Magnetic Resonance Imaging Brain and Electroencephalogram (EEG) in the Evaluation of New-Onset Seizures in a Tertiary Care Centre of Nepal

Introduction: Seizure is a common neurological condition with multiple etiological factors. This study aims to evaluate the role of magnetic resonance imaging (MRI) Brain and electroencephalography (EEG) in the diagnosis of new-onset seizures in the Nepalese population. Methods: A total of 106 patients aged between 7 to 85 years of age with first onset seizure, who underwent MRI and EEG were enrolled in the study. The sensitivity of MRI and EEG for the diagnosis of seizure when used in combination was compared with that of MRI or EEG alone. Results: Out of 106 patients, 58.5% (n=62) were males and 41.5% (n=44) were females. In 52.8% (n= 56) of the patients, there was epileptogenic lesion in MRI, and 39.6% (n=42) of the patients had an abnormal EEG. The combination of MRI with EEG was significantly better than either MRI or EEG alone in the diagnosis of seizures (p <0.001). Conclusion: MRI and EEG are frequently used for the evaluation of seizures. MRI Brain when used in combination with EEG significantly improves the diagnostic accuracy of seizures.

ACT-6 Clinical manifestations of the patients with relapsed glioblastoma after bevacizumab treatment

Introduction:The outcome of glioblastoma (GBM) is improving recently, but still only temozolomide and bevacizumab (BEV) are recognized as the effective agents that are reimbursed in Japan. On large clinical trials, BEV prolonged progression free survival (PFS) but the remaining survival period from the relapse after BEV is only 3–5 month. On this study, we retrospectively analyzed the data of GBM patients who were treated with BEV to explore the best usage of BEV.Methods:230 patients were diagnosed as GBM and received BEV from July 2013 to March 2021 in our institution. Among them, 104 patient, whose clinical courses were followed, were included in this study. (M:F=59:45, median age was 65.5) Results:The patients were divided into three groups by when they used BEV; upfront group at first line therapy, 1st relapse group at second line, and 2nd+ relapse group at more than third line. There were 42, 35, 27 patients in each group. The median overall survival (OS) was 17.6, 24.7, 46.1 month (p&lt;0.0001), median PFS after BEV treatment (PFSpBEV) was 8.8, 5.1, 5.0 month (p=0.2532), and the median survival after BEV treatment (OSpBEV) was 15.0, 9.9, 9.2 month (p=0.4437), respectively. There were 64 patients (22, 25, 17 in each group) who reached progressive disease (PD) after BEV. The median survival after PD (OSpBEVpPD) was 4.5, 5.8, 4.3 month (p=0.1590), respectively.Discussion:At the first onset, we use BEV only when the patients have low PS. Our results showed that OS was significantly longer when BEV was used in the later stage, but there was no significant difference in OS or PFS after BEV treatment. Especially OSpBEVpPD was 4–6 month regardless of the timing of BEV. To improve the treatment outcome of GBM, breakthrough therapy is needed in addition to optimizing the usage of BEV.

Dynamic risk for first onset of depressive disorders in adolescence: does change matter?

Background Risk factors for depressive disorders (DD) change substantially over time, but the prognostic value of these changes remains unclear. Two basic types of dynamic effects are possible. The ‘Risk Escalation hypothesis’ posits that worsening of risk levels predicts DD onset above average level of risk factors. Alternatively, the ‘Chronic Risk hypothesis’ posits that the average level rather than change predicts first-onset DD. Methods We utilized data from the ADEPT project, a cohort of 496 girls (baseline age 13.5–15.5 years) from the community followed for 3 years. Participants underwent five waves of assessments for risk factors and diagnostic interviews for DD. For illustration purposes, we selected 16 well-established dynamic risk factors for adolescent depression, such as depressive and anxiety symptoms, personality traits, clinical traits, and social risk factors. We conducted Cox regression analyses with time-varying covariates to predict first DD onset. Results Consistently elevated risk factors (i.e. the mean of multiple waves), but not recent escalation, predicted first-onset DD, consistent with the Chronic Risk hypothesis. This hypothesis was supported across all 16 risk factors. Conclusions Across a range of risk factors, girls who had first-onset DD generally did not experience a sharp increase in risk level shortly before the onset of disorder; rather, for years before onset, they exhibited elevated levels of risk. Our findings suggest that chronicity of risk should be a particular focus in screening high-risk populations to prevent the onset of DDs. In particular, regular monitoring of risk factors in school settings is highly informative.

