC
October 2020

Importance of etiology-based workup and diagnosis in acute multiple infarcts in multiple cerebral circulations.

Neurol India 2019 May-Jun;67(3):696-697

Department of Pathology, Janakpuri Super Speciality Hospital, Janakpuri, New Delhi, India.

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http://dx.doi.org/10.4103/0028-3886.263225DOI Listing
March 2020

Stroke-related education to emergency department staff.

Neurol India 2019 Jan-Feb;67(1):134-135

Department of Neurology, Virginia Commonwealth University, Virginia, USA.

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http://dx.doi.org/10.4103/0028-3886.253598DOI Listing
February 2020

Corticosteroids for chronic inflammatory demyelinating polyradiculoneuropathy.

Cochrane Database Syst Rev 2017 11 29;11:CD002062. Epub 2017 Nov 29.

MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, PO Box 114, Queen Square, London, UK, WC1N 3BG.

Background: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a progressive or relapsing and remitting paralysing illness, probably due to an autoimmune response, which should benefit from corticosteroid treatment. Non-randomised studies suggest that corticosteroids are beneficial. Two commonly used corticosteroids are prednisone and prednisolone. Both are usually given as oral tablets. Prednisone is converted into prednisolone in the liver so that the effect of the two drugs is usually the same. Another corticosteroid, dexamethasone, is more potent and is used in smaller doses. The review was first published in 2001 and last updated in 2015; we undertook this update to identify any new evidence.

Objectives: To assess the effects of corticosteroid treatment for CIDP compared to placebo or no treatment, and to compare the effects of different corticosteroid regimens.

Search Methods: On 8 November 2016, we searched the Cochrane Neuromuscular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for randomised trials of corticosteroids for CIDP. We searched clinical trials registries for ongoing trials.

Selection Criteria: We included randomised controlled trials (RCTs) or quasi-RCTs of treatment with any corticosteroid or adrenocorticotrophic hormone for CIDP, diagnosed by an internationally accepted definition.

Data Collection And Analysis: Two authors extracted data from included studies and assessed the risk of bias independently. The intended primary outcome was change in disability, with change in impairment after 12 weeks and side effects as secondary outcomes. We assessed strength of evidence using the GRADE approach.

Main Results: One non-blinded RCT comparing prednisone with no treatment in 35 eligible participants did not measure the primary outcome for this systematic review. The trial had a high risk of bias. Neuropathy Impairment Scale scores after 12 weeks improved in 12 of 19 participants randomised to prednisone, compared with five of 16 participants randomised to no treatment (risk ratio (RR) for improvement 2.02 (95% confidence interval (CI) 0.90 to 4.52; very low-quality evidence). The trial did not report side effects in detail, but one prednisone-treated participant died.A double-blind RCT comparing daily standard-dose oral prednisolone with monthly high-dose oral dexamethasone in 40 participants reported none of the prespecified outcomes for this review. The trial had a low risk of bias, but the quality of evidence was limited as it came from a single small study. There was little or no difference in number of participants who achieved remission (RR 1.11; 95% CI 0.50 to 2.45 in favour of monthly dexamethasone; moderate-quality evidence), or change in disability or impairment after one year (low-quality evidence). Change of grip strength or Medical Research Council (MRC) scores demonstrated little or no difference between groups (moderate-quality to low-quality evidence). Eight of 16 people in the prednisolone group and seven of 24 people in the dexamethasone group deteriorated. Side effects were similar with each regimen, except that sleeplessness was less common with monthly dexamethasone (low-quality evidence) as was moon facies (moon-shaped appearance of the face) (moderate-quality evidence).Experience from large non-randomised studies suggests that corticosteroids are beneficial, but long-term use causes serious side effects.

