CLINICAL AND OBJECTIVE TEST CHARACTERISTICS OF VESTIBULAR MIGRAINE: IMPLICATIONS FOR DIAGNOSIS AND MANAGEMENT

The research we provided look at a number of factors, such as age, unilateral testing, and squinting both during the ictal and interictal periods to define vestibular migraine. One hundred and ten adults with recurrent spontaneous and positional vertigo participated in the study, which the investigators did. Vestibular migraines (VM) or probable vestibular migraine constituted the two diagnoses given to the patients (n = 29 and n = 76, respectively). The findings revealed those surveyed frequently complained of headache (85.3%), spinning vertigo (76.2%), and Mal de Débarquement (60.2%), with movement hypersensitivity (32.6%). After an episode, 75.2% of individuals having vestibular migraine showed spontaneous squinting, whereas 16.5% did so among assaults, although fixing was forbidden. 27.3% of people had clear spatial squinting after an assault, while 57.3% did so after assaults. In 51.2% of instances, the direction of ictal spontaneous Nystagmus was straight, while in 19.5% of cases, it was vertical. Positional and spontaneously ictal squinting was evaluated at speeds between 0.0 and 59.3 degrees per second and 0.0 and 99.9 levels per minute, respectively. In 92.6% and 25.1% of instances, respectively, the interact spontaneous and positional nystagmus velocities were typically less than 3 degrees/second. When contrasted with the time within assaults, squinting speeds were substantially greater after an assault. According to additional tests, 98.6% of those tested exhibited normal lateral video head impulse test gains, indicating that their vestibule-ocular responses were in place. The calorie test findings were symmetrical in 86.4% of the instances, showing normal vestibular function. In 90.4% and 95.2% of cases misogynic potentials displayed symmetrical magnitudes. In 69.8% and 98.1% of instances, misogynic possibilities were identical. In 89.3% of cases, the audiometer data is generally uniform and age-consistent. In outcome, low-velocity squinting that can be horizontal, vertical, or torsional motions occur throughout a sensory migraines event. The investigation also discovered that patients with vestibular migraine often had acceptable audio vestibular test findings.

Epidemiology, clinical presentation and management of COVID-19 associated mucormycosis: A single center experience from Pune, Western India

Background

The second COVID‐19 wave in India has been associated with an unprecedented increase in cases of COVID‐19 associated mucormycosis (CAM), mainly Rhino‐orbito‐cerebral mucormycosis (ROCM).

Methods

This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India, between 1 April, 2020, and 1 August, 2021, to identify CAM patients and assess their management outcomes. The primary endpoint was incidence of all‐cause mortality due to CAM.

Results

59 patients were diagnosed with CAM. Median duration from the first positive COVID‐19 RT PCR test to diagnosis of CAM was 17 (IQR: 12,22) days. 90% patients were diabetic with 89% having uncontrolled sugar level (HbA1c >7%). All patients were prescribed steroids during treatment for COVID‐19. 56% patients were prescribed steroids for non‐hypoxemic, mild COVID‐19 (irrational steroid therapy), while in 9%, steroids were prescribed in inappropriately high dose. Patients were treated with a combination of surgical debridement (94%), intravenous liposomal Amphotericin B (91%) and concomitant oral Posaconazole (95.4%). 74.6% patients were discharged after clinical and radiologic recovery while 25.4% died. On relative risk analysis, COVID‐19 CT severity index ≥18 (p = .017), presence of orbital symptoms (p = .002), presence of diabetic ketoacidosis (p = .011) and cerebral involvement (p = .0004) were associated with increased risk of death.

Conclusions

CAM is a rapidly progressive, angio‐invasive, opportunistic fungal infection, which is fatal if left untreated. Combination of surgical debridement and antifungal therapy leads to clinical and radiologic improvement in majority of cases.