Risk factors analysis and establishment of a clinical predictive model for recurrence after first attack of myasthenia gravis: a single-center retrospective study

Background Myasthenia gravis (MG) is a rare and recurrent disease. The purpose of this study was to investigate the risk factors for relapse in MG patients after their first attack and establish a clinical predictive model. We conducted a retrospective study of 86 MG patients, followed and reviewed the clinical data of patients from the first onset to the first relapse, including age of onset, site of first symptom, MGFA at onset, thymoma, surgical resection of the thymoma, infection history, irregular drug use, combination of other autoimmune diseases, AChR antibody, and anti-Musk antibody, etc. The R software was used for statistical analysis. Univariate analysis and multivariate analysis were used to analyze risk factors. The clinical predictive model was established by Logistic regression analysis. Results Within 2 years after the first attack, 61.2% of MG patients relapsed. MGFA at onset, irregular drug use and infection history were independent risk factors for MG relapse within 2 years after the first attack ( p < 0.05). The clinical prediction model has good discrimination and calibration. Conclusion The relapse of MG is affected by a variety of factors. The clinical predictive model that was established in this study can help clinicians predict the probability of relapse in MG patients, identify early high-risk relapse patients, and serve for high-quality clinical management.

Weekly Variations of Intracerebral Hemorrhage Occurrence Among Different Populations: A Cross-Sectional Study

Background and purpose: The causes of the higher incidence of intracerebral hemorrhage (ICH) on a given day are unclear. Previous studies have shown that it may vary by region and population. The purpose of this study was to detect weekly variations in ICH occurrence in southwest China and to assess differences in ICH occurrence among different populations.Methods: This hospital-based study included patients with first-onset ICH that occurred from January 1, 2012, to December 31, 2019. The weekly variation in ICH occurrence was analyzed and stratified by sex, age, comorbidities, living habits, and residence.Results: A total of 5,038 patients with first-onset ICH were enrolled. ICH occurrence was higher on Monday [odds ratio (OR), 1.22; 95% CI, 1.09–1.36; P &lt; 0.001] and Friday (OR, 1.15; 95% CI, 1.03–1.28; P &lt; 0.001) among all patients, and this pattern was consistent with that of men, whereas women showed a higher incidence on Mondays, Saturdays, and Sundays. The increase in the number of ICH events on Monday and Friday was pronounced in the age range of 41–60 years; however, no significant weekly variation in ICH occurrence was observed among other age groups. After stratifying by comorbidities, a significant weekly variation in ICH occurrence was observed in patients with hypertension or diabetes. Smoking and alcohol consumption was associated with a higher incidence of ICH on Friday; otherwise, a Monday excess was observed. The urban population demonstrated a significant weekly variation in ICH occurrence, whereas the rural population did not.Conclusions: Intracerebral hemorrhage occurrence showed weekly variations in southwest China and was significantly affected by sex, age, comorbidities, living habits, and residence. This suggests that weekly variations in ICH occurrence maybe dependent on the region and population.

Long-term outcome of postpartum psychosis: a prospective clinical cohort study in 106 women

Objective We aimed to investigate the outcome of postpartum psychosis over a four-year follow-up, and to identify potential clinical markers of mood/psychotic episodes outside of the postpartum period. Methods One hundred and six women with a diagnosis of first-onset mania or psychosis during the postpartum period were included in this prospective longitudinal study. Women were categorized into either (1) recurrence of non-postpartum mood/psychotic episodes or (2) mania/psychosis limited to the postpartum period. We summarize the longitudinal course of the illness per group. We used a logistic regression model to identify clinical predictors of recurrence of mood/psychotic episodes outside of the postpartum period. Results Over two thirds of the women included in this study did not have major psychiatric episodes outside of the postpartum period during follow-up. The overall recurrence rate of mood/psychotic episodes outside the postpartum period was ~ 32%. Of these women, most transitioned to a bipolar disorder diagnosis. None of the women fulfilled diagnostic criteria for schizophrenia or schizophreniform disorder. No clinical markers significantly predicted recurrence outside of the postpartum period. Conclusions For the majority of women with first-onset postpartum psychosis, the risk of illness was limited to the period after childbirth. For the remaining women, postpartum psychosis was part of a mood/psychotic disorder with severe non-postpartum recurrence, mainly in the bipolar spectrum. No clinical predictors for risk of severe episodes outside the postpartum period emerged. Our findings add to previous evidence suggesting a fundamental link between postpartum psychosis and bipolar disorder, which may represent two distinct diagnoses within the same spectrum.

CEREBRAL VENOUS THROMBOSIS SECONDARY TO SARS-COV-2 INFECTION

Cerebral venous thrombosis (CVT) is a relatively rare form of neurovascular emergency, and may present as headache, seizure, or focal neurological deficit. It typically has a higher occurrence in younger women. Recently, there are increasingly cases of CVTreported in association with COVID-19, which fall outside the typical demographics, suggesting a hyper-coagulable state attributable to COVID-19. Here, we present a case of CVTin a young gentleman with concomitant COVID-19, who presented with first-onset seizure.

Unexpected high level of severe events even in low-risk profile chest pain unit patients

Aims Early heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile. Methods and results In this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5–2.8%. Those patients with preinfarction angina experienced fewer events. Conclusions When educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina.