Epidemiology of neurological disorders in India: review of background, prevalence and incidence of epilepsy, stroke, Parkinson's disease and tremors

Assessment of disease pattern and drug utilization among neurology intensive care unit patients in a developing country: an observational analysis

OBJECTIVE

This study aimed to assess the disease pattern and drug utilization among admitted patients in a tertiary-care hospital's neurology intensive care unit (neuro ICU).

METHODS

A prospective observational cohort study was conducted between August 2022 and January 2023. Patients of any age and gender admitted to the neuro ICU were included, but those who declined to participate were excluded. Demographics, clinical, and medication details were consistently gathered and maintained until discharge. The World Health Organization (WHO)/International Network of Rational Use of Drugs (INRUD) prescribing indicators and the Anatomical Therapeutic Chemical (ATC) classification/Defined Daily Dose (DDD) system were used to evaluate drug use.

RESULTS

A total of 516 patients were included, predominantly male (65.1%), with an average age of 54.62 ± 15.02 years. The most common diagnosis was stroke [72.3%, comprised of hemorrhagic (46.7%) and ischemic (25.6%)], followed by seizure disorders (6.6%), and central nervous system infections (5.4%). Patients received an average of 7.8 medications, 32.3% prescribed by generic name, 16.0% antibiotics, 74.1% injections, and 100% essential drugs. A (28.5%), C (19.2%), N (17.3%), J (19.2%), B (13.5%), and R (2.3%) were commonly prescribed ATC classes of medications. Number of DDDs was maximum for pantoprazole and furosemide. Based on discharged status, 41.0% were discharged on request, 24.8% against medical advice, 23.8% routine, and 10.2% mortality during hospitalization.

CONCLUSION

Our study reveals a high prevalence of hemorrhagic stroke, especially among men, diverging from global ischemic stroke trends. Irregular hypertension treatment is the primary cause, exacerbated by low healthcare knowledge in rural areas, where patients often discharge on request, probably due to poor socio-economic conditions. Urgent public awareness campaigns and further research are needed to address this elevated hemorrhagic stroke incidence.

A Mutual Nexus Between Epilepsy and α-Synuclein: A Puzzle Pathway

Alpha-synuclein (α-Syn) is a specific neuronal protein that regulates neurotransmitter release and trafficking of synaptic vesicles. Exosome-associated α-Syn which is specific to the central nervous system (CNS) is involved in the pathogenesis of epilepsy. Therefore, this review aimed to elucidate the possible link between α-Syn and epilepsy, and how it affects the pathophysiology of epilepsy. A neurodegenerative protein such as α-Syn is implicated in the pathogenesis of epilepsy. Evidence from preclinical and clinical studies revealed that upregulation of α-Syn induces progressive neuronal dysfunctions through induction of oxidative stress, neuroinflammation, and inhibition of autophagy in a vicious cycle with subsequent development of severe epilepsy. In addition, accumulation of α-Syn in epilepsy could be secondary to the different cellular alterations including oxidative stress, neuroinflammation, reduction of brain-derived neurotrophic factor (BDNF) and progranulin (PGN), and failure of the autophagy pathway. However, the mechanism of α-Syn-induced-epileptogenesis is not well elucidated. Therefore, α-Syn could be a secondary consequence of epilepsy. Preclinical and clinical studies are warranted to confirm this causal relationship.

A Clinical Pharmacist-led Approach on Reducing Drug Related Problems Among Patients with Neurological Disorders: An Interventional Study

Background

Neurological disorders are common in the general population and the majority of patients have other chronic diseases, necessitating the use of multiple medications, which increases the incidence of drug-related problems (DRPs). Studies from different countries discovered an average of 0.29-1.45 DRPs per patient admitted into the neurology unit.

Objectives

To identify common DRPs and to evaluate the impact of clinical pharmacist's interventions in resolving the identified DRPs in patients with neurological disorders.

Methods

A prospective interventional study was conducted in the Department of Neurology in a tertiary care teaching hospital in Southern India, for a period of six months. Patients aged ≥18 years and had been hospitalized for >24 h, were intensively monitored until discharge for the occurrence of any DRPs and pharmacist interventions were provided. The identified DRPs were classified according to Hepler and Strand's Classification.

Results

A total of 310 prescriptions were reviewed, of which 174 patients (mean age 45.93 ± 2.49 years) experienced at least one DRP during their hospital stay. The average DRP per patient was found to be 1.75, with drug-drug interactions [254 (83%)] being the predominant DRPs, followed by adverse drug reactions [13 (4%)], and drug duplications [9 (3%)]. Most of the drug-drug interactions were pharmacokinetic [144 (56.69%)]. Hyponatremia [2 (15%)]; and nausea and vomiting [2 (15%)] were most commonly reported ADRs. All 306 DRPs involved active clinical pharmacist intervention, of which [275 (89.87%)] of pharmacists' interventions were accepted, which led to modification of the therapy.

Conclusion

Monitoring the use of drugs allowed the clinical pharmacist to detect DRPs and to suggest interventions that promote rational drug prescribing, therapy optimization and enhanced patient safety.

Conceptualizing a Rehabilitation 'Model of Care' for Improving the Quality of Life of People with Parkinson's in India

Given the rise in the elderly population and predicted increase in age-related diseases like Parkinson's disease, as well as the treatment gaps in Low-and-Middle-Income Countries (LMICs), there is an urgent need to develop a culturally and socioeconomically viable Parkinson's model of care that would be multidisciplinary, replicable, affordable, and accessible to those who need it the most. We present here an outline of a rehabilitation model of care, which incorporates a standardized group therapy format, community-based Parkinson's Support Centers, collaboration with local stakeholders to ensure sustainability, and active engagement of People with Parkinson's (PwPs) and caregivers (CGs) in rehabilitation programs. This model of care incorporates a unique 16-session multi-disciplinary community rehabilitation module for PwPs and CGs which is evidence-based, easily deliverable by non-medical facilitators, relevant to PwPs and CGs, adaptable to different groups, practical and beneficial, and effective in a group - format. This rehabilitation model of care, encompassing the multidisciplinary rehabilitation module, holds promise for implementation in LMICs due to its dynamic nature, cost-effectiveness, community-based approach and easy adaptability to telehealth platforms. We share our experience of developing the model and outline implications for practice and insights about community rehabilitation work in LMICs.

In silico identification of novel stilbenes analogs for potential multi-targeted drugs against Alzheimer's disease

CONTEXT

Alzheimer's disease (AD) is a chronic progressive neurodegenerative syndrome, which adversely disturbs cognitive abilities as well as intellectual processes and frequently occurs in the elderly. Inhibition of cholinesterase is a valuable approach to upsurge acetylcholine concentrations in the brain and persuades the development of multi-targeted ligands against cholinesterases.

METHODS

The current study aims to determine the binding potential accompanied by antioxidant and anti-inflammatory activities of stilbenes-designed analogs against both cholinesterases (Acetylcholinesterase and butyrylcholinesterase) and neurotrophin targets for effective AD therapeutics. Docking results have shown that the WS6 compound exhibited the least binding energy - 10.1 kcal/mol with Acetylcholinesterase and - 7.8 kcal/mol with butyrylcholinesterase. The WS6 also showed a better binding potential with neurotrophin targets that are Brain-derived Neurotrophic Factor, Neurotrophin 4, Nerve Growth Factor, and Neurotrophin 3. The tested compounds particularly WS6 revealed significant antioxidant and anti-inflammatory activities through the comparative docking analysis with Fluorouracil and Melatonin as control drugs of antioxidants while Celecoxib and Anakinra as anti-inflammatory. The bioinformatics approaches including molecular docking calculations followed by the pharmacokinetics analysis and molecular dynamic simulations were accomplished to explore the capabilities of designed stilbenes as effective and potential leads. Root mean square deviation, root mean square fluctuations, and MM-GBSA calculations were performed through molecular dynamic simulations to extract the structural and residual variations and binding free energies through the 50-ns time scale.

Apoptotic Factors and Mitochondrial Complexes Assist Determination of Strain-Specific Susceptibility of Mice to Parkinsonian Neurotoxin MPTP

Identification of genetic mutations in Parkinson's disease (PD) promulgates the genetic nature of disease susceptibility. Resilience-associated genes being unknown till date, the normal genetic makeup of an individual may be determinative too. Our earlier studies comparing the substantia nigra (SN) and striatum of C57BL/6J, CD-1 mice, and their F1-crossbreds demonstrated the neuroprotective role of admixing against the neurotoxin MPTP. Furthermore, the differences in levels of mitochondrial fission/fusion proteins in the SN of parent strains imply effects on mitochondrial biogenesis. Our present investigations suggest that the baseline levels of apoptotic factors Bcl-2, Bax, and AIF differ across the three strains and are differentially altered in SN following MPTP administration. The reduction in complex-I levels exclusively in MPTP-injected C57BL/6J reiterates mitochondrial involvement in PD pathogenesis. The MPTP-induced increase in complex-IV, in the nigra of both parent strains, may be compensatory in nature. The ultrastructural evaluation showed fairly preserved mitochondria in the dopaminergic neurons of CD-1 and F1-crossbreds. However, in CD-1, the endoplasmic reticulum demonstrated distinct luminal enlargement, bordering onto ballooning, suggesting proteinopathy as a possible initial trigger.The increase in α-synuclein in the pars reticulata of crossbreds suggests a supportive role for this output nucleus in compensating for the lost function of pars compacta. Alternatively, since α-synuclein over-expression occurs in different brain regions in PD, the α-synuclein increase here may suggest a similar pathogenic outcome. Further understanding is required to resolve this biological contraption. Nevertheless, admixing reduces the risk to MPTP by favoring anti-apoptotic consequences. Similar neuroprotection may be envisaged in the admixed populace of Anglo-Indians.

A modern history of neurosurgery and neurology in India: lessons for the world

The compendia of medical knowledge of the great ancient Indian physicians Suśruta, Caraka, Jīvaka, and Vāgbhaṭa all attest to the practice of neurosurgery and neurology starting in the 1st millennium bce. Although a period of scientific stagnation ensued between the 12th and 20th centuries ce, Indian medical neurosciences once again flourished after India’s independence from British rule in 1947. The pioneers of modern Indian neurosurgery, neurology, and their ancillary fields made numerous scientific and clinical discoveries, advancements, and innovations that proved influential on a global scale. Most importantly, the efforts of Indian neurosurgeons and neurologists were unified at the national level through the Neurological Society of India, which was established in 1951 and enabled an unprecedented degree of collaboration within the aforementioned medical specialties. The growth and success of the Indian model bears several lessons that can be applied to other nations in order to garner better collaboration among neurosurgeons, neurologists, and physicians in related fields. Here, the authors elaborate on the origins, growth, and development of neurosurgery and neurology in India and discuss their current state in order to glean valuable lessons on interdisciplinary collaboration, which forms the basis of the authors’ proposal for the continued growth of societies dedicated to medical neurosciences across the world.

Knowledge, Attitude, and Practice of epilepsy in Wayanad, Kerala

OBJECTIVE

Epilepsy is a common neurological condition characterized by recurrent seizures. The aim of the study was to assess the level of Knowledge, Attitude, and Practices (KAP) in epilepsy in the district of Wayanad.

METHODS

This study was conducted among adults residing in Wayanad. This was a community-based door-to-door survey conducted among adults residing in Wayanad District between August 2021 and November 2021. A semi-structured questionnaire was used for data collection. The questionnaire included 23 items that could define the information on the level of knowledge and attitude toward epilepsy.

RESULT

A total of 394 subjects without epilepsy were included in this study. According to the results of this study, 68.8% of respondents were female and 85.3% of them had completed at least primary school education. 93.1% of participants had heard about epilepsy and 64.5% of participants were aware that epilepsy was a brain disorder. 30.5% of participants believed that a person with epilepsy could not get married. 73.9% of participants recommended allopathic treatment for epilepsy and only 9.9% of participants knew about surgical treatment option for epilepsy.

CONCLUSION

Despite having a good understanding of the disease, there is a general tendency in the population to consider patients with epilepsy as incapable of leading a normal life. The choice of modern treatment methods over traditional is also a positive aspect.

Novel inflammasome and oxidative modulators in Parkinson's disease: A prospective study

INTRODUCTION

The etiopathogenesis of Parkinson's disease (PD) is not clear. Yet, it seems likely that inflammation as well as oxidative stress plays a major role in the disease pathogenesis. Based on our previous findings, we aimed to investigate prospective changes in peripheral inflammasome and oxidative modulators in relation to the progression of motor symptoms and severity of PD.

METHODS

Levels of inflammatory and oxidative markers in the serum of PD patients and healthy controls were estimated by quantitative ELISA and spectrophotometric methods at the baseline and at the end of one year.

RESULTS

In PD patients, serum NLRP3 inflammasome and IL-1β levels increased significantly over a year, compared to the baseline. The average enzymatic activity of serum SOD1 was also augmented at one-year follow-up. Alongside these serummarker changes, the mean motorseverity of this patient cohort worsened over the time period.

CONCLUSION

This pioneering study identified a novel association of peripheral inflammatory and oxidative markers with the progression of PD. Correlation of these serum proteins with the central pathological changes in PD and disease severity in a prospective manner might be useful not only for prognostication, but for understanding disease mechanisms and for planning future therapeutic strategies.

What are the challenges with multi-targeted drug design for complex diseases?

INTRODUCTION

Current findings on multifactorial diseases with a complex pathomechanism confirm that multi-target drugs are more efficient ways in treating them as opposed to single-target drugs. However, to design multi-target ligands, a number of factors and challenges must be taken into account.

AREAS COVERED

In this perspective, we summarize the concept of application of multi-target drugs for the treatment of complex diseases such as neurodegenerative diseases, schizophrenia, diabetes, and cancer. We discuss the aspects of target selection for multifunctional ligands and the application of in silico methods in their design and optimization. Furthermore, we highlight other challenges such as balancing affinities to different targets and drug-likeness of obtained compounds. Finally, we present success stories in the design of multi-target ligands for the treatment of common complex diseases.

EXPERT OPINION

Despite numerous challenges resulting from the design of multi-target ligands, these efforts are worth making. Appropriate target selection, activity balancing, and ligand drug-likeness belong to key aspects in the design of ligands acting on multiple targets. It should be emphasized that in silico methods, in particular inverse docking, pharmacophore modeling, machine learning methods and approaches derived from network pharmacology are valuable tools for the design of multi-target drugs.

Evaluation of gait termination strategy in individuals with Essential Tremor and Parkinson's disease

INTRODUCTION

Gait termination (GT) is a challenging transitory task involving converting from a dynamic state of motion to a static state. These transitional locomotor tasks are particularly troublesome for populations with postural deficits, i.e., Parkinson's disease (PD) and Essential Tremor (ET). They demand greater postural control and intricate integration of the neuromuscular system. The mechanisms involved in GT in these populations have not been well studied despite the safety concerns and potential risk for falls. The purpose of this investigation was to examine the different control strategies utilized during GT between individuals with ET and PD.

METHODS

Twenty-four individuals with ET (66 ± 8 yrs), twenty-four individuals with PD (64 ± 8 yrs), and twenty healthy older adults (HOA: 63 ± 9 yrs) participated in this study. Average self-selected gait velocity for each group was collected during the GT trial walking portion. Ground reaction force (GRF) data were used to calculate braking and propulsive forces from the last two steps during GT. GRF data measured the dynamic postural stability index (DPSI), defined as an individual's ability to maintain balance while transitioning from a dynamic to a stable state.

