Complete agenesis of dorsal pancreas: A rare cause of insulin-dependent diabetes mellitus

ABSTRACT

We report a 16-year-old boy who presented with abdominal pain and severe hyperglycemia. His random blood glucose on admission was above 300 mg/dL, without ketosis. Urine examination revealed mild ketonuria. Renal function tests were normal. Antibodies to glutamate acid decarboxylase (anti-GAD) and islet tyrosine phosphatase 2 (anti-IA2) were negative. Findings on enhanced abdominal computed tomography scan were compatible with complete dorsal pancreatic agenesis. The body and tail of the pancreas were not visualized. Additionally, ectopic and malrotated left kidney was detected. Magnetic resonance cholangiopancreatography confirmed the absence of the dorsal pancreatic duct. The patient was treated with multiple subcutaneous insulin injections and attained good glycemic control. He is currently doing well on follow-up. The present case is a rare combination of complete agenesis of the dorsal pancreas with an ectopic, malrotated kidney. Clinical awareness of this rare association will help improve patient management.

Movement Disorders and Other Neurologic Impairment Associated With Hypomagnesemia: A Systematic Review

Purpose of Review

The objective of this study was to explore the clinical spectrum of movement disorders and associated neurologic findings in hypomagnesemia and challenges in diagnosis and treatment.

Recent Findings

Sixty patients were identified in the literature for analysis. Movement disorders observed were postural tremor (23.3%, n = 14), resting tremor (8.3%, n = 5), intention tremor (10%, n = 6), ataxia involving the trunk (48.3%, n = 29) or limbs (25%, n = 15) and dysarthria (21.7%, n = 13), athetosis (8.3%, n = 5), myoclonus (6.7%, n = 4), and chorea (1.8%, n = 1). Symptoms may be accompanied by downbeat nystagmus, tetany, drowsiness, vertigo, and proximal muscle weakness. Residual deficits were noted in 16 (26.67%) patients. Serum magnesium was 1.3 mg/dL or lower in 53 patients (88.3%). Imaging findings include bilateral cerebellar (20%, n = 11) and vermis hyperintensities (9.09%, n = 5) and normal imaging. Proton pump inhibitors are the commonest etiology.

Summary

The movement disorders linked with hypomagnesemia can be associated with varied neurologic symptoms. A high degree of suspicion will enable early diagnosis to prevent residual deficits.

Rapid expansion of Neisseria gonorrhoeae ST7827 clone in Australia, with variable ceftriaxone phenotype unexplained by genotype

BACKGROUND

Neisseria gonorrhoeae is identified as a priority pathogen due to its capacity to rapidly develop antimicrobial resistance (AMR). Following the easing of SARS-CoV-2 pandemic travel restrictions across international borders in the state of New South Wales (NSW), Australia, a surge of gonococcal isolates with raised ceftriaxone MIC values were detected.

METHODS

All N. gonorrhoeae isolates (n = 150) with increased ceftriaxone MIC values in NSW between 1 January 2021 and July 2022 from males and females from all sites were sequenced.

RESULTS

A new emergence and rapid expansion of an N. gonorrhoeae ST7827 clone was documented within NSW, Australia and provides further evidence of the ability of N. gonorrhoeae to undergo sufficient genomic changes and re-emerge as a geographically restricted subclone. Mapping AMR determinants to MIC results did not reveal any genomic pattern that correlated with MIC values.

CONCLUSIONS

The rapid dissemination and establishment of this clone at the population level is a new and concerning demonstration of the agility of this pathogen, and underscores concerns about similar incursions and establishment of MDR clones. Moreover, it is notable that in this context the AMR genotype-phenotype correlates remain unclear, which requires further investigation to enable better understanding of genomic aspects of AMR in N. gonorrhoeae.

Beta-blockers and mechanical dyssynchrony in heart failure assessed by radionuclide ventriculography

BACKGROUND

Radionuclide ventriculography (RNVG) can be used to quantify mechanical dyssynchrony and may be a valuable adjunct in the assessment of heart failure with reduced ejection fraction (HFrEF). The study aims to investigate the effect of beta-blockers on mechanical dyssynchrony using novel RNVG phase parameters.

METHODS

A retrospective study was carried out in a group of 98 patients with HFrEF. LVEF and dyssynchrony were assessed pre and post beta-blockade. Dyssynchrony was assessed using synchrony, entropy, phase standard deviation, approximate entropy, and sample entropy from planar RNVG phase images. Subgroups split by ischemic etiology were also investigated.

RESULTS

An improvement in dyssynchrony and LVEF was measured six months post beta-blockade for both ischemic and non-ischemic groups.

CONCLUSIONS

A significant improvement in dyssynchrony and LVEF was measured post beta-blockade using novel measures of dyssynchrony.

An Individualized Multi-Modal Approach for Detection of Medication "Off" Episodes in Parkinson's Disease via Wearable Sensors

The primary treatment for Parkinson's disease (PD) is supplementation of levodopa (L-dopa). With disease progression, people may experience motor and non-motor fluctuations, whereby the PD symptoms return before the next dose of medication. Paradoxically, in order to prevent wearing-off, one must take the next dose while still feeling well, as the upcoming off episodes can be unpredictable. Waiting until feeling wearing-off and then taking the next dose of medication is a sub-optimal strategy, as the medication can take up to an hour to be absorbed. Ultimately, early detection of wearing-off before people are consciously aware would be ideal. Towards this goal, we examined whether or not a wearable sensor recording autonomic nervous system (ANS) activity could be used to predict wearing-off in people on L-dopa. We had PD subjects on L-dopa record a diary of their on/off status over 24 hours while wearing a wearable sensor (E4 wristband^®) that recorded ANS dynamics, including electrodermal activity (EDA), heart rate (HR), blood volume pulse (BVP), and skin temperature (TEMP). A joint empirical mode decomposition (EMD) / regression analysis was used to predict wearing-off (WO) time. When we used individually specific models assessed with cross-validation, we obtained > 90% correlation between the original OFF state logged by the patients and the reconstructed signal. However, a pooled model using the same combination of ASR measures across subjects was not statistically significant. This proof-of-principle study suggests that ANS dynamics can be used to assess the on/off phenomenon in people with PD taking L-dopa, but must be individually calibrated. More work is required to determine if individual wearing-off detection can take place before people become consciously aware of it.

