Acute motor-sensory axonal neuropathy after cervical spine surgery

The authors report the case of a 55-year-old man who presented with acute motor-sensory axonal neuropathy (AMSAN), a variant of Guillain-Barré syndrome with a poor prognosis, immediately after surgery for resection of a cervical chondroma. A misdiagnosis of spinal cord shock due to an acute surgical or vascular postoperative complication was initially made in this patient. Nevertheless, there was continuous transient improvement that was followed by progressive worsening, and further investigation was necessary. The diagnosis of AMSAN, associated with acute colitis caused by Helicobacter pylori, was made based on neurophysiological examinations and colonoscopy. Interestingly, the patient also developed nephrotic syndrome, which was thought to be a further complication of the autoimmune reaction. Delayed administration of immunoglobulins (400 mg/kg/day), mesalazine (800 mg 3×/day), and meropenem (3 g/day) was used to treat the Helicobacter infection and the autoimmune reaction, leading to restoration of renal function and slight neurological improvement. The patient's general condition and neurological status improved slightly, but he remained seriously disabled (Frankel Grade C). This case demonstrates that a new onset of neurological symptoms in the early postoperative period after spine surgery could be related to causes other than iatrogenic myelopathy, and that an early diagnosis can reduce neurological sequelae, leading to a better outcome.

Ayurvedic medicinal plants for Alzheimer's disease: a review

Alzheimer's disease is an age-associated, irreversible, progressive neurodegenerative disease that is characterized by severe memory loss, unusual behavior, personality changes, and a decline in cognitive function. No cure for Alzheimer's exists, and the drugs currently available to treat the disease have limited effectiveness. It is believed that therapeutic intervention that could postpone the onset or progression of Alzheimer's disease would dramatically reduce the number of cases in the next 50 years. Ayurvedic medicinal plants have been the single most productive source of leads for the development of drugs, and over a hundred new products are already in clinical development. Indeed, several scientific studies have described the use of various Ayurvedic medicinal plants and their constituents for treatment of Alzheimer's disease. Although the exact mechanism of their action is still not clear, phytochemical studies of the different parts of the plants have shown the presence of many valuable compounds, such as lignans, flavonoids, tannins, polyphenols, triterpenes, sterols, and alkaloids, that show a wide spectrum of pharmacological activities, including anti-inflammatory, anti-amyloidogenic, anti-cholinesterase, hypolipidemic, and antioxidant effects. This review gathers research on various medicinal plants that have shown promise in reversing the Alzheimer's disease pathology. The report summarizes information concerning the phytochemistry, biological, and cellular activities and clinical applications of these various plants in order to provide sufficient baseline information that could be used in drug discovery campaigns and development process, thereby providing new functional leads for Alzheimer's disease.

Influence of Withania somnifera on obsessive compulsive disorder in mice

OBJECTIVE

To study the influence of methanolic and aqueous extract of Withania somnifera (W. somnifera) root on the marble-burying behavior of mice a well-accepted model of obsessive compulsive behavior.

METHODS

Mice were divided in different groups (n = 6). Fluoxetine (5, 10, 15 mg/kg), (10, 25, 50, 100 mg/kg) and methanolic extract W. somnifera (MEWS) (10, 25, 50, 100 mg/kg) were administered i.p. 30 min. prior to the assessment of marble burying behavior and locomotor activity. The control group received vehicle of the extract.

RESULTS

Administration of aqueous extracts W. somnifera (AEWS) and MEWS (50 mg/kg) successively decreased the marble burying behavior activity without affecting motor activity. This effect of AEWS and MEWS was comparable to standard fluoxetine, ritanserin and parachlorophenylalanine.

CONCLUSIONS

W. somnifera extract is effective in treating obsessive compulsive disorder.

Characterizing cognitive deficits and dementia in an aging urban population in India

Rapid rise in the population of older adults in India will lead to the need for increased health care services related to diagnosis, management, and long-term care for those with dementia and cognitive impairment. A direct approach for service provision through memory clinics can be an effective, successful, and sustaining means of delivering specialized health care services. We have established a memory clinic in Mumbai, India by employing the diverse clinical skills available in Indian academic institutions, diagnostic and research expertise of clinicians and psychologists, and the support of the U.S. National Institutes of Health. Our project involved recruitment of patients, clinical and neuropsychological assessment, and standardized diagnostic procedures, demonstrating the feasibility of using research methods to develop a memory clinic. In this paper, we describe the development of a community-based memory clinic in urban India, including linguistic and cultural factors and present detailed results, including diagnostic characterization, on 194 subjects with various stages of cognitive deficits. Our findings support the feasibility of developing a memory clinic in a public hospital and successful use of research diagnostic criteria to categorize cognitive deficits observed in this population, which may be used to inform the development of other such clinics.

Functional MRI applications in epilepsy surgery

Functional magnetic resonance imaging (fMRI) is a non-invasive neuroimaging technique that has grown rapidly in popularity over the past decade. It is already prevalent in psychology, cognitive and basic neuroscience research and is being used increasingly as a tool for clinical decision-making in epilepsy. It has been used to determine language location and laterality in patients, sometimes eliminating the need for invasive tests. fMRI can been used pre-surgically to guide resection margins, preserving eloquent cortex. Other fMRI paradigms assessing memory, visual and somatosensory systems have limited clinical applications currently, but show great promise. Simultaneous recording of electroencephalogram (EEG) and fMRI has also provided insights into the networks underlying seizure generation and is increasingly being used in epilepsy centres. In this review, we present some of the current clinical applications for fMRI in the pre-surgical assessment of epilepsy patients, and examine a number of new techniques that may soon become clinically relevant.

Matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 expression in early focal cerebral infarction following urokinase thrombolysis in rats

Activity of matrix metalloproteinase-9 increases following cerebral ischemia/reperfusion, and is associated with cerebral microvascular permeability, blood-brain barrier destruction, inflammatory cell infiltration and brain edema. Matrix metalloproteinase-9 also likely participates in thrombolysis. A rat model of middle cerebral artery infarction was established by injecting autologous blood clots into the internal carotid artery. At 3 hours following model induction, urokinase was injected into the caudal vein. Decreased neurological severity score, reduced infarct volume, and increased expression of matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 were observed in the cerebral cortex 24 hours after urokinase thrombolysis. These results suggest that urokinase can suppress damage in the acute-early stage of cerebral infarction.

Intrathecal synthesis in particular types of multiple sclerosis

AIM

The aim of this study was to determine whether there were any differences in intrathecal synthesis of immunoglobulin G (IgG) (IgG index) and number of oligoclonal bands (OCB) among particular types of multiple sclerosis (MS).

METHODS

120 cerebrospinal fluid (CSF) samples were examined from 29 clinically isolated syndrome (CIS) patients and 91 MS patients (77 patients with relapsing-remitting MS (RR), 6 patients with primary progressive course of the disease (PP) and 8 patients in secondary progression (SP)); mean age = 42 years (range = 18 to 70 years). Albumin and IgG in serum and CSF was evaluated using nephelometry; an albumin quotient (CSF albumin/serum albumin), an IgG quotient (CSF IgG/serum IgG) and an IgG index (IgG quotient / albumin quotient) were then calculated. OCB were assessed using isoelectric focusing (IEF) on agarose gel, followed by immunoblotting. All patients were evaluated using the Kurtzke Expanded Disability Status Scale (EDSS).

RESULTS

No statistically significant differences between the IgG index and OC bands relative to particular types of MS were found. Further, there were no significant correlations between EDSS values and intrathecal synthesis (IgG index: QIgG / Qalbumin) and OC bands.

CONCLUSION

No difference in intrathecal synthesis (IgG index) and the number of OCB between different types of MS was confirmed.

Neurological complications of venomous snake bites: a review

Snake bite envenoming is a neglected tropical disease affecting millions of people living in the developing world. According to the offending snake species, the clinical picture may be dominated by swelling and soft tissue necrosis in the bitten limb, or by systemic or neurological manifestations. Serious neurological complications, including stroke and muscle paralysis, are related to the toxic effects of the venom, which contains a complex mixture of toxins affecting the coagulation cascade, the neuromuscular transmission, or both. Metalloproteinases, serine proteases, and C-type lentins (common in viper and colubrid venoms) have anticoagulant or procoagulant activity and may be either agonists or antagonists of platelet aggregation; as a result, ischemic or hemorrhagic strokes may occur. In contrast, the venom of elapids is rich in phospholipase A(2) and three-finger proteins, which are potent neurotoxins affecting the neuromuscular transmission at either presynaptic or post-synaptic levels. Presynaptic-acting neurotoxins (called β-neurotoxins) inhibit the release of acetylcholine, while post-synaptic-acting neurotoxins (called α-neurotoxins) cause a reversible blockage of acetylcholine receptors. Proper management of the envenomed patient, including prompt transport to the hospital, correction of the hemostatic disorder, ventilatory support, and administration of antivenom, significantly reduces the risk of neurological complications which, in turn, reduce the mortality and improve the functional outcome of survivors.

Prevalence of dementia and its correlates among participants in the National Early Dementia Detection Program during 2006-2009

OBJECTIVE

To investigate the prevalence of dementia and its correlates among people with poor socioeconomic status, poor social support systems, and poor performance on the Korean version of the Mini-Mental Status Exam (MMSE-KC).

METHODS

We used 2006-2009 data of the National Early Dementia Detection Program (NEDDP) conducted on Jeju Island. This program included all residents >65 years old who were receiving financial assistance. We examined those who performed poorly (standard deviation from the norm of <-1.5) on the MMSE-KC administered as part of the NEDDP, using age-, gender-, and education-adjusted norms for Korean elders. A total of 1708 people were included in this category.

RESULTS

The prevalence of dementia in this group was 20.5%. Multivariate logistic regression analysis revealed that the following factors were statistically significantly associated with dementia: age of 80 or older, no education, nursing home residence, and depression.

CONCLUSION

The prevalence of dementia is very high among those with lower MMSE-KC scores, and significant correlates include older age, no education, living in a nursing home, and depression. Enhancing lifetime education to improve individuals' cognitive reserves by providing intellectually challenging activities, encouraging living at home rather than in a nursing home, and preventing and treating depression in its early phase could reduce the prevalence of dementia in this population.

Prevalence of anxiety and depression among outpatients with type 2 diabetes in the Mexican population

Background

Depression and anxiety are common in diabetic patients; however, in recent years the frequency of these symptoms has markedly increased worldwide. Therefore, it is necessary to establish the frequency and factors associated with depression and anxiety, since they can be responsible for premature morbidity, mortality, risk of developing comorbidities, complications, suffering of patients, as well as escalation of costs. We studied the frequency of depression and anxiety in Mexican outpatients with type 2 diabetes and identified the risk factors for depression and anxiety.

