Gutka Associated Optic Neuropathy

Optic neuropathy may be multi factorial in origin. It’s association with gutka use in South East Asia is most likely under diagnosed and often overlooked, considering it is a diagnosis of exclusion. The Optic nerve toxicity is well known occurring due to medications, metals, organic solvents, methanol, and carbon dioxide.1 Over recent years the effect of smokeless tobacco has been highlighted as one of the common causes of toxic optic neuropathy (TON), as visual impairment is already a colossal global health issue. Nonetheless,as high as 80 percent of the total burden of cases of blindness globally are due to causes that are actually preventable as per the World Health Organization (WHO). Various forms of tobacco have been used traditionally across cultures. A distinct form of chewable tobacco is gutka commonly used in South East Asia ,it is as an amalgam with additional areca or betel nuts, slaked lime, and spices.2 Out of 303 million smokeless tobacco users, 248 million (81%) live in south east Asia. In this region 24% men and 11% women use smokeless tobacco.3 However, in the age of global connectivity and escalating immigrant settlements gutka use is now a reason for public health concern in western countries as well

Effects of Intermittent Fasting On Cognition and Neurodegeneration

Intermittent fasting (IF) can facilitate neurodegenerative, neuroadaptive and neuroprotective processes leading to profound effects on cognition and dementias. The impact that IF has on the central nervous system is still not fully known. Several factors come into likely effect including changes in energy metabolism, oxidative damage, insulin sensitivity, inflammation, and functional changes related to various neurotransmitters and hormones. During IF ketones are produced in large quantities and the brain consumes these for energy. The presence of ketone bodies increases the expression of the genes for brain derived neurotrophic factor which has a powerful effect on dementia and cognition. Brain derived neurotrophic factor (BDNF) in the hippocampus, the striatum, and cerebral cortex affects learning capabilities and memory. This process is enhanced by IF. IF also has multiple effects on the endocrine wellbeing, including control of hypertension, metabolic syndrome, insulin resistance and dyslipidemia. In ancient times, fasting was a common practice but with recent cellular studies the beneficial effects on the brain of IF are being truly proven. In a world of costly health care with an increase in neurological disorders, IF could be an effective therapy that is multi targeted, self-controlled and cost free .Further research is required to question the effect of IF in the long-term and whether pharmaceuticals can come up with safer medication options that imitate the effects of IF without a drastic change in the eating patterns

Neurological manifestations of COVID-19

Coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) has turned out to be a formidable pandemic. Upcoming evidence from confirmed cases of COVID-19 suggests an anticipated incursion of patients with neurological manifestations in the weeks to come. An expression of the angiotensin-converting enzyme 2 (ACE 2), the cellular receptor for SARS-CoV-2 over the glial cells and neurons have made the brain a potential target. Neurotoxicity may occur as a result of direct, indirect and post-infectious complications. Attention to neurological deficits in COVID-19 is fundamental to ensure appropriate, timely, beneficial management of the affected patients. Most common neurological manifestations seen include dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizures. Anosmia and ageusia have recently been hinted as significant early symptoms in COVID-19. As cases with neurological deficits in COVID-19 emerge, the overall prognosis is yet unknown

NEUROLOGICAL INVOLVEMENT IN COVID-19 INFECTIONS; PATHOPHYSIOLOGY, PRESENTATION AND OUTCOME.

Severe acute respiratory syndrome corona virus 2 (SARS CoV 2) seems to display an increasing affinity for the nervous system. The ongoing pandemic has made evident that diverse neurological manifestations may occur with COVID 19. Headache and dizziness remain the most common symptoms however stroke, seizures, encephalopathy, neuropathy and skeletal muscle injury may be seen. An increasing number of patients report initial anosmia and ageusia. Tendency for serious illness is believed to be in the elderly or people with a history of diabetes, high blood pressure and heart disease. Many patients on immunosuppressive therapies such as multiple sclerosis, myasthenia gravis or sarcoidosis are additionally high risk. Angiotensin-converting enzyme 2 (ACE 2) has been identified as the cellular receptor for SARS CoV 2 present in both neurons and glial tissue. The pathophysiology of neurotoxicity at best remains elusive with dysregulation of homeostasis and pro inflammatory cytokine production causing direct, indirect and post infectious neurological complications. Vigilant observation for neurological involvement is important not only to prevent spread of this highly contagious disease but also for appropriate, timely management. A directed neurological examination limiting exposure of medical personnel to potentially infected patients is mandatory. Appropriate constrained investigations should be considered only if there is a likelihood of changing management. Tele neurology consultations, whenever possible is the need of the hour. Outcomes of COVID 19 patients with severe illness and neurological complications remains grave. Pharmaceutical research needs to change directions to expedite the development of a possible vaccine and also accelerate in the quest for newer antiviral agents

Clinical profiles, management and outcome of myasthenic crisis in a tertiary care center in Karachi, Pakistan

To determine the clinical profiles, management and outcome of myasthenic crisis (MC) in patients presenting to a tertiary care hospital in Karachi, Pakistan. This was a retrospective study of forty patients with Myasthenic crisis(MC) admitted at the Aga Khan University Hospital, Karachi between 1999 and 2014.Demographics, clinical presentation, hospital course, management and outcomes were reviewed. Ventilatory support for respiratory muscle or bulbar weakness was taken as crisis identification at arrival. Out of the total 40 patients with MC; generalized onset was seen in 28 (70%) and isolated bulbar symptoms in 12 (30%) patients. Fifteen patients (37.5%) had MC as a first presentation. In a third world country with insufficient resources and limited access to specialist care, early recognition of MC by general practitioners is important. Patient education about avoidance of possible precipitating factors and recognition of early symptoms of MC is essential