Periplasmic stress contributes to a tradeoff between protein secretion and cell growth in E. Coli Nissile

Maximizing protein secretion is an important target in the design of engineered living systems. In this paper, we characterize a tradeoff between cell growth and per cell protein secretion in the curli biofilm secretion system of E Coli Nissile 1917. Initial characterization using 24-hour continuous growth and protein production monitoring confirms decreased growth rates at high induction leading to a local maximum in total protein production at intermediate induction. Propidium iodide staining at the endpoint indicates that cellular death is a dominant cause of growth reduction. Assaying variants with combinatorial constructs of inner and outer membrane secretion tags, we find that diminished growth at high production is specific to secretory variants associated with accumulation of protein containing the outer membrane transport tag in the periplasmic space. RNA sequencing experiments indicate upregulation of known periplasmic stress response genes in the highly secreting variant, further implicating periplasmic stress in the growth-secretion tradeoff. Overall, these results motivate additional strategies for optimizing total protein production and longevity of secretory engineered living systems.

Brachial monomelic amyotrophy as an initial manifestation of stiff person syndrome

Stiff person syndrome (SPS) is characterized by rigidity of truncal and proximal muscles. The presence of abdominal and paraspinal rigidity is a defining clinical feature of SPS. It is rarely associated with the lower motor neuron (LMN) features. We report a patient with SPS whose initial clinical presentation was that of brachial monomelic amyotrophy (BMA). A 24-year-old gentleman presented with a history of the left upper limb wasting and weakness. In addition, he reported stiffness of the lower limbs and abdomen while walking. On examination, patient had left upper limb monomelic amyotrophy and hypertonia, exaggerated deep tendon reflexes in all four limbs. He also had abdominal and paraspinal rigidity. Serum was strongly positive for GAD 65 antibodies suggestive of SPS. Patient showed dramatic improvement to immunomodulation. Patient presented with features of BMA. Symptoms related to SPS were mild. Abdominal rigidity was the clue to the diagnosis. LMN features have been reported previously in stiff person plus syndrome with an atypical course and progressive encephalomyelitis with myoclonus and rigidity, but not in classical SPS.

Hemichorea-hemiballism in a diabetic patient with euglycemia at presentation

Hemichorea hemiballismus syndrome (HCHB) is commonly seen in an acute setting of non ketotic hyperglycaemia. Hemichorea hemiballismus has been rarely reported in the setting of normal blood sugars in a diabetic patient. We report an 84-year-old lady who initially presented with uncontrolled diabetes and acute left hemiparesis. Imaging did not reveal any evidence of recent infarction. After sugars were normalised, five weeks later she presented with involuntary movements of left upper and lower limb. On examination, patient had left hemichorea hemiballismus. Repeat MRI brain showed right putamen hyperintensity in T1 weighted images. Venous blood glucose was 123 mg/dl (6.8 mmol/L). Patient improved significantly with haloperidol and clonazepam. In conclusion, hemichorea hemiballismus can be observed in a patient with previously uncontrolled diabetes mellitus after normalization of blood sugars akin to that seen in patients with HCHB associated with hyperglycaemia.

Radionuclide ventriculography phase analysis for risk stratification of patients undergoing cardiotoxic cancer therapy

BACKGROUND

Accurate diagnostic tools to identify patients at risk of cancer therapy-related cardiac dysfunction (CTRCD) are critical. For patients undergoing cardiotoxic cancer therapy, ejection fraction assessment using radionuclide ventriculography (RNVG) is commonly used for serial assessment of left ventricular (LV) function.

METHODS

In this retrospective study, approximate entropy (ApEn), synchrony, entropy, and standard deviation from the phase histogram (phase SD) were investigated as potential early markers of LV dysfunction to predict CTRCD. These phase parameters were calculated from the baseline RNVG phase image for 177 breast cancer patients before commencing cardiotoxic therapy.

RESULTS

Of the 177 patients, 11 had a decline in left ventricular ejection fraction (LVEF) of over 10% to an LVEF below 50% after treatment had commenced. This patient group had a significantly higher ApEn at baseline to those who maintained a normal LVEF throughout treatment. Of the parameters investigated, ApEn was superior for predicting the risk of CTRCD. Combining ApEn with the baseline LVEF further improved the discrimination between the groups.

CONCLUSIONS

The results suggest that RNVG phase analysis using approximate entropy may aid in the detection of sub-clinical LV contraction abnormalities, not detectable by baseline LVEF measurement, predicting a subsequent decline in LVEF.

Impact of plasma glucose and duration of type 2 diabetes mellitus on SYNTAX Score II in patients suffering from non ST-elevation myocardial infarction

Aim    The objective was to assess the correlation of fasting plasma glucose (FPG), HbA1c, and the duration of type 2 diabetes mellitus (T2DM) with SYNTAX score (SS) II in patients with non-ST elevation myocardial infarction (NSTEMI).Material and methods    FPG and HbA1C were measured in 398 patients presenting with NSTEMI at admission. SS II was calculated using an online calculator. Patients were stratified according to SS II (≤21.5, 21.5-30.6, and ≥30.6), defined as SS II low, mid, and high, respectively.Results    37.7 % of subjects were diabetic. Correlations of FPG (R=0.402, R2=0.162, p<0.001) and HbA1c (R=0.359, R2=0.129, p<0.001) with SS II were weak in the overall population. Duration of T2DM showed very strong correlation with SS II (R=0.827, R2=0.347). For the prediction of high SS II in the study population, FPG≥98.5 mg / dl demonstrated a sensitivity of 58 % and a specificity of 60 %, and HbA1c ≥6.05 demonstrated a sensitivity of 63 % and a specificity of 69 %. Duration of T2DM (adjusted odds ratio (OR): 1.182; 95 % confidence interval (CI): 1.185-2.773) and FPG (OR: 0.987; 95 % CI: 0.976-0.9959) were significantly associated with high SS II after controlling for other risk factors. Duration of T2DM (Beta=0.439) contributed strongly to variance of SS II, whereas HbA1c (Beta=0.063) contributed weakly.Conclusion    Duration of T2DM is a very important risk factor for severity of coronary artery disease.

