Association of Catechol-O-Methyltransferase Gene rs4680 Polymorphism and Levodopa Induced Dyskinesia in Parkinson's Disease: A Meta-Analysis and Systematic Review

INTRODUCTION

Long-term levodopa therapy for Parkinson's disease (PD) can cause levodopa induced dyskinesia (LID). Genetic predisposition has a significant role to play in inter-individual heterogeneity in the clinical manifestation of LID. Despite accumulating evidence for the role of COMT gene polymorphism (rs4680) as a genetic basis for LID, to date results have been inconsistent. Early assessment of the Catechol-O-Methyltransferase (COMT) genotype might be helpful to stratify PD patients concerning their individual risk for LID.

METHOD

In this meta-analysis, we have used 9 studies, which were selected through online databases. Statistical analysis was performed using R (v-3.6) software. 5 genetic models have been used in the present study: Allele model (A vs. G), Dominant model (AA+AG vs. GG), Homozygote model (AA vs. GG), Co-dominant/heterozygote model (AG vs. GG), and Recessive model (AA vs. AG + GG).

RESULTS

The results indicated a significant association between COMT rs4680 (Val158Met) polymorphism and LID risk. The genotype AA of COMT rs4680 is a risk factor for LID in PD patients under the recessive model (AA vs GG+AG) in the random-effect model. Analysis based on ethnicity showed that COMT rs4680 SNP allele A is a risk factor for LID development in Asian PD patients, while GG genotype is a risk factor for LID development in non-Asian PD patients using different genetic models.

CONCLUSION

The results of the present meta-analysis support that the COMT Val158Met polymorphism is a risk factor for the development of LID in PD patients having ethnic variations.

Study of Abnormal Liver Function Test during Pregnancy in a Tertiary Care Hospital in Chhattisgarh

INTRODUCTION

Abnormal liver function tests (LFTs) in pregnancy require proper interpretation in order to avoid pitfalls in the diagnosis. The underlying disorder can have a significant effect on the outcome of both mother and foetus. The present study was done with the objective to study the clinical profile, incidence and possible causes of derangements of liver function tests.

MATERIAL AND METHOD

Eighty pregnant women with abnormal liver dysfunction were studied prospectively. Women with chronic liver disease and drug-induced abnormal liver function test were excluded. All available LFTs including LDH were studied along with some more definitive tests to aid identification of underlying cause. Foetomaternal outcome was noted in all.

RESULT

The incidence of abnormal LFT was 0.9 %. 13/80 (16.75 %) women had liver disorder not specific to pregnancy, whereas 67/80 (83.25 %) women had pregnancy-specific liver dysfunction. Of these, 65(81.25 %) women with liver dysfunction had pre-eclampsia including 11 (13.75 %) with HELLP and six women with eclampsia. 48/65 (60 %) women had pre-eclampsia in the absence of HELLP syndrome or eclampsia. The mean value for bilirubin (mg %) in hypertensive disorders of pregnancy ranged from 1.64 to 3.8, between 5 and 10 for ICP and AFLP and >10 in infective hepatitis. Transaminases were highest in infective hepatitis, whereas alkaline phosphate was highest in ICP. Total 27 (33.75 %) women suffered from adverse outcome with four (5 %) maternal deaths and 23 (28.75 %) major maternal morbidities. 33/80 (41.25 %) women had intrauterine death. 26.25 % babies were small for date.

CONCLUSION

Pregnancy-specific disorders are the leading cause of abnormal liver function test during pregnant state particularly in the third trimester. Pre-eclampsia-related disorder is the commonest. Gestational age of pregnancy and relative values of various liver function tests in different pregnancy-specific and pregnancy nonspecific disorders appear to be the best guide to clinch the diagnosis.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare type of cardiomyopathy of unknown aetiology associated with significant mortality and morbidity and characterized by heart failure in late pregnancy or puerperium. Recently PPCM workshop committee has recommended inclusion of echocardiographic features of LV dysfunction to redefine PPCM. Subsequent pregnancies are associated with a very high mortality in these patients and hence should be avoided. Women with PPCM continue to have significant mortality despite the use of conventional drugs for managing heart failure. Use of newer drugs such as immunoglobulin, pentoxifylline, bromocriptine, and cabergoline along with newer interventions such as plasmapheresis, immunoadsorption, ventricular assist devices and last but not the least the heart transplantation hold promise for future.