Methods and Findings

We performed a study in 820 patients with type 2 diabetes. The prevalence of depression and anxiety was estimated using the Hamilton Depression Rating Scale and the Hamilton Anxiety Rating Scale, respectively. We calculated the proportions for depression and anxiety and, after adjusting for confounding variables, we performed multivariate analysis using multiple logistic regressions to evaluate the combined effect of the various factors associated with anxiety and depression among persons with type 2 diabetes. The rates for depression and anxiety were 48.27% (95% CI: 44.48–52.06) and 55.10% (95% CI: 51.44–58.93), respectively. Occupation and complications in diabetes were the factors associated with anxiety, whereas glucose level and complications in diabetes were associated with depression. Complications in diabetes was a factor common to depression and anxiety (p<0.0001; OR 1.79, 95% CI 1.29–2.4).

Conclusions

Our findings demonstrate that a large proportion of diabetic patients present depression and/or anxiety. We also identified a significant association between complications in diabetes with depression and anxiety. Interventions are necessary to hinder the appearance of complications in diabetes and in consequence prevent depression and anxiety.

Neurosarcoidosis: Clinical manifestations, diagnosis and treatment

Sarcoidosis is an idiopathic granulomatous disease affecting multiple organs. Neurosarcoidosis, involving the central and/or peripheral nervous systems, is a relatively rare form of sarcoidosis. Its clinical manifestations include cranial neuropathies, meningitis, neuroendocrinological dysfunction, hydrocephalus, seizures, neuropsychiatric symptoms, myelopathy and neuropathies. The diagnosis is problematic, especially when occurring as an isolated form without other organ involvement. Distinguishing neurosarcoidosis from other granulomatous diseases and multiple sclerosis is especially important. Although biopsy of neural tissue is the gold standard for the diagnosis of neurosarcoidosis, this is often not practical and the diagnosis must be inferred though other tests, often coupled with biopsy of extraneural organs. Corticosteroids and other immuno-suppressants are frequently used for the treatment of neurosarcoidosis. This article reviews the epidemiology, pathogenesis, pathology, clinical features, diagnosis, diagnostic tests, diagnostic criteria, and therapy of neurosarcoidosis.

Effects of an enjoyable nurse-led intervention to promote movement in poststroke inpatients

It is important to have the stroke survivors move as soon as possible to improve disability as well as related problems such as fatigue, sleep, and depression. However, there were few reports on a movement intervention for the inpatients who were in the rehabilitation unit just after taking acute care. An enjoyable intervention was developed that promoted movement focusing on plegic limbs and looked more like a game or a play; the game was designed to be a group activity that could be led by nurses. Twenty participants participated in 30- to 40-min sessions, 3 times a week for 2 weeks. Functional status (cognitive, motor, and total), fatigue, sleep, and depression were measured. Except for the cognitive function, all outcomes were significantly improved in the experimental group as compared to those in the control group. Safe and enjoyable nursing interventions should be developed and implemented to improve disability and related problems for the poststroke inpatients.

Sensory nerve action potentials and sensory perception in women with arthritis of the hand

Background

Arthritis of the hand can limit a person’s ability to perform daily activities. Whether or not sensory deficits contribute to the disability in this population remains unknown. The primary purpose of this study was to determine if women with osteoarthritis (OA) or rheumatoid arthritis (RA) of the hand have sensory impairments.

Methods

Sensory function in the dominant hand of women with hand OA or RA and healthy women was evaluated by measuring sensory nerve action potentials (SNAPs) from the median, ulnar and radial nerves, sensory mapping (SM), and vibratory and current perception thresholds (VPT and CPT, respectively) of the second and fifth digits.

Results

All SNAP amplitudes were significantly lower for the hand OA and hand RA groups compared with the healthy group (p < 0.05). No group differences were found for SNAP conduction velocities, SM, VPT, and CPT.

Discussion

We propose, based on these findings, that women with hand OA or RA may have axonal loss of sensory fibers in the median, ulnar and radial nerves. Less apparent were losses in conduction speed or sensory perception.

B cells contribute to MS pathogenesis through antibody-dependent and antibody-independent mechanisms

For many years, central dogma defined multiple sclerosis (MS) as a T cell-driven autoimmune disorder; however, over the past decade there has been a burgeoning recognition that B cells contribute to the pathogenesis of certain MS disease subtypes. B cells may contribute to MS pathogenesis through production of autoantibodies (or antibodies directed at foreign bodies, which unfortunately cross-react with self-antigens), through promotion of T cell activation via antigen presentation, or through production of cytokines. This review highlights evidence for antibody-dependent and antibody-independent B cell involvement in MS pathogenesis.

Nerve conduction studies and needle EMG in very small children

Nerve conduction studies and needle EMG in children under two years of age present a considerable technical challenge to the neurophysiologist. However, with adaptations of both the equipment used and the methods applied, useful results can be obtained in most cases. Normative data exists against which results can be compared exists but are not comprehensive and often the experience of the practitioner is most important for interpretation of the results. Conditions, which are diagnosed fall under the broad categories of disorders of nerve, anterior horn cell, muscle or neuromuscular junction, with certain conditions seen more commonly than in older children. Examples include hypomyelinating neuropathy, SMARD, myotonic dystrophy, congenital myasthenic syndrome, and neonatal brachial plexopathy. While few practitioners perform EMG in children so young the rewards may be considerable with information obtained that is almost always important in the management of the children. It is feasible for any trained neurophysiologists to do and more should be encouraged to offer this service which comprises one quarter of the author's clinical case load.

Oxidative stress correlates with headache symptoms in fibromyalgia: coenzyme Q₁₀ effect on clinical improvement

BACKGROUND

Fibromyalgia (FM) is a chronic pain syndrome with unknown etiology and a wide spectrum of symptoms such as allodynia, debilitating fatigue, joint stiffness and migraine. Recent studies have shown some evidences demonstrating that oxidative stress is associated to clinical symptoms in FM of fibromyalgia. We examined oxidative stress and bioenergetic status in blood mononuclear cells (BMCs) and its association to headache symptoms in FM patients. The effects of oral coenzyme Q(10) (CoQ(10)) supplementation on biochemical markers and clinical improvement were also evaluated.

