The Pitfalls of NIHSS: Time for a New Clinical Acute Stroke Severity Scoring System in the Emergency?

Stroke is the second leading cause of death and a major cause of disability worldwide. Stroke severity scales serve as reliable means to track a patient's neurological deficit, predict outcome, and guide treatment decisions in clinical practice. The National Institute of Health Stroke Scale (NIHSS) was introduced over 30 years ago, marking a significant milestone in the field of stroke. Over the years, there have been notable advancements in acute stroke care. Despite several modifications made to NIHSS, none has yet succeeded in effectively capturing all the complex effects of a stroke. This review focuses on the pitfalls of NIHSS and emphasizes the need for a quick and comprehensive clinical and upgraded version of the stroke severity rating scale.

Differentiation between Anemia of Chronic Disease and Iron Deficiency Anemia Using Newer Erythrocyte Parameters

Both Iron deficiency anemia (IDA) and anemia of chronic disease (ACD) can present as microcytic anemia. It is important to differentiate between the two, because the treatment is different. In patients presenting with microcytic anemia, bone marrow is often required for differentiation between IDA and ACD. But since bone marrow is an invasive and cumbersome procedure, newer erythrocytic parameters and reticulocyte indices are being studied in differentiation of these two entities. Life span of Reticulocyte is just 1-2 days compared to 120 days of that of an RBC. Therefore, the decrease in reticulocyte hemoglobin content occurs much earlier than an erythrocyte. This makes reticulocyte indices early and reliable indicators of IDA. We explored the value of reticulocyte hemoglobin (Ret Hb) and percentage microcytic RBCs (%Micro R) in the differentiation of both these conditions with bone marrow iron studies being the gold standard.

MATERIAL

Overall 130 patients with iron deficiency anemia and anemia of chronic disease were recruited and they underwent detailed evaluation including RBC indices, Ret Hb, %Micro R, serum iron studies, bone marrow examination including estimation of bone marrow iron. The diagnostic accuracy of Ret Hb and %Micro in differentiation between the two conditions was determined.

OBSERVATION

Ret Hb was found to be positively correlated to serum iron, ferritin and TIBC in diagnosing IDA. At a cut-off value of RET HB of 27 pg/mL, the diagnosis of IDA could be made at a sensitivity of 93.4% and a specificity of 95.83%. Positive predicitive value for Ret Hb was 99% and negative predicitive value was 76.6%. RET HB was found to have best diagnostic efficiency (area under the curve 0.96) on ROC analysis in the differentiation of these two conditions. MICRO R was found to be inferior to other parameters (AUC of 0.39) in the differentiation of these two conditions.

CONCLUSION

Ret Hb differentiates iron deficiency anemia from anemia of chronic disease with a high accuracy rate of 96%. It can be used as a marker of IDA across all situations.

Primary Evans syndrome in an adult man

Evans syndrome (ES) is a simultaneous or subsequent development of two haematological disorders, autoimmune haemolytic anaemia (AIHA) and immune thrombocytopenia (ITP). It can be primary (idiopathic) or secondary (associated with an underlying disease). Primary Evans is a diagnosis of exclusion and has a poorer prognosis than AIHA or ITP alone. We present a 55-year-old man who presented with weakness and lethargy and was diagnosed to be suffering from primary ES.

Hypokalaemic quadriparesis with respiratory failure due to latent Sjogren syndrome

Sjogren's syndrome (SS) is an autoimmune disease with involvement of multiple organs, including both glandular and extraglandular organs. Usually involvement of glandular organs manifests before the extraglandular ones, but when the sequence is reversed, diagnosis may be missed. Hypokalaemic quadriparesis in SS is not uncommon. Respiratory failure in hypokalaemia is not usually seen, but in SS, it has been reported. We report a case of a 55-year-old woman who presented with sudden onset flaccid quadriparesis and respiratory muscle paralysis secondary to severe hypokalaemia. On detailed investigation, she was detected to have distal renal tubular acidosis secondary to clinically inapparent and asymptomatic SS.