Long-Term Outcome of Hemimasticatory Spasm

Objective

This study aims to identify the demographic, clinical, and therapeutic characteristics of four patients with hemimasticatory spasm (HMS) seen in our outpatient department over a period of 20 years.

Methods

We performed a retrospective chart review of four patients with HMS who visited outpatient services in the Department of Neurology from 2001 to 2020.

Results

The follow-up for all patients ranged from 2 years to 9 years. Three patients had facial or bucco-oral morphea. Two patients maintained long-term improvements in symptoms after being treated with botulinum toxin for 4–7 years, while one patient reported improvement in symptoms with treatment of carbamazepine that subsequently remitted after pregnancy.

Conclusion

This report highlights the long-term outcome of HMS in our patients. Our patients reported a significant reduction or complete resolution of symptoms after treatment, and eventually, two patients were asymptomatic while off treatment.

Relative contribution of different members of OsDREB gene family to osmotic stress tolerance in indica and japonica ecotypes of rice

Drought/osmotic stress is the single largest production constraint in rain-fed rice cultivation. Different members of the DREB gene family are known to contribute to osmotic stress tolerance. In this study, an attempt was made to understand their relative contribution towards osmotic stress tolerance in indica and japonica ecotypes of rice. Two genotypes (one tolerant and one susceptible) from each ecotype were grown hydroponically, and 21-day-old seedlings were subjected to polyethylene glycol-induced osmotic stress (15% PEG-6000, equivalent to -3.0 bars osmotic potential). The tolerant genotypes CR143 and Moroberekan were found to have superior root traits (total root length, surface area and volume), better plant water status and increased total dry biomass as compared to their susceptible counterparts after 10 days of osmotic stress. Different members of the DREB gene family were differentially induced in response to osmotic shock (1 h after stress) and osmotic stress (24 h after stress), which also differed between the two rice ecotypes. From the gene expression profiles of 10 DREB genes (both DREB1 and DREB2 families), in indica two DREB genes, DREB1B and DREB1G, were significantly correlated with stress tolerance indices, whereas in japonica significant correlations with five DREB genes (DREB1A, DREB1B, DREB1D, DREB1E and DREB2B) were observed. We found that only one member, i.e. DREB1B, showed a significant correlation with drought tolerance indices in both indica and japonica ecotypes. This study provides an overview of the relative contribution of different members of the DREB gene family and their association with drought/osmotic stress tolerance in rice.

Disorders of Tetrahydrobiopterin Metabolism: Experience from South India

BACKGROUND

Disorders of tetrahydrobiopterin metabolism represent a rare group of inherited neurotransmitter disorders that manifests mainly in infancy or childhood with developmental delay, neuroregression, epilepsy, movement disorders, and autonomic symptoms.

METHODOLOGY

A retrospective review of genetically confirmed cases of disorders of tetrahydrobiopterin metabolism over a period of three years (Jan 2018 to Jan 2021) was performed across two paediatric neurology centres from South India.

RESULTS

A total of nine patients(M:F=4:5) fulfilled the eligibility criteria. The genetic variants detected include homozygous mutations in the QDPR(n=6), GCH1(n=2), and PTS(n=1) genes. The median age at onset of symptoms was 6-months(range 3-78 months), while that at diagnosis was 15-months (8-120 months), resulting in a median delay in diagnosis of 9-months. The main clinical manifestations included neuroregression (89%), developmental delay(78%), dystonia(78%) and seizures(55%). Management strategies included a phenylalanine restricted diet, levodopa/carbidopa, 5-Hydroxytryphtophan, and folinic acid. Only, Patient-2 afforded and received BH4 supplementation at a sub-optimal dose later in the disease course. We had a median duration of follow up of 15 months (range 2-48 months). Though the biochemical response has been marked; except for patients with GTPCH deficiency, only mild clinical improvement was noted with regards to developmental milestones, seizures, or dystonia in others.

CONCLUSION

Tetrahydrobiopterin deficiencies represent a rare yet potentially treatable cause for non-phenylketonuria hyperphenylalaninemia with better outcomes when treated early in life. Screening for disorders of biopterin metabolism in patients with hyperphenylalaninemia prevents delayed diagnosis. This study expands the genotype-phenotype spectrum of patients with disorders of tetrahydrobiopterin metabolism from South India.

Fulminant Reversible Cerebral Vasoconstriction Syndrome in Breakthrough COVID 19 Infection

COVID 19 infection continues to afflict people worldwide. Neurological complications of COVID infection are common. We report a case of fulminant reversible cerebrovascular constriction syndrome (RCVS) in a patient with breakthrough COVID 19 infection who was fully vaccinated. A 64 year old lady, fully vaccinated 2 months back, presented with headache, drowsiness, partial seizures, visual impairment and quadriplegia. Her nasopharyngeal swab was tested positive for SARS COV2 on real time PCR assay. MRI brain FLAIR images showed multifocal hyperintensities with MR angiogram showing arterial vasoconstriction suggestive of RCVS. Despite initiation of nimodipine, patient's symptoms worsened and she succumbed to sepsis. RCVS following COVID infection has been reported to have a benign outcome. However, despite vaccination, fulminant RCVS following a breakthrough COVID infection was observed in our patient.

The association of saccadic abnormalities with rem sleep in patients with Huntington's disease

BACKGROUND

Huntington's disease (HD) is a progressive neurodegenerative disorder characterised by chorea, cognitive impairment, psychiatric and behavioral disturbances. Sleep disturbances including reduced REM sleep have been observed in HD.