Combination therapy of Tocilizumab and steroid for management of COVID-19 associated cytokine release syndrome: A single center experience from Pune, Western India

Cytokine release syndrome (CRS) or cytokine storm is thought to be the cause of inflammatory lung damage, worsening pneumonia and death in patients with COVID-19. Steroids (Methylprednislone or Dexamethasone) and Tocilizumab (TCZ), an interleukin-6 receptor antagonist, are approved for treatment of CRS in India. The aim of this study was to evaluate the efficacy and safety of combination therapy of TCZ and steroid in COVID-19 associated CRS.This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India between April 2 and November 2, 2020. All patients administered TCZ and steroids during this period were included. The primary endpoint was incidence of all cause mortality. Secondary outcomes studied were need for mechanical ventilation and incidence of systemic and infectious complications. Baseline and time dependent risk factors significantly associated with death were identified by Relative risk estimation.Out of 2831 admitted patients, 515 (24.3% females) were administered TCZ and steroids. There were 135 deaths (26.2%), while 380 patients (73.8%) had clinical improvement. Mechanical ventilation was required in 242 (47%) patients. Of these, 44.2% (107/242) recovered and were weaned off the ventilator. Thirty seven percent patients were managed in wards and did not need intensive care unit (ICU) admission. Infectious complications like hospital acquired pneumonia, blood stream bacterial and fungal infections were observed in 2.13%, 2.13% and 0.06% patients respectively. Age ≥ 60 years (P = .014), presence of co-morbidities like hypertension (P = .011), IL-6 ≥ 100 pg/ml (P = .002), D-dimer ≥ 1000 ng/ml (P < .0001), CT severity index ≥ 18 (P < .0001) and systemic complications like lung fibrosis (P = .019), cardiac arrhythmia (P < .0001), hypotension (P < .0001) and encephalopathy (P < .0001) were associated with increased risk of death.Combination therapy of TCZ and steroids is likely to be safe and effective in management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in randomized controlled trials.

Screening patients with tuberculosis for diabetes mellitus in Gujarat, India

SETTING

Anklav Tuberculosis Unit, Anand, Gujarat, India.

OBJECTIVE

To determine in a cohort of TB patients 1) the prevalence of diabetes (DM) and impaired fasting glucose (IFG), 2) the time taken for diagnosis, 3) demographic and clinical factors associated with DM and IFG, and 4) the number needed to screen (NNS) for diagnosing new cases of DM and IFG.

DESIGN

Descriptive study. TB patients registered between January and September 2012 were asked whether they had a history of DM. Those with unknown DM were tested for random and fasting blood glucose (FBG). FBG of ≥126 mg/dl and 110-125 mg/dl were considered indicative of DM and IFG, respectively.

RESULTS

Of 556 TB patients, 553 (99%) were assessed: 36 (6.5%) had diabetes (14 had been previously diagnosed DM and 22 were newly diagnosed), and 39 (7%) had IFG. The median (interquartile range) time to DM diagnosis was 5 (1-17) days. Age ≥35 years was associated with DM. The NNS was 25 and 14 for one new case of DM and IFG, respectively, with a lower NNS in males, those aged ≥35 years, those with smear-positive pulmonary TB, retreatment patients and smokers.

CONCLUSION

This pilot project shows that it is feasible and valuable to screen patients with TB for DM in a routine setting, resulting in earlier identification of DM and opportunities for better management of comorbidity.

Posture and gait abilities in patients with myotonic dystrophy (Steinert disease). Evaluation on the short-term of a rehabilitation program

OBJECTIVES

To evaluate the effects of a rehabilitation program in terms of balance, gait and muscle strength in a population of patients with myotonic dystrophy.

PATIENTS

Twenty patients benefited, as outpatients in a hospital setting, from a rehabilitation program with clinical and instrumental evaluations. The evaluation focused on quantitative balance measurement by clinical and stabilometer tests, gait assessed by Locometre and extensors and flexors knee muscle strength measured in isokinetic concentric mode at 60°/s.

RESULTS

After the rehabilitation program, we observed a significant improvement in the patients' balance capacities measured with the Berg Balance Scale (BBS), fast gait speed and muscle strength. However, the instrumental evaluation did not report any gains for static balance and spontaneous gait speed after the training program. No correlation was found between the various improvements.

CONCLUSION

A rehabilitation program focused on strength, gait and balance allowed for significant improvements in some parameters of myotonic dystrophy. These results attest to the relevance of a short-term rehabilitation protocol for these patients in the framework of a multidisciplinary therapeutic care. The disparity observed in the results measured for these patients suggest the contribution of cognitive involvement in the limitations felt by patients with myotonic dystrophy in the areas of gait and balance.