Exercise beyond menopause: Dos and Don'ts

With a significant number of women belonging to the status of menopause and beyond, it is imperative to plan a comprehensive health program for them, including lifestyle modifications. Exercise is an integral part of the strategy. The benefits are many, most important being maintenance of muscle mass and thereby the bone mass and strength. The exercise program for postmenopausal women should include the endurance exercise (aerobic), strength exercise and balance exercise; it should aim for two hours and 30 minutes of moderate aerobic activity each week. Every woman should be aware of her target heart rate range and should track the intensity of exercise employing the talk test. Other deep breathing, yoga and stretching exercises can help to manage the stress of life and menopause-related symptoms. Exercises for women with osteoporosis should not include high impact aerobics or activities in which a fall is likely. The women and the treating medical practitioner should also be aware of the warning symptoms and contraindications regarding exercise prescription in women beyond menopause. The role of exercise in hot flashes, however, remains inconclusive. Overall, exercising beyond menopause is the only noncontroversial and beneficial aspect of lifestyle modification and must be opted by all.

Effect of neck flexion on F wave, somatosensory evoked potentials, and magnetic resonance imaging in Hirayama disease

BACKGROUND

Flexion myelopathy is one of the suggested mechanism for Hirayama disease (HD) but simultaneous radiological and neurophysiological evaluation is lacking. This study therefore evaluates the effect of neck flexion in HD using somatosensory evoked potentials (SEPs), F waves, and magnetic resonance imaging (MRI).

METHOD

Eight HD patients and seven matched controls were subjected to median and ulnar F wave (minimal latency, FM ratio, persistence, and chronodispersion), and SEPs evaluating N9, N13, and N20 potentials in neutral and neck flexion. Spinal MRI was carried out in neutral and neck flexion and evaluated for cord atrophy, signal changes, cord compression, posterior epidural tissue, and loss of dural attachment.

RESULTS

The patients were aged 19 to 30 years. Minimal F latency, FM ratio, persistence, and chronodispersion in neutral and neck flexion did not show any change nor was there any change in N13 latency and amplitude on median and ulnar SEPs. The difference in these parameters in neutral and neck flexion were also not significant in HD compared with controls. The change in N13 was also not related to loss of dural attachment and posterior epidural tissue.

CONCLUSION

Neck flexion does not produce significant changes in N13 and F wave parameters and is not related to dynamic MRI changes. The other mechanisms for HD should therefore be explored.

A Clinical, Magnetic Resonance Imaging, and Survival Motor Neuron Gene Deletion Study of Hirayama Disease

BACKGROUND

Hirayama disease (HD) is a segmental nonprogressive spinal muscular atrophy found in male patients.

OBJECTIVE

To report the results of a comprehensive evaluation of clinical, magnetic resonance imaging (MRI), electromyography (EMG), and survival motor neuron (SMN) gene analysis of HD.

DESIGN

Clinical, MRI, and SMN gene deletion study.

SETTING

Tertiary care teaching hospital.

PATIENTS

Patients with HD diagnosed according to defined criteria were included in the study.

INTERVENTIONS

Patients underwent a neurologic evaluation and pedigree charting. Concentric needle EMG was performed on a number of muscles. Motor nerve conduction study of the median, ulnar, and peroneal nerves and sensory conduction study of the median, ulnar, and sural nerves were also performed. Spinal MRI of the cervical region was performed with the 2-T scanner operating at 1.5 T. Gene deletion study of SMN1 and SMN2 was performed in all patients.

MAIN OUTCOME MEASURES

History of trauma, occupation, exercise, associated medical disease, and cold paresis and muscle wasting, power, reflex changes, and tone.

RESULTS

Fifteen male patients with HD from 14 families participated in the study (mean age at the onset of disease, 18 years; range, 15-23 years). Muscle weakness and wasting were noted in the right upper limb in 12 and the left upper limb in 3, which became bilateral in 8 patients. Cold paresis was present in 6 patients and polyminimyoclonus in all patients. The EMG revealed fibrillations in 10, fasciculations in 15, and neurogenic motor unit potentials in C7, C8, and T1 myotomes in all patients. The EMG abnormalities were unilateral in 5, bilateral in 10, and subclinical in 2 patients. Spinal MRI revealed cord atrophy in 3 of 11 patients. Although family history was present in 1 brother only, the results of both SMN1 and SMN2 gene deletion studies were negative in all patients.