Recurrent hypoglycaemia and dilated cardiomyopathy: delayed presentation of Sheehan's syndrome

Sheehan's syndrome (SS) is ischaemic necrosis of the pituitary gland due to massive postpartum haemorrhage. The clinical manifestations may vary from subtle to life-threatening and may present immediately after delivery or many years later. We present a case history of a 58-year-old non-diabetic woman who had undetected SS and presented with two unusual manifestations, including recurrent hypoglycaemia and dilated cardiomyopathy 34 years after delivery. The dilated cardiomyopathy reversed partially after treatment.

A study on different forms of intelligence in Indian school-going children

INTRODUCTION

Most definitions of intelligence focus on capabilities that are relevant to scholastic performances. However, there are seven forms of intelligences. There is a lack of data on multiple intelligences in Indian children. Hence, this study was conducted to assess different forms of intelligences in students and compared these diverse intelligences with intelligence quotient (IQ) scores.

MATERIALS AND METHODS

In this cross-sectional observational study, we recruited 1065 school children between the age of 12 and 16 years from two government and 13 private schools in five towns, six cities, and two villages across India. All the children were administered multiple intelligences questionnaire by Armstrong, consisting of thirty true/false types of questions to assess the intelligences of a child in seven domains including linguistic skills, logical/mathematical abilities, musical skills, spatial intelligence, bodily-kinesthetic skills, intrapersonal intelligence, and interpersonal intelligence. IQ scores were assessed by Ravens Standard Progressive Matrices.

RESULTS

We found that different students possessed different forms of intelligences and most students had more than one forms of intelligence. Of seven forms of intelligence, only three forms of intelligence such as logical/mathematical, musical, and spatial were positively correlated with the IQ score.

CONCLUSIONS

Even in the children with low IQ, many students had other forms of intelligences. The IQ scores correlated with only logical/mathematical, spatial, and musical intelligence. Hence, tapping the intelligences of students can help enhance their learning process. Our curriculum should have an amalgamation of teaching for all kinds of intelligences for maximum productivity.

Patients with mild enteropathy have apoptotic injury of enterocytes similar to that in advanced enteropathy in celiac disease

BACKGROUND

Severity of villous atrophy in celiac disease (CeD) is the cumulative effect of enterocyte loss and cell regeneration. Gluten-free diet has been shown to benefit even in patients having a positive anti-tissue transglutaminase (tTG) antibody titre and mild enteropathy.

AIM

We explored the balance between mucosal apoptotic enterocyte loss and cell regeneration in mild and advanced enteropathies.

METHODS

Duodenal biopsies from patients with mild enteropathy (Marsh grade 0 and 1) (n=26), advanced enteropathy (Marsh grade ≥2) (n=41) and control biopsies (n=12) were subjected to immunohistochemical staining for end-apoptotic markers (M30, H2AX); markers of cell death (perforin, annexin V); and cell proliferation (Ki67). Composite H-scores based on the intensity and distribution of markers were compared.

RESULTS

End-apoptotic markers and marker of cell death (perforin) were significantly up-regulated in both mild and advanced enteropathies, in comparison to controls; without any difference between mild and advanced enteropathies. Ki67 labelling index was significantly higher in crypts of mild enteropathy, in comparison to controls, suggesting maintained regenerative activity in the former.

CONCLUSIONS

Even in patients with mild enteropathy, the rate of apoptosis is similar to those with advanced enteropathy. These findings suggest the necessity of reviewing the existing practice of not treating patients with mild enteropathy.

Effect of environmental factors on intelligence quotient of children

INTRODUCTION

A child's intelligence quotient (IQ) is determined by both genetic and environmental factors that start from the prenatal period itself. There is a lack of data on the factors which influence IQ in Indian children; therefore, we conducted a multicenter questionnaire-based study to determine the environmental factors which influence IQ in Indian children.

PARTICIPANTS AND METHODS

In this cross-sectional observational study, we recruited 1065 schoolchildren between the age of 12 and 16 years from 2 government and 13 private schools in 5 towns, 6 cities, and 2 villages across India. All the children were administered a questionnaire consisting of various environmental factors such as parents' education, occupation, income, and the physical activity of the students. IQ scores were assessed using Ravens Standard Progressive Matrices. An approximate IQ score was calculated using the score on the Ravens test. IQ scores were divided into three groups: below normal IQ (0-79), normal IQ (80-119), and high IQ (above 120). The data were analyzed using SPSS software.