Altered biology of adeno-associated virus type 2 and human papillomavirus during dual infection of natural host tissue

Adeno-associated virus (AAV), a common genital virus, may have a "protective" role against human papillomavirus (HPV)-associated cervical cancer. Epidemiological studies indicate a negative correlation between AAV infection and the incidence of cervical cancer. In contrast, HPV is positively associated with cervical cancer. To investigate interactions between these two viruses we used the organotypic "raft" culture system. The raft culture system is capable of supporting the complete HPV life cycle. Raft tissues that were actively replicating HPV were superinfected with AAV type 2 (AAV-2). We observed a multiplicity of infection (m.o.i.)-dependent enhancement and inhibition of HPV DNA replication, concomitant with AAV-2 replication. The data suggest that at low m.o.i. of AAV-2 infection, HPV DNA replication was slightly increased compared to controls and AAV-2 replicated poorly. At high AAV-2 m.o.i., HPV DNA replication was reduced and AAV-2 replicated to high levels. AAV-2 replication was increased in the presence of HPV compared to primary human keratinocyte, squamous cell carcinoma, and HaCat raft cultures infected with AAV-2 alone. These data suggest that HPV may provide types of "enhancer/helper" functions for AAV-2 replication and progeny formation. Infection with AAV-2 had significant effects on epithelial morphology. During infection with low m.o.i. of AAV-2 the epithelium stratified to a greater extent than in controls. With high m.o.i. of AAV-2 infections, tissue cytopathic effects were observed, indicating an additional factor responsible for the effect of AAV-2 on HPV replication and infection. Our results demonstrate a complex interaction between AAV-2, HPV, and skin during dual infection.

Adeno-associated virus is associated with a lower risk of high-grade cervical neoplasia

Adeno-associated virus (AAV) is a ubiquitous human helper-dependent parvovirus which may interact with human papillomaviruses (HPV) to modify a woman's risk of cervical neoplasia. This analysis was nested in a cohort study of low-income women receiving Pap smears as part of their family planning services. We selected cases (55 with high-grade cervical squamous intraepithelial lesions (HSIL) and 162 with low-grade LSIL) and controls (96 women with normal cervical cytology) and analyzed cervical DNA for AAV, using PCR amplification/dot blot hybridization, and HPV, using hybrid capture I. AAV positivity was associated with a significantly reduced risk of HSIL (age and HPV-adjusted odds ratio (aOR) = 0.32) yet not with LSIL (aOR = 0.78); 53.8% of HSIL, 66.9% of LSIL, and 70.7% of controls were AAV+. AAV appears to interact with HPV to reduce SIL risk; relative to the HPV-/AAV+ exposure, the respective aORs for HSIL and HPV+/AAV-, HPV+/AAV+, and HPV-/AAV+ were 17.0, 6.9, and 3.5. AAV+ was not associated with age, race, HPV status, or sexual or reproductive risk factors. These results strongly suggest that AAV may play a protective or inhibitory role in late stage cervical carcinogenesis. This conclusion needs to be verified in additional epidemiologic studies.

Ubiquitous human adeno-associated virus type 2 autonomously replicates in differentiating keratinocytes of a normal skin model

Since its discovery in 1966, adeno-associated virus type 2 (AAV) has been described as a helper-dependent parvovirus. However, in this study we demonstrate that AAV undergoes its complete life cycle, devoid of helper viruses or genotoxic agents, in the organotypic epithelial raft tissue culture system, a model of normal skin. AAV progeny production directly correlated with epithelial differentiation, as nondifferentiating keratinocytes were defective for this activity. Large nuclear virus arrays of particles of approximately 26 nm (parvovirus size) were observed in the granular layers of the raft epithelium by electron microscopy. Additionally, dosage-dependent histologic changes, some of which might be interpreted as cytopathology, were induced in the AAV-infected epithelial tissues. These data suggest a new biological model for AAV; that is, AAV is an epithelial-tropic autonomous parvovirus that can alter normal squamous differentiation.