OBJECTIVES

The aim of the study was to study the polysomnography findings in HD and to assess whether oculomotor abnormalities are associated with poor REM sleep.

METHODS

Twenty-nine genetically confirmed HD patients underwent clinical evaluation including extraocular movement and OKN examination. Twenty-six patients and 15 controls underwent overnight video polysomnography (VPSG).

RESULTS

VPSG of 23 HD patients and 13 controls were considered for analysis. Compared to controls, HD patients had higher median wake period and higher WASO percentage (p = 0.005). REM sleep percentage was reduced significantly in HD in comparison to controls (p < 0.001). Out of 23 patients, only two patients had REM sleep above 20% while 14 patients had REM sleep percentage less than 15%. Poor horizontal OKN (grades 2 and 3) was associated with the presence of low REM sleep percentage (REM sleep less than 15%) (p = 0.02). Low REM sleep was also associated with severe illness (UHDRS) (p = 0.038).

CONCLUSION

An association between decreased REM sleep and OKN abnormalities indicate that EOM abnormalities seen in HD could lead to errors in scoring REM sleep. To understand the actual degree of decreased REM sleep percentage will require additional parameters in AASM guidelines to score REM sleep in patients with EOM abnormalities like that seen in HD.

Efficacy and safety of bisoprolol compared to other selective beta-1 blockers in the treatment of hypertension: a systematic review and meta-analysis of randomized parallel clinical trials

Background

Bisoprolol, a highly cardioselective beta-1 blocker (s-BB) has theoretical advantage over other cardio selective betablockers by way of better potency and tolerability in treating hypertension (HT). Individual published trials comparing s-BB are typically small. Meta-analysis of such trials clarifies the issue and position of bisoprolol in HT therapy.

Purpose

This meta-analysis compares bisoprolol with other s-BBs (Atenolol, Betaxolol, Esmolol, Acebutolol, Metoprolol, Nebivolol) for their efficacy and safety in patients with HT.

Methods

Literature databases PubMed, Embase, Cochrane Library, Clinicaltrials.gov, Surveillance, Epidemiology and End Results Program and 12 PV databases were searched systematically to identify randomized, parallel clinical trials published from inception to October 2019. Studies which compared bisoprolol with other s-BBs in HT patients were evaluated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Random effects meta-analyses were conducted to assess mean difference (MD) and 95% confidence interval (95% CI) for blood pressure (BP), heart rate (HR) and lipid profile.

Results

13 studies compared bisoprolol with other s-BBs (metoprolol, atenolol) were included in this meta-analysis. Bisoprolol reported significant reduction in aortic systolic BP [MD: −8.00; 95% CI: −11.57, −4.43; P&lt;0.01] and diastolic BP [MD: −2.90; 95% CI: −4.98, −0.82; P&lt;0.01] during 8 weeks (w) treatment compared to other s-BBs. Bisoprolol treatment for 12w showed significant change in ambulatory heart rate (AHR) [MD: −5.22; 95% CI: −8.37, −2.07; P&lt;0.01], daytime AHR [MD: −5.75; 95% CI: −9.16, 2.34; P&lt;0.01] and nighttime AHR [MD: −3.22; 95% CI: −6.18, −0.26; P=0.03] in comparison to other s-BBs. Significant increase in low frequency HR variability [MD: 100.79; 95% CI: 16.66, 184.91; P=0.02] was reported with bisoprolol treated for 8w compared to other s-BBs. Baroreflex sensitivity significantly favored bisoprolol treated for 8w [MD: 1.01; 95% CI: 0.03, 1.98; P=0.04] in comparison to other s-BBs. HDL-C significantly increased with bisoprolol treated for 52w [MD: 6.80; 95% CI: 3.01, 10.60; P&lt;0.01], 104w [MD: 12.00; 95% CI: 5.04, 18.96; P&lt;0.01] and 156w [MD: 8.00; 95% CI: 0.58, 15.42; P=0.03]. There were no significant changes in total cholesterol [MD: −3.06; P=0.38], LDL-C [MD: −3.60; P=0.18] and triglyceride [MD: −21.00; P=0.26] on treatment with bisoprolol. Serious adverse events did not differ significantly on treatment with bisoprolol compared to other s-BBs.

Conclusion

The results of this meta-analysis reveal that bisoprolol showed a significant reduction of BP, HR, baroreflex sensitivity and improved HDL cholesterol levels compared to other s-BBs. Our results highlight the heterogeneity amongst the s-BBs and highlights the benefit of choosing bisoprolol in comparison to other s-BB in the management of HT.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness of bisoprolol versus selective beta-1 blockers in the management of hypertension: a systematic review and meta-analysis of randomized cross-over trials

Background

Cross-over trials carry a higher weightage in choosing a therapeutic agent in clinical practice. A meta-analysis of cross-over trials involving the use of bisoprolol in hypertension (HT) would bring about clarity in positioning this drug.

Purpose

The present study aimed to clarify the underlying benefits of bisoprolol in the reduction of blood pressure (BP) in HT patients when compared to selective beta-1 blockers (s-BBs - Atenolol, Betaxolol hydrochloride, Esmolol, Acebutolol hydrochloride, Metoprolol succinate, Nebivolol) by performing a meta-analysis of “cross-over” trials published in literature.

Methods

Systematic search was undertaken in PubMed, Embase, Cochrane Library, Clinicaltrials.gov registry, Surveillance, Epidemiology and End Results Program and 12 pharmacovigilance databases. Randomized, cross-over studies published up to October 2019 which compared bisoprolol with other s-BBs in HT patients were evaluated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A meta-analysis was performed using random effects model in terms of mean difference (MD) and 95% confidence intervals (95% CI) for BP, heart rate (HR) and lipid profile.