Spectrum of neuromuscular injuries in victims of bomb blasts

Introduction: Bomb blast (BB) injuries outside war zones were a rare phenomenon until recently. With the spreading wave of terrorism across the globe, BB related trauma is resurfacing. Explosions can produce unique patterns of neuromuscular injury. No recent data exists categorizing such injuries. Methods: Medical records and electrodiagnostic findings of 20 patients with BB related neuromuscular injuries (NMI) were reviewed retrospectively. Results: Most common site of injury was the lower extremities (55%) with majority presenting clinically with foot drop (40%) or weakness (30%). 9/17 patients (45%) had associated shrapnel or penetrating trauma. 6/20 patients had associated fractures. The most common finding was of mononeuropathies. Discussion: As we re-enter an era of war, we need to recreate awareness of the possible spectrum of NMI. Awareness of such injuries will lead to early identification of nerve trauma and the possibility of reduction in overall disability if treated appropriately soon after the injury

Comparison of neonatal outcomes between category-1 and non-category-1 primary emergency cesarean section: A retrospective record review in a tertiary care hospital

Objective: To compare neonatal outcomes between Category-1 and Non-Category-1 Primary Emergency Cesarean Section.Methods: This was a retrospective analysis, conducted at Aga Khan University Hospital Karachi from January 1st 2016 till December 31st 2016. Non-probability purposive sampling technique was used. A sample size of 375 patients who had primary Emergency Caesarean Section (Em-CS) was identified by keeping CS rate of 41.5% and 5% bond on error. Data was collected from labor ward, operating theatre and neonatal ward records by using structured questionnaire.Results: In the current study, out of 375 participants who underwent primary Em-CS; majority (89.3%) were booked cases. Two-hundred-eighty-two (75.2%) were primiparous women. Two hundred and thirty (61.3%) were at term and 145(38.7%) were preterm. The main indication among Category-1 CS was fetal distress (15.7%). For Non-Category-1 CS, non-progress of labour (45.1%) was the leading cause of abdominal delivery. Except for APGAR score at one minute (p value = 0.048), no other variables were statistically significant when neonatal outcomes were compared among Category 1 and Non-Category-1 CS.Conclusion: In this study, fetal distress and non-progress of labor were the main indications for Category-1 and Non-Category-1 CS respectively. We did not find statistically significant association between indications of Em CS and neonatal outcomes. However further prospective studies are required to confirm this association

Chikungunya encephalitis: Usual presentation at an unusual time. a case report

CHIK is an arboviral infection caused by chikungunya virus transmitted by Aedes mosquito worldwide. It usually manifests as a self-limiting acute febrile illness with rash, body ache and severe polyarthralgia; in some patients, symptoms persist up to months or even years. Neurological manifestations are relatively uncommon. In recent years Pakistan and other South East Asian countries have been hit several times by its epidemics1. We report a case of a middle-aged male who presented in our hospital with acute febrile illness along with neurological manifestations. Extensive laboratory investigations were done and he was diagnosed with seropositive CHIKV. He was treated symptomatically and recovered without any complication. Although previously cases of chikungunya meningoencephalitis have been reported in Pakistan during epidemics; such cases sporadically have not been reported so far1

Current Status of Non-Disease Modifying Gene Therapy in Parkinson’s Disease

Parkinson’s disease (PD) is a chronic progressive neurological disorder characterized by bradykinesia, tremor, muscular rigidity, and postural instability. The world-wide prevalence is expected to rise further with increasing mean age. Theoretically, if all desired elements required for dopamine synthesis are functionally available, need for exogenous L-DOPA administration can be eliminated or markedly reduced. However, lack of effective long-term treatment has led to extensive gene therapy research focusing both on disease modifying as well as non-disease modifying aspects. Since genetic lesions are found in both familial as well as sporadic PD cases, the principle of introducing a normal gene to cure a disease can also be applied in PD. Success in effective gene delivery to the target brain regions and its tolerability owing to negligible immune response against the vector has further encouraged the work. The likelihood of gene therapy becoming future and true cure for PD is very high. This commentary describes status of non-disease modifying gene therapy in PD

Longitudinally extensive transverse myelitis with seropositive chikungunya

Chikungunya viral (CHIKV) fever is often a self-limiting febrile illness associated with severe debilitating arthralgia. Neurological complications associated with CHIKV, although rare, have been reported in literature; however, longitudinally extensive transverse myelitis (LTEM) is rarely associated with it. We present a case of a middle-aged man with a 1-week history of low-grade fever and arthralgia followed by urinary retention and quadriplegia. A sensory level was noted at T2. On subsequent investigations, he was diagnosed with LETM. Although LETM is commonly seen in patients with neuromyelitis optica, the other possible etiologies are inflammatory and parainfectious. To date, only two cases of LETM are reported worldwide in association with CHIKV fever and this is the first case from Pakistan. With frequent chikungunya outbreaks, neurological complications are increasingly seen in clinical practice. The knowledge of these associations will result in their early diagnosis and treatment