Transduction and utility of the granulocyte-macrophage colony-stimulating factor gene into monocytes and dendritic cells by adeno-associated virus

The genetic manipulation of antigen-presenting dendritic cells (DC) offers promise for stimulating the immune response, in particular for anticancer and antiviral protocols. As adeno-associated virus (AAV) has shown promise as a gene delivery vector for transducing a variety of hematopoietic cell types, we have investigated AAV's ability to genetically alter DC. In this analysis, we modified the standard granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-4 (IL-4) treatment of adherent monocytes to generate DC. In our protocol, adherent monocytes were first infected with an AAV/GM-CSF/Neo vector, and the addition of IL-4 was delayed for 2 days to allow for a brief period of monocyte proliferation. AAV-mediated transduction of the GM-CSF and Neo genes into monocytes/DC precursors was demonstrated by G418 selection, GM-CSF secretion, GM-CSF RNA expression (reverse transcriptase-polymerase chain reaction amplification [RT-PCR]), and cell proliferation. Cells resulting from infection with AAV/GM-CSF/Neo virus, and subsequent IL-4 and tumor necrosis factor-alpha (TNF-alpha) treatment, displayed multiple classic markers consistent with mature DC. Finally, chromosomal integration of the AAV vector was also demonstrated in sorted CD83+ DC. These data strongly suggest that AAV vectors will be useful for the genetic manipulation of DC and suggest that the transduction of the GM-CSF gene was able to fully replace the need for exogenous GM-CSF in the production of mature DC.

Chromosomal latency and expression at map unit 96 of a wild-type plus adeno-associated virus (AAV)/Neo vector and identification of p81, a new AAV transcriptional promoter

OBJECTIVE

Human adeno-associated virus (AAV) is ubiquitous and known to establish latency by chromosomal integration. We have constructed a wild-type plus AAV vector, ins96-0.9Neo, containing the neomycin resistance gene open reading frame (Neo ORF) of 960 bases in length at map unit 96 of the virus. Ins96-0.9Neo was constructed in an unconventional manner in that the Neo ORF lacked a dedicated heterologous promoter. In this study, this wild-type plus AAV vector was to used to test AAV's packaging capacity and ability for chromosome 19 AAVS1 integration. However, when it was discovered that ins96-0.9Neo also transduced cells to G418 resistance, we also investigated the mechanism of Neo ORF expression in this vector.

STUDY DESIGN/METHODS

We investigated the ability of ins96-0.9Neo to produce virus at high titers and to retain the Neo sequences by Southern blot analysis. The ability of ins96 0.9Neo virus to transduce the Neo gene into cells was analyzed by colony formation under G418 selection, and the ability of ins96-0.9Neo to latently infect cells, including the AAVS1 region of chromosome 19, was investigated by a series of polymerase chain reaction (PCR) amplifications. Finally, the RNA expression of the Neo gene at map unit 96 was investigated by reverse transcriptase primer extension (RTPE) analyses with two different primers and by S1 nuclease protection.

RESULTS

High titers of the ins96-0.9Neo virus could be generated (10(9) infectious units [IU]/mL without concentration), the Neo gene was retained in the encapsidated viral genome, infection by this virus resulted in G418 resistance, and significant integration was taking place within the AAVS1 sequences of human chromosome 19 on transduction. Analysis of mRNA by RTPE using both primers and by the S1 nuclease protection assay mapped the 5' end of the Neo transcripts to approximately 700 bases upstream of the Neo ATG at map unit 81 (nt 3793-3813), thus identifying a new AAV promoter.

CONCLUSIONS

These data demonstrate that ins96-0.9Neo will be useful for studying wild-type AAV integration and suggest that such wild-type plus recombinant AAV vectors may be useful for human gene therapy. The advantages of using such wild-type plus AAV vectors over defective AAV vectors include the ease in production of recombinant virus and the ability for site-specific integration into chromosome 19. This study also uncovered a previously unknown AAV promoter, p81. This finding suggests that the as yet uncharacterized ORF (nt 3922-4388) located just downstream of this promoter is likely an expressed gene. Furthermore, these data support our earlier findings that the AAV virion can package >900 bases more than can the wild-type.

Side effects of chronic intrathecal baclofen on erection and ejaculation in patients with spinal cord lesions

OBJECTIVE

Assess modifications of sexual function in men treated with intrathecal baclofen for spinal spasticity.