Authors' Conclusions: We are very uncertain about the effects of oral prednisone compared with no treatment, because the quality of evidence from the only RCT that exists is very low. Nevertheless, corticosteroids are commonly used in practice, supported by very low-quality evidence from observational studies. We also know from observational studies that corticosteroids carry the long-term risk of serious side effects. The efficacy of high-dose monthly oral dexamethasone is probably little different from that of daily standard-dose oral prednisolone. Most side effects occurred with similar frequencies in both groups, but with high-dose monthly oral dexamethasone moon facies is probably less common and sleeplessness may be less common than with oral prednisolone. We need further research to identify factors that predict response.
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http://dx.doi.org/10.1002/14651858.CD002062.pub4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6747552PMC
November 2017

The professional practice and training of neurology in the Asian and Oceanian Region: A cross-sectional survey by the Asian and Oceanian Association of Neurology (AOAN).

J Neurol Sci 2017 Nov 20;382:108-115. Epub 2017 Sep 20.

Stroke Consultant, The People 's 115 hospital - Pham Ngoc Thach School of Medicine, 527 Thanh Thai street, Dist. 10, HCM City, Vietnam. Electronic address:

Objective: To survey AOAN member countries regarding their organizational structure, postgraduate neurology training program, and resources for neurological care provision.

Methodology: A cross-sectional survey using a 36-item questionnaire was conducted among country representatives to AOAN from August 2015 to August 2016.

Results: A total of 18/20 AOAN member countries participated in the survey. All the countries have organized association with regular meetings, election of officers and neurology training program. In 9/18 countries, professionals other than neurologists were eligible for affiliation. In 11/18 countries, prior Internal medicine training (or equivalent postgraduate housemanship) is prerequisite to neurology program. Recertification examination is not a practice, but submission of CME is required in 7/18 countries to maintain membership. 12/18 countries publish peer-reviewed journals with at least 1 issue per year. Subspecialty training is offered in 14/18 countries. The ratio of neurologist to population ranges from 1:14,000 to as low as 1:32 million with 9/18 having <1 neurologist per 100,000 population. 6/18 countries have at least 1 specialized center solely for neurological diseases. In government-funded hospitals, the lag time to be seen by a neurologist and/or obtain neuroimaging scan ranges from 1day to 3months. All except one country have several medical- and lay- advocacy or support groups for different neurological conditions.

Implications: The data generated can be used for benchmarking to improve neurological care, training, collaborative work and research in the field of neurosciences among the AOAN member countries. The paper presented several strategies used by the different organizations to increase their number of neurologists and improve the quality of training. Sharing of best practices, academic networking, exchange programs and use of telemedicine have been suggested.
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http://dx.doi.org/10.1016/j.jns.2017.09.022DOI Listing
November 2017

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review.

Neuroepidemiology 2017 19;49(1-2):45-61. Epub 2017 Aug 19.

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

Background: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services.

Aims And Objectives: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care.

Methods: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included.

Results: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible.

Conclusion: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.
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http://dx.doi.org/10.1159/000479518DOI Listing
May 2018

The effect of sensory-level electrical stimulation of the masseter muscle in early stroke patients with dysphagia.

Neurol India 2017 Jul-Aug;65(4):743-745

Department of Microbiology, Janakpuri Superspecialty Hospital Society, Janakpuri, New Delhi, India.

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http://dx.doi.org/10.4103/neuroindia.NI_522_17DOI Listing
July 2019

Electrophysiological features of Gullian Barre syndrome: Newer insights.

Neurol India 2016 Sep-Oct;64(5):921-2

Department of Neurology, Janakpuri Super Speciality Hospital, New Delhi, India.

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http://dx.doi.org/10.4103/0028-3886.190277DOI Listing
November 2018

Bloodstream infections in NNICU: Blight on ICU stay.

Ann Indian Acad Neurol 2016 Jul-Sep;19(3):327-31

Department of Neurosurgery, G.B. Pant Hospital, New Delhi, India.

Background: Bloodstream infections (BSIs) are among the serious hospital-acquired infections. Data regarding BSIs in intensive care units (ICUs) are available but there is limited information regarding these infections in neurology and neurosurgery intensive care units (NNICUs).

Objectives: This study was conducted to find out the occurrence of BSI in NNICU patients of a tertiary care institute in India, along with the microbiological profile and risk factors associated with it.

Materials And Methods: One hundred patients admitted in the NNICU of a tertiary care hospital for more than 24 h were included in the study. After detailed history, blood samples were collected from catheter hub and peripheral vein of all patients for culture, followed by identification and antibiotic sensitivity testing of the isolates.

Results: Out of 100 patients, laboratory-confirmed bloodstream infection (LCBI) was detected in 16 patients. Five patients had secondary BSI, while 11 had central venous catheter (CVC)-related primary BSI. Gram-positive organisms constituted 64% of the isolates, especially coagulase-negative staphylococci and Staphylococcus aureus. Increased duration of CVC was a significant risk factor for catheter-related BSI (CR-BSI).

Conclusion: BSIs pose a significant burden for NNICU patients, and increased duration of catheter insertion is a significant risk factor for CR-BSI.
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http://dx.doi.org/10.4103/0972-2327.179983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4980954PMC
August 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

Transcranial Doppler: Techniques and advanced applications: Part 2.

Ann Indian Acad Neurol 2016 Jan-Mar;19(1):102-7

Department of Neurology, National University Hospital and YLL School of Medicine, National University of Singapore, Singapore.

Transcranial Doppler (TCD) is the only diagnostic tool that can provide continuous information about cerebral hemodynamics in real time and over extended periods. In the previous paper (Part 1), we have already presented the basic ultrasound physics pertaining to TCD, insonation methods, and various flow patterns. This article describes various advanced applications of TCD such as detection of right-to-left shunt, emboli monitoring, vasomotor reactivity (VMR), monitoring of vasospasm in subarachnoid hemorrhage (SAH), monitoring of intracranial pressure, its role in stoke prevention in sickle cell disease, and as a supplementary test for confirmation of brain death.
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http://dx.doi.org/10.4103/0972-2327.173407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4782524PMC
March 2016

Ventilators in ICU: A boon or burden.

Ann Indian Acad Neurol 2016 Jan-Mar;19(1):69-73

Institute of Liver and Biliary Sciences, New Delhi, India.

Background And Aims: Ventilator-associated pneumonia (VAP) is a major challenge in intensive care units (ICUs). This challenge is even more discernible in a neurological setting owing to the predispositions of patients. Data on VAP in the neurology and neurosurgery ICUs (NNICUs) are scanty in developing countries. This study was conducted to find out the occurrence of VAP, its risk factors, microbiological profile, and antibiotic resistance in patients admitted to the NNICU of a tertiary care institute in India.

Materials And Methods: Endotracheal aspirate and blood samples were collected from 100 patients admitted to the NNICU. Complete blood count, microscopic examination, culture and sensitivity testing of aspirate were done. Chest x-ray was also performed to aid in the diagnosis of VAP.

Results: Incidence rate of VAP was found to be 24%. Acinetobacter baumannii was the most common pathogen (24.3%) isolated from patients with VAP, and all of these isolates were sensitive to meropenem. Duration of mechanical ventilation (P < 0.0001) and associated comorbid illness (P = 0.005) were found to be significantly associated with VAP, and the duration of mechanical ventilation was found to be the only independent risk factor (P < 0.0001).

Conclusions: This study highlights the risks and microbiological perspective of ventilator use among neurology patients so that adequate preventive strategies can be adopted on time.
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http://dx.doi.org/10.4103/0972-2327.167706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4782556PMC
March 2016

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Lancet 2015 Dec 11;386(10010):2287-323. Epub 2015 Sep 11.

Background: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.

Methods: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol.

Findings: All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa.

Interpretation: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Funding: Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S0140-6736(15)00128-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4685753PMC
December 2015

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition.

Lancet 2015 Nov 28;386(10009):2145-91. Epub 2015 Aug 28.