CONCLUSIONS

The SMN gene deletion is not found in HD. Exclusive occurrence in male patients and the presence of this disease in 2 brothers suggest a possible role of the X chromosome, which needs further evaluation.

A central demyelinating disease with atypical features

There are clinical, laboratory and imaging criteria to distinguish multiple sclerosis (MS) from neuromyelitis optica (NMO) and acute disseminated encephalomyelitis (ADEM). While MS has unknown aetiology, NMO is commonly associated with vasculitis and ADEM is supposed to be parainfectious in origin. In the present study, six patients are described from a group of 67 with a central demyelinating disorder whose clinical presentation did not conform to existing diagnostic criteria for ADEM, NMO or MS. Their clinical, laboratory and imaging characteristics were studied and analysed. Some features suggested a particular diagnosis but some other features favoured another diagnosis. The features included spinal cord involvement in a large vertical segment with cord swelling, optic neuritis, no lesions in the cerebral cortex, paraplegia with urinary retention during the acute phase, no oligoclonal band in cerebrospinal fluid, absence of any evidence of vasculitis, wide time-gap between spinal cord and optic nerve involvement, good recovery from acute phase of disease and a relatively benign course. We conclude that there exists a subpopulation of patients with central demyelinating disease in this region with mixed clinical features. Overall features suggested either a widened clinical spectrum of MS, NMO or ADEM or a possible overlap between them.

A clinical and genetic study of spinal muscular atrophy

AIMS

This study evaluates clinical, electromyography (EMG) and genetic analysis of consecutive patients with spinal muscular atrophy (SMA) in a tertiary care adult neurology practice in India.

METHODS

Consecutive patients with SMA attending the neurology out patient department during 2001-2003 were included. They were subjected to a detailed clinical examination, nerve conduction and EMG and muscle biopsy. Clinically patients were classified into generalised and segmental SMA. SMN gene deletion study was carried out in all the patients.

RESULTS

There were 15 patients with type III and type IV SMA and 15 with segmental SMA (Hirayama disease). The age ranged between 5 and 23 years in type III SMA, 33-50 years in type IV SMA and 16-30 years in Hirayama disease (HD). The latter was found exclusively in males. Family history was observed in 1 patient each in all the groups. In SMA III mother and brother were affected, in SMA IV two siblings and in HD one brother had similar disease. One type III SMA family was associated with deafness and one type IV family had strong association with maturity onset diabetes in young. The EMG was characterised by lack of fibrillations in all type III and IV SMA patients except 1 whereas in HD, 11 out of 15 had fibrillations suggesting ongoing denervation. The EMG was suggestive of reinnervation in generalised SMA in both upper and lower limb muscles where as these abnormalities were restricted to C7-T1 mytomes in HD. Muscle biopsy in 10 patients with generalised SMA revealed group atrophy in all, and loss of fascicular architecture in 3, clumping of nuclei in 7 and hypertrophic fibers in 4. SMN1 gene deletion was present in 3 patients with type III but none in type IV and HD.

CONCLUSION

SMN gene deletion was positive in 33% type III SMA whereas it was negative in type IV and HD. Presence of HD only in males may be consistent with X-linked disorder.

Pitfalls in diagnosis of epilepsy of Janz and its implications

84 patients of juvenile myoclonic epilepsy (JME) of Janz were studied. Diagnosis was confirmed using clinical and electro-encephalographic (EEG) criterias. 58 (78%) patients of JME were referred as 'refractory or uncontrolled seizures'. Ignoring myoclonic episodes and non-use of activation procedures in EEG were important reasons for diagnostic delay. Sodium valproate (VPA) or clonazepam are the drugs of choice while phenobarbitone (PB), carbamazepine (CZ), and phenytoin (PHT) are ineffective. Clinical spectrum of JME is slightly different in India. Family history of epilepsy or JME is not forthcoming and there is gross delay in the diagnosis. Other differences include age of presentation and mild cognitive impairment. All juvenile patients of generalized epilepsy, not responding to more commonly used CZ, PB and PHT should be strongly suspected for JME by carefully searching for myoclonus.

Clinicoradiological observation in three patients with suicidal hanging

STUDY DESIGN

A hospital-based clinical, radiological and neurophysiological study.

OBJECTIVES

Hanging is a common mode of suicide in India, but there is paucity of MRI and neurophysiological findings in the context of clinical and neurological changes. We report the clinical, neurophysiological and MRI studies of three females who attempted suicide by hanging.