RESULTS

Persons with ET had a significantly slower approach velocity (0.63 m/s) when compared to HOA (0.92 m/s) and PD (0.77 m/s). Persons with PD had significantly slower approach velocity when compared to HOA. Examination of GRF data found that those with ET generated significantly smaller propulsive and braking forces (p < .05). Forces increased in those with PD and then even more in the HOA group. Postural stability analysis revealed that ET had significantly worse stability scores than PD and HOA (p < .05).

CONCLUSION

Individuals with PD and ET utilize different control strategies for planned GT, which suggests both the cerebellum and the basal ganglia play central yet potentially different roles in anticipatory control during self-directed activities.

Metabolomics of neurological disorders in India

Metabolomics is the comprehensive study of the metabolome and its alterations within biological fluids and tissues. Over the years, applications of metabolomics have been explored in several areas, including personalised medicine in diseases, metabolome-wide association studies (MWAS), pharmacometabolomics and in combination with other branches of omics such as proteomics, transcriptomics and genomics. Mass spectrometry (MS) and nuclear magnetic resonance (NMR) spectroscopy are the major analytical techniques widely employed in metabolomics. In addition, MS is coupled with chromatography techniques like gas chromatography (GC) and liquid chromatography (LC) to separate metabolites before analysis. These analytical techniques have made possible identification and quantification of large numbers of metabolites, encompassing characterization of diseases and facilitating a systematic and rational therapeutic strategy based on metabolic patterns. In recent years, the metabolomics approach has been used to obtain a deeper insight into the underlying biochemistry of neurodegenerative disorders and the discovery of biomarkers of clinical implications. The current review mainly focuses on an Indian perspective of metabolomics for the identification of metabolites and metabolic alterations serving as potential diagnostic biomarkers for neurological diseases including acute spinal cord injury, amyotrophic lateral sclerosis, tethered cord syndrome, spina bifida, stroke, Parkinson's disease, glioblastoma and neurological disorders with inborn errors of metabolism.

Association of HLA-DRB1, DQA1 and DQB1 alleles and haplotype in Parkinson's disease from South India

Parkinson's disease (PD) is a chronic, neurodegenerative motor disease exhibiting familial and sporadic forms. The present study was aimed to elucidate the association of HLA-DRB1*, DQA1* and DQB1* alleles with PD. A total of 105 PD patients and 100 healthy controls were typed by PCR-SSP method. We further carried out high-resolution genotyping for DQB1 and DQA1. Results revealed the increased frequencies of alleles DRB1*04 (OR = 2.36), DRB1* 13 (OR = 4.04), DQA1* 01:04:01 (OR = 4.51), DQB1*02:01 (OR = 2.66) and DQB1*06:03 (OR = 2.65) in PD patients suggesting susceptible associations. Further, decreased frequencies observed for alleles DRB1*10 (OR = 0.34), DRB1*15 (OR = 0.44), DQA1*04:01 (OR = 0.28), DQA1*06:01 (OR = 0.11) and HLA-DQB1*05:01 (OR = 0.37) among patients have suggested protective associations. Significant disease associations were observed for two-locus haplotype such as DRB1*13-DQB1*06:03 (OR = 11.52), DQA1*01:041-DQB1*06:03 (OR = 16.50), DQA1*01:041-DQB1*05:02 (OR = 5.38) and DQA1*04:01-DQB1*06:03 (OR = 3.027). Protective associations were observed for haplotypes DRB1*10-DQB1*05:01 (OR = 0.21), DRB1*15-DQB1*06 (OR = 0.006), DQA1*04:01-DQB1*05:01 (OR = 0.400) and DQA1*04:01-DQB1*05:03 (OR = 0.196). The critical amino acid residue analyses have revealed strong susceptible association for the residues of DQB1 alleles such as: L²⁶, S²⁸, K⁷¹, T⁷¹ and A⁷⁴, Y⁹, S³⁰, D³⁷, I³⁷, A³⁸, A⁵⁷ and S⁵⁷; and for the residues of DQA1 alleles such as: C¹¹, F⁶¹, I⁷⁴, and M⁷⁶. Similarly, amino acid residues such as A¹³, G²⁶, Y²⁶, A⁷¹, S⁷⁴, L⁹ and V³⁸ of HLA-DQB1 alleles and residues such as Y¹¹, G⁶¹, S⁷⁴ and L⁷⁶ of DQA1 alleles showed protective associations. Thus, our study documented the susceptible and protective associations of DRB1*, DQB1 and DQA1 alleles and haplotypes in developing the disease and their influence on longevity of PD patients in south India.

Risk factors predisposing to acute stroke in India: a prospective study

BACKGROUND

Stroke is an important neurological disorder with significant morbidity and mortality. In India, the risk factors for stroke (obesity, diabetes mellitus, alcoholism, hypertension, and sedentary lifestyle) are mounting with economic growth and increasing the disease burden.

OBJECTIVE

To assess the severity and risk factors of stroke in India and identify any new predisposing factors.

METHODS

A multicentric (six tertiary care hospitals across India) prospective observational study (from September 2016 to July 2017) was conducted on 526 stroke patients, presenting within the first 24 h to examine the risk factors for ischemic and hemorrhagic strokes. Severity was determined using the National Institutes of Health Stroke Scale (NIHSS).

RESULTS

Predominantly male (72.3%), 75% of the sample was >50 years old, with a mean body mass index (BMI) of 25.8 ± 4.3 kg/m2 and 14.6% obese patients. Hypertension and diabetes mellitus were the commonest comorbidities, followed by a history of ischemic heart disease and familial history of stroke. 20.5% of patients had mild strokes, 57.4% had moderate, 8.4% experienced moderate-severe strokes, whereas 7.2% had severe strokes. Regarding the admission diagnoses, 56.8% were ischemic, 18.6% were hemorrhagic, 1.1% had a transient ischemic attack, 6.6% suffered recurrent strokes, and 17% were other forms.

CONCLUSION

The foremost risk factors for stroke in India, hypertension and diabetes, need to be controlled and treated like other global high-risk populations for stroke prevention. The NIHSS scores highlight the relationship between risk factors and stroke severity.

An overview on therapeutic and medicinal potential of poly-hydroxy flavone viz. Heptamethoxyflavone, Kaempferitrin, Vitexin and Amentoflavone for management of Alzheimer's and Parkinson's diseases: a critical analysis on mechanistic insight

Neurodegenerative disorders occur when nerve cells in the brain or peripheral nervous system partial or complete fail in their functions and sometimes even die due to some injuries or aging. Neurodegenerative disorders such as Alzheimer's Disease (AD) and Parkinson's Disease (PD), have been majorly resulted due to degeneration of neurons and neuroinflammation progressively. There are many similarities that correlates both AD and PD on a cellular and sub-cellular level. Therefore, a hope for therapeutic advancement for simultaneous upgradation in both the diseases are directly depending on the discovery of common mechanism at molecular and cellular level. Recent and past evidences from scientific literature supporting the efficacy of plants flavonoids in treatment and protection of both AD and PD. Further, dietary flavones, specially Heptamethoxyflavone, Kaempferitrin, Vitexin and Amentoflavone gains recently much more attention for producing many health beneficiary effects including neuroprotection. Despite of these evidence a detailed updated overview of neuroprotective effects against both AD and PD by Heptamethoxyflavone, Kaempferitrin, Vitexin and Amentoflavone are still missing. In this context several published studies were assessed by using various online electronic search engines/databases to meet the objective from 1981 to 2021 (Approx. 224). Therefore, present review was designed to deliver the detailed description on these flavones including therapeutic benefits in AD, PD and other CNS complications with critical analysis on underlying mechanisms.

Good Death in Neurological Practice

Background

Clinicians in neurological practice, particularly surgeons, encounter more deaths than most other specialists.

Objective

This communication reviews the literature on "good death" and extrapolates the observations and inferences to neurological practice. Changes in approaches to "good death" in the COVID-19 era (coronavirus disease 2019) are also discussed.

Materials and Methods

The author, over a 40-year period, has come across 2,500 deaths in a government, trust, and corporate hospital in Chennai, India. Retrospectively, the author questions if, in spite of his conservatism and obsession with quality of life, he should have taken proactive measures to also ensure a good quality of death.

Results and Conclusion

In the background of the lessons learned in a metro, across various socioeconomic groups and with varied access to technology, the author concludes that ensuring "good death" should also fall within the domain of neurologic practice.

The burden of neurological disorders across the states of India: the Global Burden of Disease Study 1990-2019

BACKGROUND

A systematic understanding of the burden of neurological disorders at the subnational level is not readily available for India. We present a comprehensive analysis of the disease burden and trends of neurological disorders at the state level in India.

METHODS

Using all accessible data from multiple sources, we estimated the prevalence or incidence and disability-adjusted life-years (DALYs) for neurological disorders from 1990 to 2019 for all states of India as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. We assessed the contribution of each neurological disorder to deaths and DALYs in India in 2019, their trends in prevalence or incidence and DALY rates over time, and heterogeneity between the states of India. We also assessed the Pearson correlation coefficient between Socio-demographic Index (SDI) of the states and the prevalence or incidence and DALY rates of each neurological disorder. Additionally, we estimated the contribution of known risk factors to DALYs from neurological disorders. We calculated 95% uncertainty intervals (UIs) for the mean estimates.

FINDINGS

The contribution of non-communicable neurological disorders to total DALYs in India doubled from 4·0% (95% UI 3·2-5·0) in 1990 to 8·2% (6·6-10·2) in 2019, and the contribution of injury-related neurological disorders increased from 0·2% (0·2-0·3) to 0·6% (0·5-0·7). Conversely, the contribution of communicable neurological disorders decreased from 4·1% (3·5-4·8) to 1·1% (0·9-1·5) during the same period. In 2019, the largest contributors to the total neurological disorder DALYs in India were stroke (37·9% [29·9-46·1]), headache disorders (17·5% [3·6-32·5]), epilepsy (11·3% [9·0-14·3]), cerebral palsy (5·7% [4·2-7·7]), and encephalitis (5·3% [3·7-8·9]). The crude DALY rate of several neurological disorders had considerable heterogeneity between the states in 2019, with the highest variation for tetanus (93·2 times), meningitis (8·3 times), and stroke (5·5 times). SDI of the states had a moderate significant negative correlation with communicable neurological disorder DALY rate and a moderate significant positive correlation with injury-related neurological disorder DALY rate in 2019. For most of the non-communicable neurological disorders, there was an increase in prevalence or incidence from 1990 to 2019. Substantial decreases were evident in the incidence and DALY rates of communicable neurological disorders during the same period. Migraine and multiple sclerosis were more prevalent among females than males and traumatic brain injuries were more common among males than females in 2019. Communicable diseases contributed to the majority of total neurological disorder DALYs in children younger than 5 years, and non-communicable neurological disorders were the highest contributor in all other age groups. In 2019, the leading risk factors contributing to DALYs due to non-communicable neurological disorders in India included high systolic blood pressure, air pollution, dietary risks, high fasting plasma glucose, and high body-mass index. For communicable disorders, the identified risk factors with modest contributions to DALYs were low birthweight and short gestation and air pollution.

INTERPRETATION

The increasing contribution of non-communicable and injury-related neurological disorders to the overall disease burden in India, and the substantial state-level variation in the burden of many neurological disorders highlight the need for state-specific health system responses to address the gaps in neurology services related to awareness, early identification, treatment, and rehabilitation.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Recalling the pathology of Parkinson's disease; lacking exact figure of prevalence and genetic evidence in Asia with an alarming outcome: A time to step-up

Parkinson's disease (PD) is the second most common and progressive neurodegenerative disease globally, with major symptoms like bradykinesia, impaired posture, and tremor. Several genetic and environmental factors have been identified but elucidating the main factors have been challenging due to the disease's complex nature. Diagnosis, prognosis, and management of such diseases are challenging and require effective targeted attention in developing countries. Recently, PD is growing rapidly in many crowded Asian countries as an alarming threat with inadequate knowledge of its prevalence, genetic architecture, and geographic distribution. This study gave an in-depth overview of the prevalence, incidence and genomic/genetics studies published so far in the Asian population. To the best of our knowledge, PD has increased significantly in several Asian countries, including China, South Korea, Japan, Thailand, and Israel over the past few years, requiring a greater level of care and attention. Genetic screening of families with PD at national levels and establishing an official database of PD cases are essential to get a comprehensive and conclusive view of the exact prevalence and genetic diversity of PD in the Asian population to properly manage and treat the disease.

Chronic Neurological Disorders: Genetic and Epigenetic Markers for Monitoring of Pharmacotherapy

Introduction

Chronic neurological diseases are a major cause of mortality and morbidity in the world. With increasing life expectancy in the developing world, the incidence and prevalence of these diseases are predicted to rise even further. This has also contributed to an increase in disability-adjusted life years (DALYs) for noncommunicable diseases. Treatment for such diseases also poses a challenge with multiple genetic and epigenetic factors leading to a varied outcome. Personalization of treatment is one way that treatment outcome/prognosis of disease can be improved, and pharmacogenomics plays a significant role in this context.

Methodology

This article reviewed the evidence pertaining to the association of genetic and epigenetic markers with major neurological disorders like multiple sclerosis (MS), Alzheimer's disease (AD), and Parkinson's disease (PD), which are a major source of burden among neurological disorders. Types of studies included are peer-reviewed original research articles from the PubMed database (1999-2018).

Results

This study compiled data regarding specific genetic and epigenetic markers with a significant correlation between the clinical diagnosis of the disease and prognosis of therapy from 65 studies. In a single platform, this review highlights the clues to some vital questions, such as why interferon beta (IFN-β) therapy fails to improve symptoms in all MS patients? why cholinesterase inhibitors fail to improve cognitive impairment in a subset of people suffering from AD? or why some individuals on levodopa (L-DOPA) for PD suffer from side-effects ranging from dyskinesia to hallucination while others do not?

Conclusion

This article summarizes the genetic and epigenetic factors that may either require monitoring or help in deciding future pharmacotherapy in a patient suffering from MS, AD, and PD. As the health care system develops and reaches newer heights, we expect more and more of these biomarkers to be used as pharmacotherapeutic outcome indicators.

Epidemiology of Parkinson's Disease in Rural Gujarat, India

INTRODUCTION

In India, there have been only few published studies of Parkinson's disease (PD) showing a wide range of prevalence. We conducted this study to determine the prevalence of PD in the rural population of Gujarat, in the western region of India.

METHODS

This cross-sectional descriptive study was conducted in the villages of Anand, a district of Gujarat, India, between September 2019 and February 2020. This study used a multistep approach including a screening questionnaire and video recording followed by clinical examination by a neurologist, laboratory evaluation, and brain imaging to evaluate patients with PD.

RESULTS

A total population of 18,896 was screened. The overall crude prevalence of PD was 42.3 per 100,000, and the prevalence over the age of 60 was 308.9 per 100,000 which showed the trend of increasing disease prevalence with age. Their mean duration of illness was 39.3 ± 27.3 months, and more than half of patients with PD had multiple associated nonmotor symptoms and nearly one-third had comorbid anxiety or depression. Environmental factors are important in the pathogenesis of PD, but there was no clear association between patients with PD and certain variables including consumption of well water, exposure to pesticides or other toxins, smoking cigarettes, and drinking alcohol or coffee in our study.

CONCLUSIONS

The present study showed the current epidemiological data of PD from Gujarat, in western India. Further studies across different regions in India need to be encouraged for better understanding of PD prevalence in the Indian population.