DESIGN

Prospective before-after trial.

SETTING

A rehabilitation department of a university hospital; follow-up was on an outpatient basis.

PATIENTS

A convenience sample of nine consecutively recruited men with spinal cord injury or multiple sclerosis who were receiving intrathecal baclofen by an implantable pump; average follow-up was 44.4 months.

MAIN OUTCOME MEASURES

A questionnaire focusing on: libido; ability to sustain reflexive and psychogenic erections; rigidity, evaluated by a visual analog scale; maximum duration of erection; possibility of ejaculation.

RESULTS

Libido and the ability to obtain psychogenic or reflexogenic erections were not modified. However, eight patients reported a decrease of erection rigidity and/or duration. Ejaculation was possible in three cases before implantation. It disappeared in two patients, and was more difficult to obtain in the last one. It reappeared after treatment withdrawal. No differences were found between multiple sclerosis and spinal cord injured patients.

CONCLUSION

Intrathecal baclofen may compromise erection and ejaculation. This effect is reversible. Patients should be informed of this effect.

Intrathecal baclofen administration for control of severe spinal spasticity: functional improvement and long-term follow-up

OBJECTIVES

To assess long-term efficacy and functional benefits of intrathecal baclofen for severe spinal spasticity.

DESIGN

A prospective before-after trial.

SETTING

A neurological rehabilitation department of a university hospital. Pump implantation was realized in neurosurgery; follow-up was carried out mostly on an outpatient basis.

PATIENTS

Eighteen patients with severe and disabling spinal spasticity received intrathecal baclofen by an implantable pump; average follow-up was 37.4 months (range, 9 to 72).

MAIN OUTCOME MEASURES

Spasticity (Ashworth and spasms frequency scores); disability (Functional Independence Measure [FIM]).

RESULTS

A significant decrease in tone and spasms was observed in all patients. Tolerance appeared during the first 6 to 9 months. Later on, efficacy remained stable, except in cases of mechanical problems of the pump or catheter. Functional assessment found a highly significant (p < .001) increase of FIM score (particularly for bathing, dressing lower body, transfers, and in some cases, locomotion). This was particularly marked in patients with thoracic spinal cord lesion. In cases of severe upper limb dysfunction, FIM was only improved for wheelchair displacements, due to a better sitting position, but nursing became easier and life comfort was enhanced. Severe side effects (overdose) were observed in two cases.

CONCLUSION

Efficacy remained stable after 6 to 9 months. Marked improvement of functional independence was observed in paraplegic patients. Improvement was less spectacular in patients with severe upper limb dysfunction, but nevertheless appreciable in terms of life comfort and use of attendants.

[Urination disorders in HIV infected patients]

OBJECTIVES

Manifestations of urological involvement, including tumour development, infection and impaired micturition are frequent in patients with acquired immunodeficiency syndrome. The frequency and consequences of dysuria itself are difficult to evaluate due to the concomitant effects of underlying infections, obstructive or neurological pathologies.

METHODS

Thirty-nine HIV-positive patients presenting impaired micturition including isolated dysuria, urine retention pollakiuria or urge incontinence were followed prospectively from February 1989 to September 1992. Each patient underwent a complete neurological and urological examination. Imaging included CT-scan or magnetic resonance imaging of the brain or spinal cord, echography of the bladder and prostate, intravenous pyelography or ascending and micturition urethrocystography as required. Urinary function tests were used to determine the cause and exact type of impairment to establish therapeutic protocols.

RESULTS

A neurological origin was found in 61.5% of the cases. Cerebral toxoplasmosis and HIV encephalitis were the most commonly found causes. Symptomatic relief was obtained in most patients with bladder- sphincter active drugs. After a mean follow-up of 9 months (range 2-24 months), long-term improvement was achieved in 57.9%. Seventeen patients (44%) died within a delay of 2 to 24 months (mean 8 months) after onset of dysuria.

CONCLUSION

Signs of impaired micturition are frequently encountered in HIV-infected patients. A full work-up is needed for diagnosis and treatment adaptation. Neurological disease is the most frequent underlying cause and would appear to be a sign of poor prognosis.