METHODS

We studied 20 FM patients and 15 healthy controls. Clinical parameters were evaluated using the Fibromyalgia Impact Questionnaire (FIQ), visual analogues scales (VAS), and the Headache Impact Test (HIT-6). Oxidative stress was determined by measuring CoQ(10), catalase and lipid peroxidation (LPO) levels in BMCs. Bioenergetic status was assessed by measuring ATP levels in BMCs.

RESULTS

We found decreased CoQ(10), catalase and ATP levels in BMCs from FM patients as compared to normal control (P < 0.05 and P < 0.001, respectively) We also found increased level of LPO in BMCs from FM patients as compared to normal control (P < 0.001). Significant negative correlations between CoQ(10) or catalase levels in BMCs and headache parameters were observed (r  = -0.59, P < 0.05; r  =  -0.68, P < 0.05, respectively). Furthermore, LPO levels showed a significant positive correlation with HIT-6 (r = 0.33, P<0.05). Oral CoQ(10) supplementation restored biochemical parameters and induced a significant improvement in clinical and headache symptoms (P < 0.001).

DISCUSSION

The results of this study suggest a role for mitochondrial dysfunction and oxidative stress in the headache symptoms associated with FM. CoQ10 supplementation should be examined in a larger placebo controlled trial as a possible treatment in FM.

Prothrombolytic action of normobaric oxygen given alone or in combination with recombinant tissue-plasminogen activator in a rat model of thromboembolic stroke

The potential benefit of 100 vol% normobaric oxygen (NBO) for the treatment of acute ischemic stroke patients is still a matter of debate. To advance this critical question, we studied the effects of intraischemic normobaric oxygen alone or in combination with recombinant tissue-plasminogen activator (rtPA) on cerebral blood flow and ischemic brain damage and swelling in a clinically relevant rat model of thromboembolic stroke. We show that NBO provides neuroprotection by achieving cerebral blood flow restoration equivalent to 0.9 mg/kg rtPA through probable direct interaction and facilitation of the fibrinolytic properties of endogenous tPA. In contrast, combined NBO and rtPA has no neuroprotective effect on ischemic brain damage despite producing cerebral blood flow restoration. These results 1) by providing a new mechanism of action of NBO highlight together with previous findings the way by which intraischemic NBO shows beneficial action; 2) suggest that NBO could be an efficient primary care therapeutic intervention for patients eligible for rtPA therapy; 3) indicate that NBO could be an interesting alternative for patients not eligible for rtPA therapy; and 4) caution the use of NBO in combination with rtPA in acute stroke patients.

Epidemiological and clinical features of human rabies cases in Bali 2008-2010

BACKGROUND

Previously thought to be rabies free, Bali experienced an outbreak of animal and human rabies cases in November 2008. We describe the epidemiological and clinical data of human rabies cases occurring in the first two years of the outbreak.

METHODS

We analysed the patient records of all rabies cases from the Sanglah General Hospital in Denpasar, and district hospitals in Buleleng and Tabanan. A conventional reverse transcriptase polymerase chain reaction was developed to detect the rabies virus genome in saliva, corneal swabs, and ante- and post-mortem cerebrospinal fluid (CSF).

RESULTS

There were 104 human rabies cases in Bali during November 2008-November 2010. Patients' mean age was 36.6 years (range 3-84 years; SD 20.7), most were male (56.7%), and originated from rural districts. Almost all (92%) cases had a history of dog bite. Only 5.8% had their wounds treated and received an anti-rabies vaccine (ARV) after the bite incident. No patients received rabies immunoglobulin (RIG). The estimated time from dog bite to the onset of signs and symptoms was 110.4 days (range 12-720 days; SD 118.2). The mean length of medical care until death was 21.8 hours (range 1-220 hours; SD 32.6). Less than 50% of patients had prodromal symptoms. The most frequent prodromal symptom was pain or paraesthesia at the bite site (37.6%). The two most common central nervous system infection signs were agitation (89.2%) and confusion (83.3%). Signs of autonomic nervous system dysfunction included hydrophobia (93.1%), hypersalivation (88.2%), and dyspnea (74.4%). On admission, 22 of 102 patients (21.6%) showed paralytic manifestations, while the rest (78.4%) showed furious rabies manifestations. The case-fatality rate was 100%. The rabies virus genome was detected in 50 of 101 patients (49.5%) with the highest detection rate from post-mortem CSF samples.

CONCLUSIONS

Rabies is a major public health problem in Bali. Human fatalities occur because of a lack of knowledge regarding rabies risk, the poor management of dog bites, and the limited availability of RIG. Increasing public awareness of dog bite management, increasing the availability of ARV and RIG, and implementing an island-wide dog vaccination campaign will help prevent human rabies cases.

Dentists' knowledge, attitudes and practices toward patients with epilepsy in Hyderabad city, India

AIM

The present study was designed to assess the knowledge, attitudes and practices about epilepsy among a group of dentists in Hyderabad city, India.

MATERIALS AND METHODS

All dentists registered with the local Dental Association branch were eligible to participate in this questionnaire study. Descriptive and Inferential Statistics were used. Multiple group analysis was done using Kruskal-Wallis, and Mann Whitney U Test was used for two-group comparison. The variables were taken as significant at a p value of 0.05.