Results

Nine randomized cross-over studies which compared bisoprolol with other s-BBs (atenolol and nebivolol) were included in this meta-analysis. Bisoprolol reported significant reduction of sitting BP [MD: −3.35, 95% CI: −6.75, 0.05; P=0.05] and reduction of diastolic BP [MD: −2.00; 95% CI: −8.04, 4.04; P=0.52, non-significant] among patients with HT when compared to other s-BBs. Heart rate (HR) decreased significantly among HT patients in bisoprolol group treated for 2 w [MD: −6.00; 95% CI: −11.30, −0.70; P=0.03] when compared to those treated with other s-BBs. Analysis of lipid profile showed non-significant reduction of serum cholesterol [MD: −7.74; 95% CI: −17.18, 1.70; P=0.11] and triglyceride [MD: −26.57; 95% CI: −64.34, 11.20; P=0.17] levels in the bisoprolol group compared to other s-BBs. Bisoprolol treatment for 8 w resulted in a slight but statistically significant change in potassium levels [MD: −0.10; 95% CI: −0.16, −0.04; P&lt;0.01] among HT patients.

Conclusion

The results of this meta-analysis reported significant efficacy of bisoprolol on BP and HR in comparison to other s-BBs in a meta-analysis of cross-over trials. Our findings show that use of bisoprolol as a therapeutic option is efficacious and safe compared to other s-BBs in this patient population.

Funding Acknowledgement

Type of funding sources: None.

Sleep and other Non-motor Symptoms in Patients with Idiopathic Oromandibular Dystonia and Meige Syndrome: A Questionnaire-based Study

Introduction:

Non-motor symptoms are an essential cause of comorbidity in generalized and focal dystonia. However, there are few studies on dystonia involving the craniofacial regions.

Methods:

We studied non-motor symptoms in patients with oromandibular dystonia (OMD) and Meige syndrome using a questionnaire, and validated instruments for depression, anxiety, REM behaviour disorder, restless leg syndrome, sleep quality, excessive daytime sleepiness, and self-esteem. The severity of dystonia and blepharospasm was also studied.

Results:

Nineteen patients with OMD were recruited into the study. Among patients with OMD, depression was seen in 63.6% (n = 7), sleep impairment in 27.3% (n = 3), excessive daytime sleepiness in 27.3% (n = 3), and poor self- esteem in 18.2% (n = 2) of the patients. Among patients with Meige syndrome, depression was seen in 37.5% (n = 3), sleep impairment in 12.5% (n = 1), excessive daytime sleepiness in 25% (n = 2), low self-esteem in 25% (n = 2) of the patients.

Conclusion:

This study highlights the significant frequency of depression and sleep disturbances in patients with idiopathic OMD and Meige syndrome.

DNAJC6 mutation causing cranial-onset dystonia with tremor dominant levodopa non-responsive parkinsonism: A novel phenotype

DNAJC6 mutation causes two types of phenotypes: slowly progressive parkinsonism with levodopa response and rapidly progressive parkinsonism with additional manifestations like intellectual disability, epilepsy etc. We report a new phenotype wherein an adolescent girl developed blepharospasm followed by jaw opening, lingual and cervical dystonia followed by tremors of limbs (rest and action) with rigidity, bradykinesia. The dystonia-parkinsonism phenotype has not been described. She had novel homozygous missense mutation in DNAJC6 gene.

Effects of Vector Maturation Time on the Dynamics of Cassava Mosaic Disease

Many plant diseases are caused by plant viruses that are often transmitted to plants by vectors. For instance, the cassava mosaic disease, which is spread by whiteflies, has a significant negative effect on plant growth and development. Since only mature whiteflies can contribute to the spread of the cassava mosaic virus, and the maturation time is non-negligible compared to whitefly lifetime, it is important to consider the effects this maturation time can have on the dynamics. In this paper, we propose a mathematical model for dynamics of cassava mosaic disease that includes immature and mature vectors and explicitly includes a time delay representing vector maturation time. A special feature of our plant epidemic model is that vector recruitment is negatively related to the delayed ratio between vector density and plant density. We identify conditions of biological feasibility and stability of different steady states in terms of system parameters and the time delay. Numerical stability analyses and simulations are performed to explore the role of various parameters, and to illustrate the behaviour of the model in different dynamical regimes. We show that the maturation delay may stabilise epidemiological dynamics that would otherwise be cyclic.

The role of infrared dermal thermometry in the management of neuropathic diabetic foot ulcers

AIM

This prospective observational study evaluated the role of infrared (IR) dermal thermometry in the management of diabetic foot ulcers.

METHODS

Thirty participants with unilateral neuropathic diabetic foot ulcers of University of Texas grade 1 or 2 (stage A) were followed up monthly for 1 year. At each visit, skin temperatures were measured with an IR dermal thermometer at corresponding sites on both feet, using the contralateral feet without ulcers as controls.

RESULTS

Average temperature and ulcer temperature in affected feet were significantly higher than in unaffected feet, with a mean difference of 1.2 °C [95% confidence interval (CI) 0.7 to 1.7] and 3.1 °C (95% CI 2.3 to 3.9), respectively. Although the gradient between average temperature of affected foot and that of unaffected foot normalized (mean difference 0.2 °C, 95% CI -0.2 to 0.7) at healing, the temperature gradient between the ulcer and a corresponding site on the unaffected foot decreased but did not normalize (mean difference 2.1 °C, 95% CI 1.2 to 3.1) even at healing, as documented by skin closure, and persisted for up to 1 month after skin closure. A gradient of ≥1 °C between average temperature of affected foot and that of unaffected foot at initial presentation or at any time during ulcer healing was found to predict impaired healing and should alert clinicians to ulcers requiring more attention. An incremental trend in temperature gradient (median difference 2.2 °C; range 0.1-6.3 °C) at a site on the foot was predictive of a recurrent ulcer involving the same site.

CONCLUSIONS

IR dermal thermometry may have a role in predicting diabetic foot ulcer healing, in determining the completeness of healing and in guiding the duration of offloading. Serial monitoring of the temperature gradient may predict the development of recurrent diabetic foot ulcers.

Altered REM sleep architecture in patients with Myotonic dystrophy type 1: is related to sleep apnea?