RESULTS

In this study, it was observed that the environmental factors such as place of residence, physical activity, family income, parental education, and occupation of the father had an impact on the IQ of the children. Children living in cities (P = 0.001), children having physical activity more than 5 h/weeks (P = 0.001), children with parents having a postgraduate or graduate level of education (P = 0.001), children whose father having a professional job (P = 0.001), and those with a higher family income (P = 0.001) were more likely to have high IQ.

CONCLUSIONS

In the present study, we found that various environmental factors such as place of residence, physical exercise, family income, parents' occupation and education influence the IQ of a child to a great extent. Hence, a child must be provided with an optimal environment to be able to develop to his/her full genetic potential.

Failure of pentavalent antimony in visceral leishmaniasis in India: report from the center of the Indian epidemic

In India, 320 patients with visceral leishmaniasis (209 in the state of Bihar and 11 in the neighboring state of Uttar Pradesh) received identical pentavalent antimony (Sb) treatment. Sb induced long-term cure in 35% (95% confidence interval [CI], 28%-42%) of those in Bihar versus 86% (95% CI, 79%-93%) of those in Uttar Pradesh. In Bihar, the center of the Indian epidemic, traditional Sb treatment should be abandoned.

Short-course of oral miltefosine for treatment of visceral leishmaniasis

A total of 54 Indian patients with visceral leishmaniasis were treated with oral miltefosine, 50 mg given twice daily, for 14 days (18 patients; group A), 21 days (18; group B), or 28 days (18; group C). Cure was achieved in 89% of group A, 100% of group B, and 100% of group C. Adverse reactions were self-limited and primarily mild. The 21-day miltefosine regimen combines high-level efficacy, convenient dosing, and a relatively short duration.

Evidence that the high incidence of treatment failures in Indian kala-azar is due to the emergence of antimony-resistant strains of Leishmania donovani

The possibility that the high frequency of treatment failures in Indian kala-azar might be due to infection with antimony-resistant strains of Leishmania donovani has not been experimentally addressed. L. donovani isolates were obtained from splenic aspiration smears of 24 patients in Bihar, India, who either did not respond (15) or did respond (9) to 1 or more full courses of treatment with sodium antimony gluconate (SAG). A strong correlation (P<.001) between clinical response and SAG sensitivity in vitro was observed only when strains were assayed as intracellular amastigotes: responsive isolates ED50=2.4+/-2.6, ED90=6.4+/-7.8 microgram SAG/mL; unresponsive isolates ED50=7.4+/-3.7 microgram SAG/mL, ED90=29.1+/-11.1 SAG/mL. No correlation with clinical response was found by use of extracellular promastigotes (ED50=48+/-22 vs. 52+/-29 microgram/mL). The emergence of antimony-resistant L. donovani strains appears to be a cause of treatment failures in India.

Brainstem auditory evoked response in tuberculous meningitis

Brainstem auditory evoked response (BAER) abnormalities in tuberculous meningitis (TBM) were determined in 50 cases of tuberculous meningitis (36 male and 14 female) and 50 normal healthy children. Fifty six per cent cases had abnormal BAER findings. The commonest BAER abnormality observed in 32% was a combination of prolonged latency and prolonged interval while unilateral and bilateral absent response was observed in 4% cases. Prolonged latency was observed in 16% patients. Seizure activities, modified glasgow coma scale (GCS), raised intracranial pressure (ICP) and TBM stage III were significantly correlated with abnormal BAER, while age, sex, duration of illness, depressed sensorium, neurological deficit and CSF findings did not have a significant correlation with abnormal BAER. Follow up could be done in ten patients only. All the three patients with only prolonged latency had a normal BAER on follow up, two out of four patients with prolonged latency and prolonged interval had normalization of BAER while in three patients, initial as well as follow up BAER was normal. The present study shows that BAER abnormalities are observed in more than fifty per cent of the patients of tuberculous meningitis.