RESULTS

A total of 217 respondents with mean age of 33.16±10.4 years participated in the study. Most respondents possessed a post-graduate (Master of Dental Surgery - MDS) degree (59.4%). A convulsion or shaking was identified as the most familiar recognizable symptom of epilepsy. 84.3% of the dentists would not object to their children having association with patients with epilepsy, and 61.3% would not object to their relative marrying a person with a history of epilepsy. A large number of dentists (178; 82%) were confident to treat a person with epilepsy. 95.3% assumed that they have an ethical responsibility to treat this population. None of the practice-related questions showed any significant difference with respect to different age groups, gender or the education levels (BDS/MDS).

CONCLUSION

Our study reflects that this group of Indian dentists has a fairly high knowledge and positive attitudes toward patients with epilepsy. This encouraging approach and confidence among dentists may positively influence patients with epilepsy to seek dental care.

Prognostic Value of a Single Prehospital Measurement of N-Terminal Pro-Brain Natriuretic Peptide and Troponin T after Acute Ischaemic Stroke

OBJECTIVE: Data regarding the value of prehospital measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin T as prognostic indicators of in-hospital mortality are limited. This prospective pilot study aimed to determine the value of a single combined measurement of NT-proBNP and troponin T for predicting in-hospital mortality in patients with acute ischaemic stroke in a prehospital emergency medicine centre. METHODS: Blood samples were collected in the prehospital setting and analysed for NT-proBNP and troponin T, using a portable device. Parameters previously associated with stroke severity (including prognostic scoring systems) were recorded and assessed as independent predictors of in-hospital mortality. RESULTS: In logistic regression analysis, elevated troponin T (odds ratio [OR] 1.8 [95% CI 1.1, 8.4) and elevated NT-proBNP (OR 5.80 [95% CI 1.3, 22.7]) were significantly associated with poor outcome in patients with acute ischaemic stroke. Combined measurement of troponin T plus NT-proBNP was most predictive of survival in stroke patients (93% sensitivity, 96% specificity, 80% negative predictive value, 98% positive predictive value and 92% area under the receiver operating curve). CONCLUSIONS: NT-proBNP and troponin T levels, measured during the prehospital phase of care after acute ischaemic stroke, are strong predictors of in-hospital mortality.

Hypertrophic pachymeningitis in a patient with Takayasu arteritis: One more association?

Hypertrophic pachymeningitis (HP) is a rare chronic inflammatory disease of the dura mater, described in association with various infections, systemic vasculitides such as Wegener's granulomatosis and giant cell arteritis. However, HP in association with Takayasu arteritis (TA) has not been described. We report a young woman who presented with headache, seizures, and right third and fourth cranial neuropathy. Magnetic resonance imaging of the brain showed HP in bifrontal and right temporal region extending to cavernous sinus. She was also found to have systemic hypertension, stenosis of left subclavian, and left renal artery with narrowing of abdominal aorta, satisfying the diagnostic criteria for TA. A detailed evaluation for secondary causes of HP failed to reveal an alternative etiology. This report describes an unusual association of HP in a patient with TA, also emphasizing that seizures and cranial neuropathy may further expand the spectrum of neurological manifestations in patients with TA.

Kleine Levin syndrome in Malaysia: first typical case

A 13-year-old boy presented with a 2 weeks history of tearfulness, childish behaviour, separation anxiety, hypersomnia, hyperphagia and sexual disinhibition following a brief episode of fever. He had been experiencing the episodes since he was seven. The episodes lasted from a few days to 3 weeks and would normally occur once in a year. Most of the time it started with fever and resolved spontaneously. In the past he described auditory hallucination but not this time. Examination revealed a slightly overweight adolescent male appearing appropriate to his age. During the session he was restless, sleepy and burst into tears frequently. He constantly asked his mother when he could go home to sleep. He was very childish and clung to his mother. He was given a trial of risperidone 1 mg to be taken once a day for 3 days. On follow-up he had completely recovered.

Profiles of Alzheimer's disease-related pathology in an aging urban population sample in India

Systematic studies on Alzheimer's disease (AD)-related pathology that complement clinical and epidemiological data on dementia from low and middle income countries are rare. We report the first large study on AD-related pathology in autopsy service-derived brains from an urban center in India, a low/middle income country, and compare findings with a similar sample from New York. Amyloid-β plaques and neurofibrillary tangles were assessed in 91 brain specimens derived from hospital autopsy cases from Mumbai, India (age 60+ years; mean age 71.1 years, ± 8.3 SD; range 60-107 years) and compared with identically examined age-matched sample obtained in New York. These cases had no known clinical history of dementia. Our study showed that in comparison with the New York sample, the mean brain weight of the Mumbai sample was lower (p = 0.013) and mean diffuse plaque density was higher (p = 0.019), while differences in mean density and counts of neurofibrillary tangles and neuritic plaques were not statistically significant (p > 0.05). Our findings indicate that the burden of AD-related pathology was approximately equivalent in Mumbai and New York samples, which is at variance with expected lower AD-related lesion burden based on the clinical/epidemiological studies suggesting lower prevalence of AD in India.