OBJECTIVE

To determine the sleep architecture and sleep respiratory abnormalities and to correlate with sleep symptoms in patients with Myotonic dystrophy type 1 (DM1).

METHODS

We recruited a cohort of genetically confirmed patients with DM1, who attended the Neuromuscular clinic between July 2016 and December 2019. Clinical, sleep and whole night polysomnography data were collected. The analysis of sleep architecture, sleep respiratory parameters and comparison with healthy controls (HC) was performed in our sleep laboratory.

RESULTS

A total of 59 patients with DM1 underwent sleep evaluation. Hypersomnolence in 42 (77.8%), ESS>10 in 23 (39%), and PSQI>5 in 18 (30.5%) were found in patients with DM1. Thirty-one (68.89%) patients with DM1 and 22 (95.65%) HC had more than 4-h of total sleep time (TST). More than 4 h of TST was taken to compare respiratory and sleep architecture parameters. Patients with DM1 had reduced sleep efficiency, reduced N2 sleep, and increase in N1 sleep, wake index, stage shift index, nocturnal sleep-onset REM periods compared to HC. AHI>15 was found in 16 (51.61%) DM1 and in 3 HC (13.64%). AHI had positive correlation with BMI, but not with age, ESS or disease progression (MIRS). All DM1 with AHI>15; 8(80%) and 1(33.33%) in AHI5to15, and AHI<5 groups, respectively had hypersomnolence.

CONCLUSION

In this first study on Indian cohort, daytime hypersomnolence, poor nocturnal sleep quality, sleep architecture irregularities are identified to be common in patients with DM1. These abnormalities may be explained by sleep-related breathing disorders that are highly prevalent in these patients.

Discrepancies between the decisions of an endocarditis team and the modified Duke's Criteria for the diagnosis of infective endocarditis

Background/Introduction

The 2015 ESC endocarditis guidelines recommend that a multi-disciplinary endocarditis team should be involved in caring for patients with endocarditis. This approach recognises the heterogeneity of infective endocarditis, and the difficulty in distinguishing endocarditis from other infective and non-infective diseases.

Purpose

This study looks at suspected cases of infective endocarditis discussed at the endocarditis MDT, discrepancies between MDT outcome and the modified Duke's criteria in diagnosing endocarditis, and number of referrals to MDT over time.

Methods

Patients were identified by review of MDT outcome forms. Demographic data, predisposing conditions, imaging findings, microbiology results and final diagnosis were identified by reviewing MDT forms and electronic charts.

Results

234 patients were identified from MDT outcome forms. 118 (50.4%) patients were over 65, 165 (70.5%) were male, and 65 (27.8%) had previous valve surgery. Crosstabulation of MDT decision against outcome by modified Duke's criteria are seen in Table 1. The endocarditis team identified 7 patients with definite or possible endocarditis who were excluded by applying the modified Duke's criteria. 1 of these patients required aortic valve replacement. 2 patients with disseminated Staphylococcal infections without endocarditis were classed as definite endocarditis by the modified Duke's criteria. Referral data and outcomes are included in Figure 1.

Conclusions

The endocarditis team can be used to improve the sensitivity and specificity of the modified Duke's criteria. As the endocarditis team became established the volume of referrals has increased, along with the number of patients who have alternate diagnoses. Practitioners should bear this in mind when establishing endocarditis teams.

Figure 1. Referrals over time by outcome

Funding Acknowledgement

Type of funding source: None

Changes in access to educational and healthcare services for individuals with intellectual and developmental disabilities during COVID-19 restrictions

BACKGROUND

COVID-19 restrictions have significantly limited access to in-person educational and healthcare services for all, including individuals with intellectual and developmental disabilities (IDDs). The objectives of this online survey that included both national and international families were to capture changes in access to healthcare and educational services for individuals with IDDs that occurred shortly after restrictions were initiated and to survey families on resources that could improve services for these individuals.

METHODS

This was an online survey for caregivers of individuals with (1) a genetic diagnosis and (2) a neurodevelopmental diagnosis, including developmental delay, intellectual disability, autism spectrum disorder or epilepsy. The survey assessed (1) demographics, (2) changes in access to educational and healthcare services and (3) available and preferred resources to help families navigate the changes in service allocation.

RESULTS

Of the 818 responses (669 within the USA and 149 outside of the USA), most families reported a loss of at least some educational or healthcare services. Seventy-four per cent of parents reported that their child lost access to at least one therapy or education service, and 36% of respondents lost access to a healthcare provider. Only 56% reported that their child received at least some continued services through tele-education. Those that needed to access healthcare providers did so primarily through telemedicine. Telehealth (both tele-education and telemedicine) was reported to be helpful when available, and caregivers most often endorsed a need for an augmentation of these remote delivery services, such as 1:1 videoconference sessions, as well as increased access to 1:1 aides in the home.

CONCLUSIONS

COVID-19 restrictions have greatly affected access to services for individuals with syndromic IDDs. Telehealth may provide opportunities for delivery of care and education in a sustainable way, not only as restrictions endure but also after they have been lifted.

Mobile Teaching Kitchen Project – eradicating and preventing malnutrition through nutrition education

Background

Global malnutrition, affecting over 2.6 billion people globally, represents a triple burden to health in the form of micronutrient deficiencies, under-and over-nutrition. Malnutrition reaches all parts of society, with those undernourished and deficient in vitamins and minerals often thought to be the poorer in society, whilst overnourished those wealthier. NNEdPro, an international think-tank working to develop nutrition capacity, performed a landscaping activity in Kolkata, India and noted significant undernutrition within the slum dwelling population and overnutrition among the inner-city workers.

Results

NNEdPro' s Mobile Teaching Kitchen (MTK) project was developed as a nutritional education tool to improve awareness of diet diversity and disease prevention amongst marginalised communities by using locally sourced foods and cooking skills. Local volunteers trained in healthy cooking transfers core principles through cooking demonstrations of sustainable, nutritional, and affordable meals. They follow a 'See One, Do One, Teach One' (S1D1T1) model to transfer knowledge to their peers. This model aims to create a sustainable solution that will enable the rural-urban slum dwellers across regions of the world to challenge food insecurity and malnutrition.