The role of the P2X4 receptor in trigeminal neuralgia, a common neurological disorder

Neurological disorders, which include various types of diseases with complex pathological mechanisms, are more common in the elderly and have shown increased prevalence, morbidity and mortality worldwide. Unfortunately, current therapies for these diseases are usually suboptimal or have undesirable side effects. This necessitates the development of new potential targets for disease-modifying therapies. P2X4R, a type of purinergic receptor, has multiple roles in neurological disorders. In this review, we briefly introduce a neurological disorder, trigeminal neuralgia and its' symptoms, etiology and pathology. Moreover, we focused on the role of P2X4R in neurological disorders and their related pathophysiologic mechanisms. Further studies of P2X4R are required to determine potential therapeutic effects for these pathophysiologies.

A Collaborative Tele-Neurology Outpatient Consulation Service in Karnataka: Seven Years of Experience From a Tele-Medicine Center

Background

Neurology services in rural and semi-urban part of India are very limited, due to poor infrastructure, resources, and manpower. Tele-neurology consultations at a non-urban setup can be considered as an alternative and innovative approach and have been quite successful in developed countries. Therefore, an initiative to bridge this health gap through Tele-Medicine has been taken by the Government of India.

Aim

To study the sociodemographic and clinical profiles of patients who have received collaborative Tele-Neurology consultations from the Tele-Medicine Centre, National Institute of Mental Health and Neurosciences, Bengaluru.

Methodology

We reviewed case files of such patients between December 2010 and March 2017. A total 189 collaborative tele-neurology outpatient consultations were provided through the Tele-Medicine Centre, located at a tertiary hospital-based research centre in southern India.

Results

The mean age of the patients was 39.6 (±19) years and 65.6% were aged between 19 to 60 years; 50.8% were male. The most common diagnosis was a seizure disorder in 17.5%, followed by cerebrovascular accident/stroke in 14.8%. Interestingly, 87.3% were found to benefit from tele-neurology consultations using interventions such as a change of medications in 30.1%, referral to a specialist for review in 15.8%, and further evaluation of illness and inpatient care for 7.93%.

Conclusion

This study has demonstrated the successful implementation of outpatient-based collaborative tele neurology consultation in Karnataka.

The development and efficacy of a mobile phone application to improve medication adherence for persons with epilepsy in limited resource settings: A preliminary study

OBJECTIVE

Persons with epilepsy (PWE), especially those with limited education backgrounds from developing countries, are challenged by complicated medication regimens, debilitating seizures, and stigmatization in their daily life. Consequently, it is difficult for physicians to ensure medication adherence. This study validates a novel mobile application which was hypothesized to increase medication adherence and self-management skills in PWE. Created by medical professionals, the application included behavioral and educational components and was built to be easy-to-understand for those of socio-economically disadvantaged backgrounds.

METHODS

This was a parallel, two-armed randomized controlled trial in which a total of 96 participants were enrolled from a Neurology Outpatient Department into a control standard care group and a mobile application group that used the smartphone application (app) in addition to the standard medical treatment. The app was intuitive and easy to understand for those coming from a socio-economically disadvantaged background. Medication adherence and self-efficacy were assessed with the Morisky Green and Levine Scale (MGLS) and the Epilepsy Self Efficacy Scale (ESES). Patients were reassessed 12 weeks later. Change in seizure frequency following administration of the application was a secondary outcome.

RESULTS

In an intent-to-treat analysis, the mobile application interventional group showed over a 60% increase in the proportion of medication adherence (P < 0.0001). The mean self-efficacy score for the mobile application group was increased from 269.5 to 289.75 (P < 0.0001). The control group showed no statistically significant increases in either the proportion adherent or mean self-efficacy scores.

SIGNIFICANCE

This study demonstrated the statistically significant performance of a mobile application in improving medication adherence and self-management skills in Indian persons with epilepsy.

Hypoxic Preconditioning Induces Neuronal Differentiation of Infrapatellar Fat Pad Stem Cells through Epigenetic Alteration

Hypoxia is considered a key factor in cellular differentiation and proliferation, particularly during embryonic development; the process of early neurogenesis also occurs under hypoxic conditions. Apart from these developmental processes, hypoxia preconditioning or mild hypoxic sensitization develops resistance against ischemic stroke in deteriorating tissues. We therefore hypothesized that neurons resulting from hypoxia-regulated neuronal differentiation could be the best choice for treating brain ischemia, which contributes to neurodegeneration. In this study, infrapatellar fat pad (IFP), an adipose tissue present beneath the knee joint, was used as the stem cell source. IFP-derived stem cells (IFPSCs) are totally adherent and are mesenchymal stem cells. The transdifferentiation protocol involved hypoxia preconditioning, the use of hypoxic-conditioned medium, and maintenance in maturation medium with α-lipoic acid. The differentiated cells were characterized using microscopy, reverse transcription PCR, real time PCR, and immunocytochemistry. To evaluate the epigenetic reprogramming of IFPSCs to become neuron-like cells, methylation microarrays were performed. Hypoxia preconditioning stabilized and allowed for the translocation of hypoxia inducible factor 1α into the nucleus and induced achaete-scute homologue 1 and doublecortin expression. Following induction, the resultant cells expressed neuronal markers neuron-specific enolase, neurofilament-light chain, growth associated protein 43, synaptosome associated protein 25, and β-III tubulin. The differentiated neural-lineage cells had functional gene expression pertaining to neurotransmitters, their release, and their receptors. The molecular signaling mechanisms regulated developmental neurogenesis. Furthermore, the in vitro physiological condition regulated neurotransmitter respecification or switching during IFPSC differentiation to neurons. Thus, differentiated neurons were fabricated against the ischemic region to treat neurodegenerative diseases.

Prevalence of major neurological disorders in predominantly rural northwest India

Background

Epidemiological studies based on hospital population, geographic isolates, smaller population, and focused groups provide valuable information on the pattern of diseases, but do not reflect on the true prevalence rates or the changing trends of disease over a period of time in different communities. The present study was undertaken to determine the prevalence and pattern of various neurological disorders in Himachal Pradesh.

Methodology

Study was carried out in urban and rural population of district Kangra of Himachal Pradesh. A proportional representation was given to each area in the allocation of sample size as per probability proportional to size (PPS) method using a two-phase design: 1) A screening phase and 2) a clinical evaluation phase. All subjects were screened and a subset (screen positive and 10% of screen negative) was identified for the detailed clinical evaluation after screening. A standardized screening battery (NIMHANS protocol) was used for this purpose. An individual was confirmed as a case of neurological disorder only after clinical evaluation.

Results

A total of 260 (out of 10,000 studied) individuals were found positive for neurological disorders yielding a crude prevalence of 2.6%. The crude prevalence for rural areas was found to be 2.28% (206/9000), whereas the crude prevalence in urban area was found to be 5.4% (54/1000). Migraine was the most common disorder.

Conclusion

In view of the high crude prevalence of major neurological disorders, there is a need to develop capacity among healthcare professionals regarding them.

Nexus between light and culture media on morphogenesis in Bacopa monnieri and saponin yield thereof

Bacopa monnieri, a well-documented nootropic plant of high commercial global demand had been explored for its effect in alleviating other diseases and symptoms. This is primarily attributed to different phytocompounds present in the plant. One of the major constituents among them are saponins. However, variation in agro-climatic conditions and choice of germplasm often affect the growth rate and yield of phytocompounds that significantly impact the efficacy of the plant and its extract. Tissue culture has been attempted to improve the yield of phytocompounds but is often restricted by higher cost and scalability. Current study explores the role of commercial hydroponic media ‘Leafy 200’ vis-à-vis Murashige and Skoog (MS) media, under different color and intensity of lights, on plant morphogenesis, biomass and saponin yield. Blue light induced more shoot differentiation than normal white light. Statistical studies performed using fractional factorial design showed no significant variations in the yield of saponins among the extracts. The study suggests that hydroponic culture to be a sustainable solution and possible substitute to tissue culture that may be exploited for scalable cultivation of the plant.

Yoga as a holistic approach for stress management in Oral Cancer patients. A prospective study

Background and Aims:

Oral cancer has been ranked as the sixth most common cancer globally. It has been reported to be increasing in incidence especially, in the southern parts of Asia which chiefly includes, India. Diagnosis of oral cancer is followed by a vigorous and highly morbid treatment protocol which drastically impacts the patient's quality of life. This in turn can cause extreme stress in a person. This study aimed to assess the impact of the practice of Yoga on stress levels in cancer patients.

Materials and Methods:

A total of 200 subjects diagnosed with oral cancer were selected for this study. Their stress levels were scored both before and after initiating the practice of Yogic exercises in a one-month interval using a questionnaire. Obtained scores were entered in Microsoft Excel 2007 worksheet and an unpaired t-test was applied. P values of less than 0.05 and 0.001 were considered statistically significant and extremely significant, respectively.

Results:

Study results showed a reduction in stress level scores (48 ± 0.99 to 37 ± 5.2) after adopting yoga for one month. An extremely significant P value of less than 0.001 was obtained.

Conclusion:

It can be concluded from this study that yoga is an effective method in reducing stress levels in individuals diagnosed with oral cancer.

Polycomb repressive complex 1: Regulators of neurogenesis from embryonic to adult stage

Development of vertebrate nervous system is a complex process which involves differential gene expression and disruptions in this process or in the mature brain, may lead to neurological disorders and diseases. Extensive work that spanned several decades using rodent models and recent work on stem cells have helped uncover the intricate process of neuronal differentiation and maturation. There are various morphological changes, genetic and epigenetic modifications which occur during normal mammalian neural development, one of the chromatin modifications that controls vital gene expression are the posttranslational modifications on histone proteins, that controls accessibility of translational machinery. Among the histone modifiers, polycomb group proteins (PcGs), such as Ezh2, Eed and Suz12 form large protein complexes-polycomb repressive complex 2 (PRC2); while Ring1b and Bmi1 proteins form core of PRC1 along with accessory proteins such as Cbx, Hph, Rybp and Pcgfs catalyse histone modifications such as H3K27me3 and H2AK119ub1. PRC1 proteins are known to play critical role in X chromosome inactivation in females but they also repress the expression of key developmental genes and tightly regulate the mammalian neuronal development. In this review we have discussed the signalling pathways, morphogens and nuclear factors that initiate, regulate and maintain cells of the nervous system. Further, we have extensively reviewed the recent literature on the role of Ring1b and Bmi1 in mammalian neuronal development and differentiation; as well as highlighted questions that are still unanswered.

Neural functions of the aging brain: Daily living, developmental and geriatric disabilities

Neuronal, microglial, astrocytic and oligodendrocytic functions of the brain are significantly affected during normal aging, and more so if inflicted with neurological diseases. Aging is a consistent risk factor for many neurodegenerative diseases that are sporadic in nature, whereas developmental neurological disabilities stem from errors in brain development. The neuronal functions are affected in both developmental disabilities and geriatric diseases. This special issue, is based on the two-days meeting at Thiruvanathapuram, India on 'Neural Functions of Aging Brain', which had several original presentations, as well as full reviews by neurobiologists and clinicians from India. Out of these, thirteen peer reviewed contributions are published in the present Special Issue of this Journal. This 'Foreword' is also a brief overview on the current scenario of neurobiology research on developmental disabilities and ageing in India based on the manuscripts included in the special issue, vis-s-vis the global scenario. Apparently, there is a void in geriatric and developmental neuroscience research in India since huge data mining and translation, concerted efforts on clinical neuroscience research, and consistent efforts on pure basic research resulting in 'first in the field' novelty are largely missing. Overall, Indian neuroscience excels in making meaningful relevance of contemporary discoveries in neuroscience and contributing towards advances in their applications.

Phytochemical Profile, Pharmacological Attributes and Medicinal Properties of Convolvulus prostratus - A Cognitive Enhancer Herb for the Management of Neurodegenerative Etiologies

Convolvulus prostratus Forssk., a nootropic herb used in traditional medicinal systems, is also frequently known by its taxonomic synonym Convolvulus pluricaulis. In Indian medicinal system - Ayurveda - it is named as Shankhpushpi. According to the ancient literature, this herb has been attributed with several therapeutic properties, such as anxiolytic, neuroprotective, antioxidant, analgesic, immunomodulatory, antimicrobial, antidiabetic and cardioprotective activities. This medicinal herb has been reported to contain many bioactive phytoconstituents, such as, alkaloid (convolamine), flavonoid (kaempferol) and phenolics (scopoletin, β-sitosterol and ceryl alcohol), that have been ascribed to the observed medicinal properties. Several research teams across the globe have highlighted the neuro-pharmacological profile of C. prostratus, wherein, the neuroprotective, nootropic and neuro-modulatory roles have been described. Besides, role of C. prostratus extracts in neurodegeneration has been well demonstrated. Despite of such elaborative preclinical pharmacological profile, detailed clinical investigations and mechanistic mode-of-action studies of this important herb are yet to be executed. The present review is attempted to showcase the phytochemical profile, pharmacological attributes and medicinal information of C. prostratus; with comprehensive research gap analysis. It is hoped that the scientific update on the ethnomedicinal aspects of this herb would thrive research propagation and development of the CNS phytopharmaceuticals, originated from C. prostratus.

Stroke Happens Suddenly so It Cannot Be Prevented: A Qualitative Study to Understand Knowledge, Attitudes, and Practices about Stroke in Rural Gadchiroli, Maharashtra, India

Background  Strokes have emerged as one of the leading causes of deaths in rural India but people often remain uninformed about it. This study sought to understand knowledge, attitudes, and healthcare-seeking practices about strokes in rural Gadchiroli, India.

Methods  A total of 12 focus group discussions were conducted with 34 female and 43 male participants from six villages. Responses were audio recorded, transcribed, coded, and analyzed using inductive method of qualitative data analysis.

Results  Respondents correctly recognized many symptoms of stroke and were aware of the sudden onset of symptoms. They were unaware of transient ischemic attacks. After stroke, healthcare was sought from private physicians, and physicians in the government run district hospital, or traditional herbal providers depending upon the accessibility, affordability, and perceived effectiveness of the therapy. Most of the respondents thought that stroke is a serious disease associated with disability as well as death and its occurrence in the community is increasing. However, only a few participants could correctly state how stroke occurs and its risk factors. Furthermore, many participants thought that stroke cannot be prevented as it occurs suddenly without any warning.

Conclusion  Rural people in Gadchiroli were aware of symptoms of stroke but awareness about the etiology and the risk factors was low. Suddenness of symptoms was perceived as a key barrier to taking any preventive action. Understanding such perceptions and addressing them can help improve counseling of patients by physicians and effectiveness of behavioral change communication to prevent stroke in rural areas.

Altered plasma prostaglandin E2 levels in epilepsy and in response to antiepileptic drug monotherapy

Prostaglandin E₂ (PGE₂), a physiologically active lipid compound, is increased in several diseases characterized by chronic inflammation. To determine its significance in epilepsy-associated inflammation and response to antiepileptic drug (AED), we evaluated the plasma PGE₂ (median, pg/ml) levels in drug-free patients with epilepsy (N = 34) and patients receiving AED monotherapy (N = 55) in addition to that in healthy controls (N = 34). When compared to controls, plasma PGE₂ levels were significantly elevated in all drug-free patients independent of the type of epilepsy (137.2 versus 475.7 pg/ml, p < 0.0001). Among the patients receiving AED monotherapy, only valproate responders showed a significant decrease compared to both drug-free patients (232.1 versus 475.7 pg/ml, p < 0.01) as well as valproate non-responders (232.1 versus 611.9 pg/ml, p < 0.0001). Both responders and non-responders on phenytoin or carbamazepine monotherapy had elevated PGE₂ levels similar to drug-free patients. In addition, no difference was observed in plasma profiles of PGE₂ precursor, arachidonic acid among the groups. Our work presents the clinical evidence of the association between plasma PGE₂ levels and valproate efficacy in patients with epilepsy.

Parkinson's Disease in the Middle East, North Africa, and South Asia: Consensus from the International Parkinson and Movement Disorder Society Task Force for the Middle East

BACKGROUND

Understanding the regional needs and available healthcare resources to treat Parkinson's disease (PD) is essential to plan appropriate future priorities. The International Parkinson and Movement Disorder Society (MDS) Task Force for the Middle East was established to raise awareness and promote education across the region on PD and other movement disorders. Broadly, the task force encompasses the countries of the Middle East but has included North Africa and South Asia as well (MENASA).

OBJECTIVE

To create a list of needs and priorities in the advancement of PD in MENASA countries based on consensuses generated by the MDS task force for the Middle East.

METHODS

A Strengths Weaknesses-Opportunities-Threats (SWOT) analysis was conducted by the task force members to generate consensus about PD care this region.

RESULTS

Eight overarching principles emerged for the consensus statement on current needs: more movement disorders specialists, multidisciplinary care, accurate epidemiologic data, educational programs, availability of drugs, and availability of more advanced therapy, enhanced health care resources and infrastructure, and greater levels of awareness within the general population and among health care professionals.

CONCLUSION

This pilot study sheds light on unmet needs for providing care to people with PD in the MENASA region. These data offer directions on priorities to increase awareness of PD, to develop better infrastructure for research and management of PD, to foster healthcare policy discussions for PD and to provide educational opportunities within these countries.

Factors affecting fear of falls in patients with chronic stroke

Objective: The aim of this study was to find the factors associated with fear of falls in patients having chronic stroke.Methods: Inclusion criterion was subjects with cerebral stroke for more than 3 months. A structured interview of 82 subjects was conducted with a questionnaire with questions regarding personal factors such as gender, side affected, number of comorbidities, and setting of physical therapy sessions. Depression was assessed using Patient Health Questionnaire-9, lower extremity motor function was assessed using Fugl-Meyer scale, and functional mobility was assessed using Timed Up and Go. Chi-square analysis was done on the above factors to find significant factors followed by logistic regression of the factors found significant in Chi square.Results: Lower extremity Fugl-Meyer score was significantly associated with fear of falls (p value 0.047 with Odds ratio of 1.136, 95% CI 1.002-1.287) in patients having chronic stroke while treatment factors, such as setting of physical therapy sessions, and personal factors, such as gender, side affected, number of comorbidities, depression, functional mobility, or use of walking aid, were not found to have significant association.Conclusion: The lower extremity Fugl-Meyer score is associated with fear of falls in patients having chronic stroke.

The Evolving Neural Tissue Engineering Landscape of India

The healthcare sector in India is witnessing unprecedented advancement. Tissue engineering has become an integral part of healthcare and medicine, particularly where treatments involve functional restoration of any injured or deceased part of the body. Not falling behind much with the progressing medical and healthcare sector of India, tissue engineering is also gaining momentum in the country. Out of several arenas of tissue engineering, India has made its mark in orthopedic and bone regeneration, cosmetic and skin regeneration, and very importantly neural regeneration. There are several articles reviewing the progress and prospects of orthopedic and skin regeneration research in India. However, there is no systematic review on progress, prospects, and pitfalls associated with neural tissue engineering in Indian context. The existing ones mainly focus on the technical advancements in the field from a global perspective. Therefore, it is worthwhile to have an organized look at the evolving neural tissue engineering landscape of India. This review will walk the readers systematically through different aspects of the topic. The review starts with an introduction to the nervous system to help readers appreciate the complexity that must be dealt with while engineering neural tissue. This is followed with a global picture of the neural tissue engineering, prominent research groups working on neural tissue engineering in India, factors that have and are currently molding the prospects of this field, and concluding with an overall perspective on present and future of neural tissue engineering in India.

Genomics of rare genetic diseases-experiences from India

Home to a culturally heterogeneous population, India is also a melting pot of genetic diversity. The population architecture characterized by multiple endogamous groups with specific marriage patterns, including the widely prevalent practice of consanguinity, not only makes the Indian population distinct from rest of the world but also provides a unique advantage and niche to understand genetic diseases. Centuries of genetic isolation of population groups have amplified the founder effects, contributing to high prevalence of recessive alleles, which translates into genetic diseases, including rare genetic diseases in India.Rare genetic diseases are becoming a public health concern in India because a large population size of close to a billion people would essentially translate to a huge disease burden for even the rarest of the rare diseases. Genomics-based approaches have been demonstrated to accelerate the diagnosis of rare genetic diseases and reduce the socio-economic burden. The Genomics for Understanding Rare Diseases: India Alliance Network (GUaRDIAN) stands for providing genomic solutions for rare diseases in India. The consortium aims to establish a unique collaborative framework in health care planning, implementation, and delivery in the specific area of rare genetic diseases. It is a nation-wide collaborative research initiative catering to rare diseases across multiple cohorts, with over 240 clinician/scientist collaborators across 70 major medical/research centers. Within the GUaRDIAN framework, clinicians refer rare disease patients, generate whole genome or exome datasets followed by computational analysis of the data for identifying the causal pathogenic variations. The outcomes of GUaRDIAN are being translated as community services through a suitable platform providing low-cost diagnostic assays in India. In addition to GUaRDIAN, several genomic investigations for diseased and healthy population are being undertaken in the country to solve the rare disease dilemma.In summary, rare diseases contribute to a significant disease burden in India. Genomics-based solutions can enable accelerated diagnosis and management of rare diseases. We discuss how a collaborative research initiative such as GUaRDIAN can provide a nation-wide framework to cater to the rare disease community of India.

Sex Hormones and Cognition: Where Do We Stand?

Hypothalamic-pituitary-gonadal axis regulates the reproductive system. The overall health and wellbeing of a woman is subject to fluctuations in the sex hormones throughout her lifespan. Menopause, either natural or surgically induced, is often associated with cognitive complaints, especially memory disturbances. Sex hormones, besides affecting the reproductive function, affect the central nervous system in many ways. Here, we aim to review the role of sex hormones in cognition and the current evidence on use of or against menopausal hormonal therapy as a cognition enhancer in women with cognitive disturbances, including those with Alzheimer's disease.

Risk for Parkinson's Disease in Patients with Behçet's Disease: A Nationwide Population-Based Dynamic Cohort Study in Korea

BACKGROUND

Although several studies have reported a correlation between Behçet's disease (BD) and Parkinson's disease, this association has not yet been clarified.

OBJECTIVE

To determine the risk of Parkinson's disease in patients with BD.

METHODS

BD patients (n = 17,179; mean age, 51.12±8.09 years; male, 34.95%) without known previous diagnosis of Parkinson's disease were selected from the Korean National Health Insurance Database between 2010 and 2013. An age- and gender-matched control population of individuals without BD was randomly sampled at a ratio of 3:1 (n = 34,575). Both cohorts were followed for development of Parkinson's disease until 2015.

RESULTS

Among a total of 11,525 BD patients, 50 (0.43%) developed Parkinson's disease, whereas only 51 among the 34,575 individuals in the non-BD group developed Parkinson's (0.15%, P < 0.0001). The incidence of Parkinson's disease was significantly higher in BD patients than in controls. In addition, during the follow-up period, patients with BD were more likely to be diagnosed with Parkinson's disease than those in the non-BD group.

CONCLUSIONS

BD patients had a higher risk of Parkinson's disease compared to non-BD controls. Physicians should carefully monitor patients with BD for potential development of Parkinson's disease.