Curcumin loaded-PLGA nanoparticles conjugated with Tet-1 peptide for potential use in Alzheimer's disease

Alzheimer's disease is a growing concern in the modern world. As the currently available medications are not very promising, there is an increased need for the fabrication of newer drugs. Curcumin is a plant derived compound which has potential activities beneficial for the treatment of Alzheimer's disease. Anti-amyloid activity and anti-oxidant activity of curcumin is highly beneficial for the treatment of Alzheimer's disease. The insolubility of curcumin in water restricts its use to a great extend, which can be overcome by the synthesis of curcumin nanoparticles. In our work, we have successfully synthesized water-soluble PLGA coated- curcumin nanoparticles and characterized it using different techniques. As drug targeting to diseases of cerebral origin are difficult due to the stringency of blood-brain barrier, we have coupled the nanoparticle with Tet-1 peptide, which has the affinity to neurons and possess retrograde transportation properties. Our results suggest that curcumin encapsulated-PLGA nanoparticles are able to destroy amyloid aggregates, exhibit anti-oxidative property and are non-cytotoxic. The encapsulation of the curcumin in PLGA does not destroy its inherent properties and so, the PLGA-curcumin nanoparticles can be used as a drug with multiple functions in treating Alzheimer's disease proving it to be a potential therapeutic tool against this dreaded disease.

Retromers in Alzheimer's disease

Amyloid-β peptide (Aβ), the key pathogenic agent in Alzheimer's disease (AD), is released after sequential proteolytic cleavage of the transmembrane amyloid precursor protein (APP). β-Site APP-cleaving enzyme 1 (BACE1) cleaves APP in early endosomes, and the cause of increased BACE cleavage of APP in AD is not fully resolved yet. It has been proposed that perturbed intracellular trafficking of APP, which leads to prolonged residence time in early endosomes, influences Aβ production and hence the risk for AD. Retromers are a family of proteins that mediate the retrieval of transmembrane proteins from the endosomes to the trans-Golgi network. Misregulation of retromers or retromer-associated proteins influences endosomal localization of APP/BACE1. Here we review the role of retromers in the amyloidogenic processing of APP and their pathogenic role in AD.

Distinct clinical and pathological characteristics of frontotemporal dementia associated with C9ORF72 mutations

The identification of a hexanucleotide repeat expansion in the C9ORF72 gene as the cause of chromosome 9-linked frontotemporal dementia and motor neuron disease offers the opportunity for greater understanding of the relationship between these disorders and other clinical forms of frontotemporal lobar degeneration. In this study, we screened a cohort of 398 patients with frontotemporal dementia, progressive non-fluent aphasia, semantic dementia or mixture of these syndromes for mutations in the C9ORF72 gene. Motor neuron disease was present in 55 patients (14%). We identified 32 patients with C9ORF72 mutations, representing 8% of the cohort. The patients' clinical phenotype at presentation varied: nine patients had frontotemporal dementia with motor neuron disease, 19 had frontotemporal dementia alone, one had mixed semantic dementia with frontal features and three had progressive non-fluent aphasia. There was, as expected, a significant association between C9ORF72 mutations and presence of motor neuron disease. Nevertheless, 46 patients, including 22 familial, had motor neuron disease but no mutation in C9ORF72. Thirty-eight per cent of the patients with C9ORF72 mutations presented with psychosis, with a further 28% exhibiting paranoid, deluded or irrational thinking, whereas <4% of non-mutation bearers presented similarly. The presence of psychosis dramatically increased the odds that patients carried the mutation. Mutation bearers showed a low incidence of motor stereotypies, and relatively high incidence of complex repetitive behaviours, largely linked to patients' delusions. They also showed a lower incidence of acquired sweet food preference than patients without C9ORF72 mutations. Post-mortem pathology in five patients revealed transactive response DNA-binding protein 43 pathology, type A in one patient and type B in three. However, one patient had corticobasal degeneration pathology. The findings indicate that C9ORF72 mutations cause some but not all cases of frontotemporal dementia with motor neuron disease. Other mutations remain to be discovered. C9ORF72 mutations are associated with variable clinical presentations and pathology. Nevertheless, the findings highlight a powerful association between C9ORF72 mutations and psychosis and suggest that the behavioural characteristics of patients with C9ORF72 mutations are qualitatively distinct. Mutations in the C9ORF72 gene may be a major cause not only of frontotemporal dementia with motor neuron disease but also of late onset psychosis.

Phagocytized corpora amylacea as a histological hallmark of astrocytic injury in neuromyelitis optica

Neuromyelitis optica (NMO) is an inflammatory demyelinating and necrotizing disorder of the CNS that mainly affects the optic nerve and spinal cord. The etiology is still uncertain; however, the discovery of serum anti-aquaporin-4 (AQP4) autoantibody is becoming the center of attention, and a new hypothesis is emerging that NMO is essentially astrocytopathy provoked by this autoantibody. In this study, we focused on corpora amylacea (CA), glycoproteinaceous inclusions in astrocytic processes. We examined 57 lesions in nine cases of NMO spectrum disorder, and demonstrated that CA were phagocytized by macrophages in 42 lesions (74%) of eight cases, while phagocytized figures were not seen in unaffected areas. Phagocytized CA were frequently encountered in early-phase lesions still retaining myelin structures, while fewer or none were found in chronic destructive lesions. Moreover, phagocytized CA were significantly smaller in diameter than intact ones, and CA were decreased or absent in most lesions assessed. These findings suggest the following pathophysiological process: the astrocytes are affected at an early phase in NMO, CA are expelled from the astrocytes and phagocytized by macrophages finally leading to clearance. A phagocytized figure and subsequent loss of CA can be a histological hallmark of astrocytic injury of NMO.

Intravenous thrombolysis for acute ischemic stroke in Asia

Data regarding thrombolysis for acute ischemic stroke in Asia are scarce and only a small percentage of patients are thrombolysed. Clinical trials that led to the recommended dose of intravenously administered tissue plasminogen activator (IV-tPA) included predominantly Caucasian patients. However, the single-arm case-controlled observational studies in Japanese patients suggested the clinical efficacy and safety of low-dose IV-tPA (0.6 mg/kg bodyweight; maximum 60 mg) comparable with standard dose (0.9 mg/kg bodyweight; maximum 90 mg). There has been no randomized clinical trial for determining the dose, efficacy or safety of IV-tPA in Asia. Accordingly, the dose of IV-tPA in Asia remains controversial. Reduced treatment cost, lower symptomatic intracerebral hemorrhage risk and comparable efficacy encouraged many Asian centers to adopt low-dose or even variable-dose IV-tPA regimens. We present the current status of thrombolysis for acute ischemic stroke in Asia.