Conclusions

The potential of the Teaching Kitchen can extend beyond creating powerful behavior change for improved health and nutrition within local communities of both developing and developed countries. In addition to improving the wellbeing of the community, the project can also potentially create livelihood opportunities through empowering women with catering skills and having a positive impact on the health and nutritional status of the wider community. After successful impacts in India, the Mobile Teaching Kitchen model has been proposed to other 8 existing regional networks of NNEdPro such as Australia & New Zealand, Brazil, Italy, Mexico, Morocco, Switzerland, USA, and UK.

Non-Motor Symptoms in Cervical Dystonia: A Review

Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive movements, postures, or both. Dystonic movements are typically patterned, associated with twisting of body parts, and may have tremulousness. Dystonia is usually initiated or worsened by voluntary action and associated with overflow muscle activation. Cervical dystonia (CD) is the most prevalent form of dystonia. CD is a condition characterized by cranial muscle overactivity leading to abnormal intermittent or continuous posturing of the head. Non-motor symptoms are comorbidity of dystonia, which significantly hampers the quality of life among these patients. The symptoms can be as a result of the dystonia itself. However, studies have highlighted the involvement of cortical-striatal-thalamocortical circuits in primary dystonia that could be the pathophysiological basis for the non-motor symptoms. The non-motor symptoms that are commonly associated with dystonia are anxiety, depression, restless leg syndrome, excessive daytime sleepiness, cognitive disturbances, and poor sleep. This review attempts to summarize the literature on non-motor symptoms in patients with CD.

Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

Cardiological Society of India: Document on acute MI care during COVID-19

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.

The association of dietary patterns and carotid intima-media thickness: A synthesis of current evidence

AIMS

Dietary pattern (DP) analysis has emerged as a holistic method to understand the effects of food intake on health outcomes. Though dietary intake has been associated with cardiovascular disease, the association of DPs and carotid intima-media thickness (CIMT), a robust early marker of cardiovascular disease progression has not been comprehensively investigated. This study systematically explores the association of a posteriori and a priori DPs and CIMT.

DATA SYNTHESIS

Through a systematic search of MEDLINE, CINAHL, and Web of Science, twenty studies that derived DPs using a posteriori or a priori methods with CIMT as an outcome were included. Four cross-sectional studies and 1 cohort paper reported a statistically significant association between increased consumption of 'unhealthy' foods (i.e processed meat, soda drinks and refined grain) and increased CIMT. While four cross-sectional studies reported a statistically significant association of DPs characterized by increased consumption of 'healthy' foods (i.e fruit and vegetables, fish) and decreased CIMT. DPs derived from each study varied depending on derivation method, study design and use of dietary data collection method.

CONCLUSION

Findings from this review are generally supportive of a trend between DPs with higher consumption of 'healthy' foods and lower consumption of 'unhealthy' foods and decreased CIMT; however, the association was largely not statistically significant. Evidence was overwhelmingly heterogeneous due to differences seen in DPs based on location and culture, sample characteristics and adjustment for confounders. Long-term prospective observational and interventional studies with standardized sample selection and dietary data collection are needed to significantly establish the role of DPs on CIMT.

P3779NT-proBNP adds incremental predictive information on incident atrial fibrillation in patients with asymptomatic aortic stenosis

Background

Incident atrial fibrillation (AF) marks an adverse shift in the prognosis of patients with aortic stenosis (AS). Identifying risk factors for AF is therefore of paramount importance for timely intervention in patients with AS. In patients without AS, brain natriuretic peptides (BNP) is a well-established biomarker for left ventricular pressure overload on the pathway to heart failure and atrial fibrillation. However, a potential role of NT-proBNP to predict risk of new-onset AF in asymptomatic patients with mild to moderate AS is not well studied.

Methods

We included 1,434 patients with mild to moderate AS from the SEAS Study (Simvastatin and Ezetimibe in Aortic Stenosis) without AF or clinically overt heart failure at baseline. The primary endpoint for this substudy was time to incident AF, as determined by the first annual in-study 12-lead ECG with AF. Multivariable Cox model were adjusted for other important predictors of incident AF as selected by Bayesian statistics. Fine and Gray competing risk regression was used to evaluate the influence of all-cause mortality on selected predictor variables of incident AF.

Results

During a median follow-up of 4.3 years (range 0.1–6.9 years), incident AF occurred in 114 (6.1%) patients (13.8 per 1,000 person-years of follow-up), who at baseline were older (69±10 vs. 67±10 years, p<0.001), had larger systolic left atrial diameter (46±24 vs. 34±18 mm, p<0.001) and higher NT-proBNP level (286 [132; 613] vs. 154 [82; 297] pg/ml, p<0.001); but same left ventricular ejection fraction (66±6 mm vs. 67±6, p=0.4). In multivariable Cox regression, adjusted for age, circumferential end-systolic stress, left atrial volume and ECG PR interval, Ln(NT-proBNP) was associated with higher risk of new-onset AF (HR: 1.9 [95% CI: 1.6–2.3], p<0.001). Similar results were found when using Fine and Gray estimates with all-cause mortality (HR: 2.0 [95% CI: 1.7–2.4], p<0.001 (Figure, panel A). NT-proBNP level added incremental predictive information on incident AF over the other important, as selected by Bayesian statistics, predictor variables (C-index 0.81, p<0.001, Figure, panel B). There was no interaction with aortic valve area (p>0.05).

Figure 1

Conclusions

In patients with asymptomatic aortic stenosis and sinus rhythm at baseline, NT-proBNP levels were significantly higher in patients who subsequently developed AF. NT-proBNP significantly improved prognostic information of incident AF over other important predictor variables. This supports the notion that incident AF is a marker of left ventricular pressure overload and possibly a novel marker of timely intervention with aortic valve replacement.