Background: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

Methods: We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

Findings: Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

Interpretation: Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

Funding: Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S0140-6736(15)61340-XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673910PMC
November 2015

Plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy.

Cochrane Database Syst Rev 2015 Aug 25(8):CD003906. Epub 2015 Aug 25.

Department of Neurology, Janakpuri Superspecialty Hospital, C-2/B, Janakpuri, New Delhi, Delhi, India, 110058.

Background: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an uncommon progressive or relapsing paralysing disease caused by inflammation of the peripheral nerves. If the hypothesis that it is due to autoimmunity is correct, removal of autoantibodies in the blood by plasma exchange should be beneficial.

Objectives: To assess the effects of plasma exchange for treating CIDP.

Search Methods: On 30 June 2015, we searched the Cochrane Neuromuscular Disease Group Specialized Register, the Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL Plus, and LILACS. We also scrutinised the bibliographies of the trials, contacted the trial authors and other disease experts, and searched trials registries for ongoing studies.

Selection Criteria: Randomised controlled trials (RCTs) or quasi-RCTs in participants of any age comparing plasma exchange with sham treatment or no treatment.

Data Collection And Analysis: Two review authors independently selected the trials, extracted the data, and assessed risk of bias. Where possible the review authors combined data according to the methods of the Cochrane Neuromuscular Disease Review Group.

Main Results:

Primary Outcome Measure: one cross-over trial including 18 participants showed after four weeks, 2 (95% confidence interval (CI) 0.8 to 3.0) points more improvement on an 11-point disability scale with plasma exchange (10 exchanges over four weeks) than with sham exchange. Rapid deterioration after plasma exchange occurred in eight of 12 who had improved.

Secondary Outcome Measures: when we combined the results of this cross-over trial and a trial with 29 participants treated in a parallel-group design, there were 31 points (95% CI 16 to 45) more improvement on an impairment scale (maximum score 280) after plasma exchange (six exchanges over three weeks) than after sham exchange. There were significant improvements in both trials in an electrophysiological measure, the proximally evoked compound muscle action potential, after three or four weeks. Nonrandomised evidence indicates that plasma exchange induces adverse events in 3% to 17% of procedures. These events are sometimes serious. Both trials had a low risk of bias. A trial that showed no significant difference in the benefit between plasma exchange and intravenous immunoglobulin is included in the Cochrane review of intravenous immunoglobulin for this condition.

Authors' Conclusions: Moderate- to high-quality evidence from two small trials shows that plasma exchange provides significant short-term improvement in disability, clinical impairment, and motor nerve conduction velocity in CIDP but rapid deterioration may occur afterwards. Adverse events related to difficulty with venous access, use of citrate, and haemodynamic changes are not uncommon. We need more research to identify agents that will prolong the beneficial action of plasma exchange.
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http://dx.doi.org/10.1002/14651858.CD003906.pub4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6734114PMC
August 2015

Author response.

Neurology 2015 Mar;84(11):1185

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March 2015

Implications of female sex on stroke risk factors, care, outcome and rehabilitation: an Asian perspective.

Cerebrovasc Dis 2015 23;39(5-6):302-8. Epub 2015 Apr 23.

Vascular Neurology Fellow, McKim Hall, University of Virginia, Charlottesville, Va., USA.

Background: Stroke affects 16.9 million people annually and the greatest burden of stroke is in low- and middle-income countries, where 69% of all strokes occur. Stroke risk factors, mortality and outcomes differ in developing countries as compared to the developed world. We performed a literature review of 28 articles pertaining to epidemiology of stroke in Asian women, stroke risk factors, gender-related differences, and stroke outcomes.

Summary: Asian women differ from women worldwide due to differences in stroke awareness, risk factor profile, stroke subtypes, and social issues that impact stroke care. While Asian men have a higher incidence of stroke as compared to women overall, the long- and short-term outcomes in Asian women tend to be poorer. Both conventional and gender-specific risk factors contribute to stroke risk. Oral contraceptive use and addictions such as tobacco and alcohol are less prevalent among Asian women due to socio cultural differences. There is however, a much higher preponderance of pregnancy-related stroke and cardio-embolic stroke secondary to rheumatic heart disease and heavy use of chewing tobacco. The overall outcome is poor due to poor access to health care and lack of resources. Key Messages: Our review exposed the gaps in our knowledge about stroke risk factors and differences in stroke care provided to Asian women. While there are sociocultural barriers that impede the provision of immediate care to these stroke patients, much needs to be done by way of prevention of recurrent stroke and treatment of risk factors.
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http://dx.doi.org/10.1159/000381832DOI Listing
March 2016

Reply from author.

J Assoc Physicians India 2014 Oct;62(10):85

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October 2014

International Epilepsy Day - A day notified for global public education & awareness.

Indian J Med Res 2015 Feb;141(2):143-4

Department of Neurology, Janakpuri Superspeciality Hospital, New Delhi 110 058, India.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4418146PMC
http://dx.doi.org/10.4103/0971-5916.155531DOI Listing
February 2015

New strategy to reduce the global burden of stroke.

Stroke 2015 Jun 16;46(6):1740-7. Epub 2015 Apr 16.

From the National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies (V.L.F., R.K., R.B., P.P., A.T.), Faculty of Health and Environmental Sciences (P.H., M.A., E.R.), Information Technology (T.H.), Research and Innovation Office (M.P.), Knowledge Engineering and Discovery Research Institute (N.K.), Translation and Interpreting Department (I.C.), and Centre for Learing and Teaching (S.F.), Auckland University of Technology, Auckland, New Zealand; School of Psychology, University of Auckland, Auckland, New Zealand (S.B.-C.); Department of Neurology, University of Auckland, Auckland, New Zealand (P.A.B.); School of Public Health, University of Auckland, Auckland, New Zealand (B.A.); Department of Preventive and Social Medicine, Otago University, Dunedin, New Zealand (R.P.); Older People Care, Waitemata DHB, Auckland, New Zealand (Y.R.); Health Intelligence, Ministry of Health, Wellington, New Zealand (M.T.); Joinville Stroke Register, University of Joinville Region, Joinville, Brazil (N.C.); Hospital de Clinicas de Porto Alegre, Hospital Moinhos de Vento, Ministry of Health, Brazil (S.C.O.M.); Department of Neurology, Universidade Federal do Ceará, Sobral-Ceará, Brazil (L.E.T.A.F.); Stroke Foundation of Canada, Ottawa, Canada (P.L.); Department of Medicine and Health Policy, Management and Evaluation University of Toronto, Toronto, Canada (G.S.); Dijon Stroke Registry, EA4184, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France (M.G., Y.B.); Department of Neurology, Ruprecht Karl University Heidelberg, Heidelberg, Germany (W.H.); Janakpuri Super Speciality Hospital, New Delhi, India (M.M.M.); Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.); Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji, New Delhi, India (S.G.); All India Institute of Medical Sciences, New Delhi, India (V.P.); Stroke Foundation of Bengal, Kolkata, West Bengal, India (D.K.M

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http://dx.doi.org/10.1161/STROKEAHA.115.008222DOI Listing
June 2015

Asian and Oceanian Congress of Neurology 2014: intraregional and interregional synergy.

Neurology 2015 Mar;84(12):1269-71

From the Department of Neurology (M.M.M.), Janakpuri Superspeciality Hospital (N.S.G.), New Delhi, India; the Department of Neurology (R.K.), Institute of Health-Bioscience, Tokushima University, Kuramoto-cho, Tokushima, Japan; the Department of Medicine and Therapeutics (K.S.L.W.), Prince of Wales Hospital, Chinese University of Hong Kong; and the Department of Medicine and Geriatrics (P.-W.N.), United Christian Hospital, Hong Kong, China.

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http://dx.doi.org/10.1212/WNL.0000000000001388DOI Listing
March 2015
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