METHODS

All three patients who attempted hanging underwent detailed clinical, electroencephalographic, motor, somatosensory and brainstem-evoked potential and magnetic resonance imaging studies. Patients were clinically followed up for 6 months.

RESULTS

Their ages were 21, 26 and 35 years. They developed altered sensorium, decorticate posturing and had a wide variety of movement disorders. Patient no. 1 had the most severe illness and recovered by the seventh month while the others recovered earlier. MRI revealed hyperintense signal changes in the globus pallidus, caudate nucleus and thalamus in all patients and in the midbrain in one patient. Electroencephalography showed nonspecific slowing. Somatosensory, motor and brainstem-evoked potential studies were normal.

CONCLUSION

Hanging leads to hypoxic brain damage resulting in signal changes mainly in the basal ganglia and thalamus and may be associated with transient movement disorders.

Effect of common anti-epileptic drugs on cognition in schoolchildren with epilepsy

This study was conducted to observe the effect of some commonly used anti-epileptic drugs (AEDs), on cognition, in 118 school going children with epilepsy, in an age range of 9-12 yrs., (Mean 10.4 +/- 1.7 yrs.). For comparison, 28 healthy, age and sex matched schoolchildren served as controls. After a clinical, electrophysiological and radiological evaluation, the cognitive functions were assessed in both groups, using a modified Wechsler's Intelligence Scale. It was observed that cognition was impaired in only 2.5% of children with epilepsy, there being no relationship between cognitive performance and the type of AED used. It is concluded that cognitive functions are impaired in only a limited number of children with epilepsy and effect of phenobarbitone and phenytoin on cognitive functions is comparable to carbamazepine and sodium valproate, particularly when demand of task is not very high.

Neonatal mortality in Meerut district

A study of neonatal mortality in Meerut district revealed an infant mortality rate of 50.1 per 1000 live births. Neonatal mortality accounted for 37.8% of infant mortality with a neonatal mortality rate of 19.0 per 1000 live births. 90.5% of these neonates were delivered at home largely by untrained personnel (57.2%). Only 28.6% of these neonates were treated by qualified doctors and only 30.9% of their mothers were fully immunized against tetanus. At least 2/3rd of neonatal mortality was due to exogenous factors with tetanus neonatorum and septicaemia being the principal causes of mortality each accounting for a mortality rate of 4.7 per 1000 live births.

Socioeconomic factors and prevalence of endemic goitre

The present study was conducted on 2611 school children of a rural area of Meerut, with the objectives to find out the prevalence and distribution of endemic goitre and the socioeconomic variables associated with the distribution of the endemic goitre. Grading of goitre was done as per the criteria laid down by the WHO-1979 (1). The overall prevalence rate of endemic goitre was 50.1%, the prevalence was more among females (55.1%) as compared to males (47.2%). Maximum number of goitre cases were having grade Ia enlargement (46.9%) followed by grade Ib (34.1%), grade 2(15.0%) and grade 3 (4.0%). Prevalence increased with increase in age. Statistically significant differences were found in the prevalence of endemic goitre in relation to different religions and caste groups, different occupations of the parents/guardians of children and types of houses used for the purpose of living.

Diabetes mellitus in geriatric females

A study was carried out on 36 geriatric diabetic females (above 60 years). Marked exhaustion and significant loss of weight were common presenting complaints (60%) besides usual symptomatology. Only 25% patients were asymptomatic for diabetes. Generalised itching (20%) and pruritus vulvae (33.3%) were other common presenting complaints. Neuropathy was found to be the commonest complication being present in 77.7% patients, followed by retinopathy (50%) and nephropathy (27.7%). Hypertension was found to be associated in 44% patients and evidence of ischaemic heart disease was found in 42%. Development of nephropathy, retinopathy, neuropathy, and hypertension showed direct correlation with duration of illness ie, longer the history of diabetes higher was the incidence of complications.

Morbidity pattern of communicable diseases in an urban area of Uttar Pradesh

The period prevalence rate of communicable diseases in Uttar Pradesh, India, in the present study was found to be 119.7 per thousand population. There were 1.08 communicable diseases per morbid person. The leading cause of morbidity was ascariasis (24.1 per 1000). The morbidity was significantly higher in young persons (below 14 years of age) and in those without spouse. The social class and educational status were found to have negative association with the morbidity. However, the sex did not show any influence on the morbidity.