Outcomes of surgery for post-cholecystectomy bile duct injuries: An audit from a tertiary referral center

AIM OF THE STUDY

Bile duct injury (BDI) after cholecystectomy is a serious complication. It often requires surgical repair. The aim of this study was to report on the short and long-term outcomes of surgery for post-cholecystectomy BDI.

PATIENTS AND METHODS

All the patients, who underwent surgery for post-cholecystectomy BDI between August 2007 and September 2017, were retrospectively reviewed. McDonald grading system was used to assess the long-term outcome. The risk factors for unsatisfactory long-term outcome were analyzed by univariate and multivatiate logistic regression analysis.

RESULTS

In total, 228 patients had a Roux-en-Y hepaticojejunostomy. Open cholecystectomy was the major cause of BDI (61%). The median time from injury to definitive repair was 6 months. The types of BDI were as follows: E1 in 13 (5.7%), E2 in 68 (29.82%), E3 in 108 (47.36%), E4 in 28 (12.28%), and E5 in 11 (4.82%) patients respectively. Postoperative morbidity and mortality were 25% and 1.31% respectively. After a median follow-up of 58 months, 90% patients had excellent to good outcome. Recurrent stricture developed in 6 (3%) patients. On multivariate analysis, long injury-repair interval and previous attempt at repair were independent predictors for unsatisfactory long-term outcome.

CONCLUSION

Surgical reconstruction affords excellent to good results for majority of the patients with post-cholecystectomy BDI. As longer delay in definitive repair and previous attempt at repair were associated with unsatisfactory long-term outcome, early referral to a specialized hepatobiliary surgery unit is recommended.

A23 Population level diversification of hepatitis C viral strains over time among people who inject drugs in Baltimore, MD

Hepatitis C virus (HCV) infection occurs in 30–90 per cent of people who inject drugs (PWID). Although cure rates can exceed 95 per cent, treatment access is limited and approximately 400,000 people die each year due to complications of chronic infection. A temporal analysis of cluster networks among PWID can be used to inform strategies to interdict transmission. In Baltimore, PWID have been recruited for The AIDS Linked to the IntraVenous Experience (ALIVE) cohort. A demographic questionnaire was administered and recorded for baseline and recent participants. Viral RNA underwent PCR with primers targeting the core and envelope-1 protein (CE1) and sequenced via Sanger sequencing. Sequences with > 400 bp reads and Q-scores >370 were used for downstream analysis resulting in 322 ALIVE baseline participants (1988–9) and 548 recently diagnosed subjects enrolled approximately two decades later (2005–16). Cluster networks were rendered with a threshold of 4 per cent in MicrobeTRACE, and statistical analyses were performed in R Studio. Of the 1988–9 subjects, the majority (259/317, 81.7%) were a part of cluster. There were nine clusters and fifty-eight singletons, with two large clusters containing most sequences of genotype 1a (73.5%). Two decades later, a minority of recently diagnosed individuals (235/512, 44.1%) were part of a cluster. There were seventeen clusters with 286 singletons with two large clusters containing 1a genotype individuals (21.5%). Additional clustering was done by parsing the two datasets by subtype 1a (n = 714) and 1b (n = 151). The genotype 1a network demonstrates a majority, 65.8 per cent, of participants in clusters. Moreover, two large clusters can be observed with baseline participants towards the center and recent participants on the outskirts indicative of high linkage at baseline. The genotype 1b network produced a single large cluster but subclusters were observed. The sequences between the two time points co-mingled but subclusters were also observed. Interestingly, the two large clusters from 1988 to 1989 were still evident in the 2005–16 viral sequences. We observed greater cluster diversity in more recently diagnosed individuals, indicative of a less connected network of individuals sharing transmission risk, though major viral strains did persist over time in this cohort.

One-Dimensional Quasicrystals with Power-Law Hopping

One-dimensional quasiperiodic systems with power-law hopping, 1/r^{a}, differ from both the standard Aubry-André (AA) model and from power-law systems with uncorrelated disorder. Whereas in the AA model all single-particle states undergo a transition from ergodic to localized at a critical quasidisorder strength, short-range power-law hops with a>1 can result in mobility edges. We find that there is no localization for long-range hops with a≤1, in contrast to the case of uncorrelated disorder. Systems with long-range hops rather present ergodic-to-multifractal edges and a phase transition from ergodic to multifractal (extended but nonergodic) states. Both mobility and ergodic-to-multifractal edges may be clearly revealed in experiments on expansion dynamics.

Establishment of a clinically relevant large animal model to assess the healing of metaphyseal bone

Despite the high incidence of metaphyseal bone fractures in patients, the mechanisms underlying the healing processes are poorly understood due to the lack of suitable experimental animal models. Hence, the present study was conducted to establish and characterise a clinically relevant large-animal model for metaphyseal bone healing. Six female adult Merino sheep underwent full wedge-shaped osteotomy at the distal left femur metaphysis. The osteotomy was stabilised internally with a customised anatomical locking titanium plate that allowed immediate post-operative full-weight bearing. Bone healing was evaluated at 12 weeks post-fracture relative to the untouched right femur. Histological and quantitative micro-computed tomography results revealed an increased mineralised bone mass with a rich bone microarchitecture. New trabeculae healed by direct intramembranous ossification, without callus and cartilaginous tissue formation. Stiffness at the cortical and trabecular regions was comparable in both groups. Functional morphological analysis of the osteocyte lacunae revealed regularly arranged spherically shaped lacunae along with the canalicular network. Bone surface biochemical analysis using time-of-flight secondary-ion mass spectrometry showed high and homogeneously distributed levels of calcium and collagenous components. Ultrastructure imaging of the new trabeculae revealed a characteristic parallel arrangement of the collagen fibrils, evenly mineralised by the dense mineral substance. The specialised bone cells were also characterised by their unique structural features. Bone remodelling in the fractured femur was evident in the higher expression levels of prominent bone formation and resorption genes. In conclusion, the novel metaphyseal fracture model is beneficial for studying healing and treatment options for the enhancement of metaphyseal bone defects.