Multi-gene testing in neurological disorders showed an improved diagnostic yield: data from over 1000 Indian patients

BACKGROUND

Neurological disorders are clinically heterogeneous group of disorders and are major causes of disability and death. Several of these disorders are caused due to genetic aberration. A precise and confirmatory diagnosis in the patients in a timely manner is essential for appropriate therapeutic and management strategies. Due to the complexity of the clinical presentations across various neurological disorders, arriving at an accurate diagnosis remains a challenge.

METHODS

We sequenced 1012 unrelated patients from India with suspected neurological disorders, using TruSight One panel. Genetic variations were identified using the Strand NGS software and interpreted using the StrandOmics platform.

RESULTS

We were able to detect mutations in 197 genes in 405 (40%) cases and 178 mutations were novel. The highest diagnostic rate was observed among patients with muscular dystrophy (64%) followed by leukodystrophy and ataxia (43%, each). In our cohort, 26% of the patients who received definitive diagnosis were primarily referred with complex neurological phenotypes with no suggestive diagnosis. In terms of mutations types, 62.8% were truncating and in addition, 13.4% were structural variants, which are also likely to cause loss of function.

CONCLUSION

In our study, we observed an improved performance of multi-gene panel testing, with an overall diagnostic yield of 40%. Furthermore, we show that NGS (next-generation sequencing)-based testing is comprehensive and can detect all types of variants including structural variants. It can be considered as a single-platform genetic test for neurological disorders that can provide a swift and definitive diagnosis in a cost-effective manner.

Epidemiological Survey of Neurological Diseases in a Tribal Population Cluster in Gujarat

Background:

There are few community-based neuroepidemiological studies based in tribal communities. This cross-sectional community-based study explored the prevalence rates of neurological disorders in the tribal region of Kaparada in Gujarat.

Methodology:

A two-stage methodology was used. Door-to-door surveys were conducted in the villages of Moti Vahiyal, Arnai, and Chavshala in Kaparada taluka in the Valsad district. Trained volunteers administered a questionnaire that assessed demographic details and common neurological symptoms in children and adults. Data were obtained from 8217 individuals from 1464 households using the questionnaire in stage 1. A number of 615 individuals reported at least one symptom. In stage 2, a team of neurologists conducted a medical camp to assess those “screened in” for neurological disorders.

Results:

The crude prevalence rate for neurological disorders in general was found to be 2592.19/100,000. The prevalence rates for lower motor neuron diseases were highest (1010.1), and the rates of epilepsy, movement disorders, stroke, vertigo, headaches, upper motor neuron diseases, and mental and behavioral disorders were found to be 255.6, 133.9, 109.53, 170.38, 511.4, 109.53, and 292.08/100,000, respectively. Age- and sex-specific rates and patterns varied for different disorders.

Conclusion:

The prevalence rates of most disorders were found to be lower than those reported elsewhere, but age and sex prevalence patterns were similar to existing research. Challenges in conducting such a study in a remote population are discussed.

Prevalence of Epilepsy and its Association with Exposure to Toxocara canis: A Community Based, Case-control Study from Rural Northern India

Objectives:

Many community-based and hospital-based studies across the world have yielded contradictory results regarding association of positive Toxocara canis serology and epilepsy. The present study was planned to analyze disease burden of epilepsy in rural community of North India and its association with exposure to T. canis in this part of the world.

Methods:

A door-to-door screening survey was carried out in the rural community using a validated questionnaire for epilepsy by trained field workers, which was finally confirmed by trained neurologists. The risk factors for epilepsy and for predisposing infections were also enquired. The results were compared with an equal number of age- and sex-matched healthy controls enrolled from the same community. Serologic evaluation was carried out to detect antibodies against T. canis.

Results:

A total of 41,973 persons from the rural community in 49 villages were enrolled in the study. Two hundred and eleven persons were confirmed to be suffering from active epilepsy, resulting in a crude prevalence of 5 per 1000 population. More than 50% of people with epilepsy were in the second or third decade of life. The prevalence of antibodies to T. canis was similar in people with epilepsy (13.7%; 29 of 211 individuals) and controls (9.95%; 21 of 211 individuals). Of the 151 persons with epilepsy, who underwent CT scan, 34 people (22.3%) had evidence of inflammatory granuloma, thereby confirming high incidence of this infestation in rural Northern India.

Significance:

Our study does not support the association between epilepsy and exposure to T. canis in rural Northern Indian population.

Preventing "Neurophobia": Remodeling Neurology Education for 21st-Century Medical Students through Effective Pedagogical Strategies for "Neurophilia"

Neurology has a reputation, particularly as a complex "head-to-toe" discipline for undergraduate medical students. Neurophobia syndrome, a global phenomenon, fundamentally stems from pedagogical deficiencies during the undergraduate curriculum, the lack of vertical integration between basic neurosciences and clinical bedside neurology, the lack of clinical reasoning exercises, cognitive heuristics, and clinical problem-solving, errors in diagnostic competence, and hyposkilia. This ultimately results in poor clinical competence and proficiency in clinical neurology and causes attrition in nurturing a passion for learning the neurology discipline. This article explores plausible factors that contribute to the genesis of neurophobia and multifaceted strategies to nurture interest in neurosciences and provide possible solutions to demystify neurology education, especially the need for evidence-based educational interventions. Remodeling neurology education through effective pedagogical strategies and remedial measures, and using the Miller's pyramid, would provide a framework for assessing clinical competence in clinical bedside neurology. Technology-enhanced education and digital classrooms would undoubtedly stamp out neurophobia in medical students of the 21^st century. It will not frighten off another generation of nonneurologist physicians to empower them to hone expertise in order to tackle the increasing burden of neurological disorders in India. Furthermore, promoting neurophilia would facilitate the next generation of medical students in pursuing career options in neurology which would be quintessential not only in closing India's looming neurologist workforce gap but also in fostering interest in research imperatives in the next generation of medical students.

Technology-enabled examinations of cardiac rhythm, optic nerve, oral health, tympanic membrane, gait and coordination evaluated jointly with routine health screenings: an observational study at the 2015 Kumbh Mela in India

OBJECTIVES

Technology-enabled non-invasive diagnostic screening (TES) using smartphones and other point-of-care medical devices was evaluated in conjunction with conventional routine health screenings for the primary care screening of patients.

DESIGN

Dental conditions, cardiac ECG arrhythmias, tympanic membrane disorders, blood oxygenation levels, optic nerve disorders and neurological fitness were evaluated using FDA-approved advanced smartphone powered technologies. Routine health screenings were also conducted. A novel remote web platform was developed to allow expert physicians to examine TES data and compare efficacy with routine health screenings.

SETTING

The study was conducted at a primary care centre during the 2015 Kumbh Mela in Maharashtra, India.

PARTICIPANTS

494 consenting 18-90 years old adults attending the 2015 Kumbh Mela were tested.

RESULTS

TES and routine health screenings identified unique clinical conditions in distinct patients. Intraoral fluorescent imaging classified 63.3% of the population with dental caries and periodontal diseases. An association between poor oral health and cardiovascular illnesses was also identified. Tympanic membrane imaging detected eardrum abnormalities in 13.0% of the population, several with a medical history of hearing difficulties. Gait and coordination issues were discovered in eight subjects and one subject had arrhythmia. Cross-correlations were observed between low oxygen saturation and low body mass index (BMI) with smokers (p=0.0087 and p=0.0122, respectively), and high BMI was associated with elevated blood pressure in middle-aged subjects.

CONCLUSIONS

TES synergistically identified clinically significant abnormalities in several subjects who otherwise presented as normal in routine health screenings. Physicians validated TES findings and used routine health screening data and medical history responses for comprehensive diagnoses for at-risk patients. TES identified high prevalence of oral diseases, hypertension, obesity and ophthalmic conditions among the middle-aged and elderly Indian population, calling for public health interventions.