Effects of Lavender Aroma on Sleep Quality in Healthy Japanese Students

This single-blind randomized study investigated the effectiveness of lavender aroma on quality of sleep in healthy Japanese students. The data of seven participants (2 men, 5 women) in the intervention group and eight participants (3 men, 5 women) in the control group were analyzed ( M age = 19.0 yr., SD = 0.9). The total procedure comprised 3 days for pre-intervention assessment, 5 days for the intervention, and 3 days for post-intervention assessment. Lavender exposure was compared with the absence of lavender (control). Information regarding the relaxing effect of aromas was provided to examine expectancy effects. Results showed that lavender aroma improved sleepiness at awakening after the intervention. Sex differences and daily variation in quality of sleep during the intervention period were not observed. The findings suggest that nighttime exposure to lavender aroma relieves sleepiness at awakening.

[Neuro-urological dysfunction of the lower urinary tract in CNS diseases: pathophysiology, epidemiology, and treatment options]

The lower urinary tract (LUT) is regulated by a complex neural network that is subject to supraspinal control. Neurological disorders, especially of the central nervous system (CNS), can rapidly lead to disruption of this control. Multiple sclerosis, Parkinson's disease, multiple system atrophy, and stroke are neurological disorders which quite frequently cause dysfunction of the LUT. With respect to the pathophysiology of bladder dysfunction in CNS diseases there are various hypotheses regarding the individual disorders: disturbances of neural communication between the frontal cortex and pontine micturition center, between the pontine micturition center and the lumbosacral parts of the spinal cord, and between the basal ganglia, thalamus, and anterior cingulate gyrus appear to play a pivotal role in the development of bladder dysfunction. The symptoms and urodynamic presentation of LUT dysfunction can vary considerably depending on the disease and disease progression and can change in the course of the disease. The incidence and prevalence of LUT dysfunctions rise with increasing progression of the underlying neurological disease.Various conservative, minimally invasive, and open surgical procedures are available to prevent harmful sequelae and to improve the quality of life of these patients. As yet, however, few data exist on most of the treatment options in cases of the above-mentioned CNS diseases. Intermittent self-catheterization and antimuscarinic medications are among the most important conservative treatment options. Injection of botulinum neurotoxin type A into the detrusor muscle and increasingly sacral or pudendal neuromodulation are among the most important minimally invasive treatment options. Surgical methods include reconstructive continent or incontinent urinary diversion.When planning therapy the patient's current needs and neurological limitations as well as possible disease progression must be taken into consideration. It is often advisable to consult with and enlist the cooperation of the attending neurologist when planning treatment.

The etiologies of new cases of cerebral venous sinus thrombosis reported in the past year

Cerebral venous sinus thrombosis (CVST) is an uncommon but life-threatening stroke subtype with extremely diverse clinical features, predisposing factors, brain imaging findings, and outcomes. Its predominant etiologies were known to be otomastoid, orbit, and central face cutaneous infections, pregnancy and complications associated with the postpartum period, and oral contraceptives. In recent years, however, infections have accounted for fewer cases while oral contraceptives, pregnancy and complications associated with the postpartum period, tumors, and coagulopathies have accounted for more cases of CVST. These conditions have become the predominant risk factors for CVST, but uncommon etiologies have also emerged. This review focuses on the new etiologies of CVST cases reported this year to broaden perspectives on the etiologies of CVST.

Protective effects of Eucommia lignans against hypertensive renal injury by inhibiting expression of aldose reductase

AIM OF THE STUDY

To investigate the protective effects and the underlying mechanism of Eucommia lignans against hypertensive renal injury.

MATERIAL AND METHODS

Ten-week-old Wistar Kyoto rats and age matched spontaneously hypertension rats were used in the study. The SHR were randomly divided into 4 groups (n=7 for each group) and received different treatment for 16 weeks, which including saline, Captopril, Epalrestat and Eucommia lignans, respectively. System blood pressures of the rats were monitored once every 4 weeks. N-Acetyl-β-D-glucosaminidase (NAG) activity and the ratio of albumin and urinary creatinine were chosen as the indices of kidney function. Then the structure and renal collagen type III expression of glomerular basement membrane were observed by microscopy and the renal aldose reductase (AR) expression was measured by immunohistochemistry. In vitro, the proliferation of mesangial cells induced by AngII was assayed by MTT, and the mRNA expression of AR was measured by RT-real-time PCR.

RESULTS

The renal function, evaluated by NAG enzyme activity and the ratio of albumin to urinary creatinine, was significantly ameliorated by Eucommia lignans treatment. Meanwhile, Eucommia lignans decreased both the protein (P<0.05) and the mRNA expressed lever of AR (P<0.05). Eucommia lignans also decreased the high expression of collagen type III in SHR (P<0.05) and inhibited the proliferation of renal mesangial cells induced by AngII (P<0.05).

CONCLUSION

Eucommia lignans have protective effects against hypertensive renal injury, and the protective effects may be partly due to inhibition of aldose reductase.

Acquired immune and inflammatory myopathies: pathologic classification

PURPOSE OF REVIEW

We discuss pathology-based characterization and classification of acquired immune and inflammatory myopathies (IIMs).

RECENT FINDINGS

Several types of IIMs do not fit well into the typical IIM subclassifications: dermatomyositis, polymyositis and inclusion body myositis (IBM). Myopathologic features that can provide additional diagnostic clarification in IIM are types of muscle fiber pathology; immune changes (cellular and humoral); and tissues with distinctive involvement (connective tissue, vessels and muscle fibers). Pathologic classification categories include immune myopathies with perimysial pathology (IMPP), a group that can be associated with antisynthetase antibodies; myovasculopathies, including childhood dermatomyositis; immune polymyopathies, active myopathies with little inflammation such as the myopathy with signal recognition particle antibodies; immune myopathies with endomysial pathology (IM-EP), illustrated by brachio-cervical inflammatory myopathy (BCIM); histiocytic inflammatory myopathies, like sarcoid myopathy; and inflammatory myopathies with vacuoles, aggregates and mitochondrial pathology (IM-VAMP), which have inclusion body myositis as a pathologic subtype and are poorly treatable. Some myopathologic features, like B-cell foci and alkaline phosphatase staining of capillaries or perimysium, are more likely to be present in treatable categories of IIM.

SUMMARY

Myopathology can be used to classify IIM. Identification of distinctive myopathologic changes in IIM can improve diagnostic and prognostic accuracy and focus treatment, therapeutic trials and studies of pathogenic factors.

Recurrent subacute visual loss presenting in a 52-year-old Caucasian woman with chronic relapsing inflammatory optic neuropathy: a case report

INTRODUCTION

Chronic relapsing inflammatory optic neuropathy is a recently described form of recurrent isolated subacute optic neuropathy. The condition is highly responsive to systemic steroid treatment and prone to relapse on steroid withdrawal. A complete work up for demyelination, autoimmune disease and sarcoidosis must be made before considering chronic relapsing inflammatory optic neuropathy.

CASE PRESENTATION

We describe the case of a 52-year-old Caucasian woman who presented with isolated subacute optic neuropathy. There was no evidence of demyelination, autoimmunity or sarcoidosis. There was an abrupt and prompt response to systemic corticosteroids and a relapse of the condition on steroid withdrawal.

CONCLUSIONS

Chronic relapsing inflammatory optic neuropathy requires careful consideration and differentiation from demyelinating optic neuritis and ischemic optic neuropathy since the treatment is different and the outcome without treatment is likely to be poor. The importance of identifying these patients has considerable clinical implications as the condition is highly responsive to steroids.

The emerging epidemiology of mould infections in developing countries

PURPOSE OF REVIEW

The present review describes the emerging trends of mould infections in developing countries, and highlights the major epidemiological differences from the developed countries.

RECENT FINDINGS

The limited data available from developing countries suggest an alarming increase in invasive mould infections, especially aspergillosis and mucormycosis, and also a difference in risk factors and causative agents between the developed and developing world. Sino-orbital, cerebral and ophthalmic infections due to Aspergillus flavus are the major clinical types in aspergillosis, after pulmonary aspergillosis. Aspergillus and Fusarium spp. are frequent causes of trauma-associated keratitis in agricultural workers. Rhino-orbito-cerebral presentation associated with uncontrolled diabetes is the predominant mucormycosis. Isolated renal mucormycosis has emerged as a new clinical entity. Apophysomyces elegans and Mucor irregularis are emerging species in these regions and uncommon agents such as Rhizopus homothallicus have also been reported. Many pathogens are geographically restricted, with Pythium insidionum, Rhinocladiella mackenziei and M. irregularis being described almost exclusively from Thailand, Middle East and China, respectively.

SUMMARY

Despite limited studies, certain peculiarities have been observed in invasive mould infections in developing countries, including a high incidence of ophthalmic lesions, mucormycosis and aspergillosis; few different clinical presentations; and a varied spectrum of pathogens involved in such lesions.

Spontaneous upper limb monoplegia secondary to probable cerebral amyloid angiopathy

Cerebral amyloid angiopathy is a clinicopathological disorder characterised by vascular amyloid deposition initially in leptomeningeal and neocortical vessels, and later affecting cortical and subcortical regions. The presence of amyloid within the walls of these vessels leads to a propensity for primary intracerebral haemorrhage. We report the unusual case of a 77-year-old female who presented to our emergency department with sudden onset isolated hypoaesthesia and right upper limb monoplegia. A CT scan demonstrated a peripheral acute haematoma involving the left perirolandic cortices. Subsequent magnetic resonance imaging demonstrated previous superficial haemorrhagic events. One week following discharge the patient re-attended with multiple short-lived episodes of aphasia and jerking of the right upper limb. Further imaging demonstrated oedematous changes around the previous haemorrhagic insult. Cerebral amyloid angiopathy is an overlooked cause of intracerebral haemorrhage; the isolated nature of the neurological deficit in this case illustrates the many guises in which it can present.

Multiple sclerosis

Multiple sclerosis (MS) is a chronic, complex neurological disease with a variable clinical course in which several pathophysiological mechanisms such as axonal/ neuronal damage, demyelination, inflammation, gliosis, remyelination and repair, oxidative injury and excitotoxicity, alteration of the immune system as well as biochemical disturbances and disruption of blood-brain barrier are involved.(1,2) Exacerbations of MS symptoms reflect inflammatory episodes, while the neurodegenerative aspects of gliosis and axonal loss result in the progression of disability. The precise aetiology of MS is not yet known, although epidemiological data indicate that it arises from a complex interactions between genetic susceptibility and environmental factors.(3) In this chapter the brain structures and processes involved in immunopathogenesis of MS are presented. Additionally, clinical phenotypes and biomarkers of MS are showed.