Harsh Gupta

Analysis of youtube as a source of information for peripheral neuropathy

Introduction: YouTube is an important resource for patients. No study has evaluated the information on peripheral neuropathy disseminated by YouTube videos. In this study, our aim was to perform a systematic review of information on YouTube regarding peripheral neuropathy. Methods: The Web site (www.youtube.com) was searched between September 19 and 21, 2014, for the terms “neuropathy,” “peripheral neuropathy,” “diabetic neuropathy,” “neuropathy causes,” and “neuropathy treatment.” Results: Two hundred videos met the inclusion criteria. Healthcare professionals accounted for almost half of the treatment videos (41 of 92; 44.6%), and most came from chiropractors (18 of 41; 43.9%). Alternative medicine was cited most frequently among the treatment discussions (54 of 145, 37.2%), followed by devices (38 of 145, 26.2%), and pharmacological treatments (23 of 145, 15.9%). Conclusions: Approximately half of the treatment options discussed in the videos were not evidence‐based. Caution should be exercised when YouTube videos are used as a patient resource. Muscle Nerve 53: 27–31, 2016

Progressive multifocal leukoencephalopathy mimicking glioma in a patient with idiopathic CD4 lymphocytopenia

Progressive multifocal leukoencephalopathy (PML) was described for the first time in 1958 by Astrom et al. as a demyelinating disease in patients with leukemia and lymphoma. A viral etiology for this condition was suggested as the oligodendrocytes contained inclusion bodies [1]. MRI features described in classical PML include hyperintense lesions on T2-weighted and FLAIR sequence which are asymmetric, devoid of contrast enhancement or mass effect, and relatively spare periventricular white matter [2]. We are reporting a case of PML in a patient with ICL (idiopathic CD4 lymphopenia) in which MRI brain showed punctate contrast enhancement, gyral swelling, and a pattern on MR spectroscopy concerning for a glioma.

Central Pontine and Extrapontine Myelinolysis: The Great Masquerader—An Autopsy Case Report

Central pontine myelinolysis is a demyelinating disorder characterized by the loss of myelin in the center of the basis pontis usually caused by rapid correction of chronic hyponatremia. The clinical features vary depending on the extent of involvement. Demyelination can occur outside the pons as well and diagnosis can be challenging if both pontine and extrapontine areas are involved. We herein report a case of myelinolysis involving pons, lateral geniculate bodies, subependymal region, and spinal cord. To the best of our knowledge, this case represents the second case of spinal cord involvement in osmotic demyelination syndrome and the first case of involvement of thoracic region of spinal cord.

Hypoxic ischemic brain injury following in hospital cardiac arrest - lessons from autopsy.

Hypoxic ischemic brain injury (HIBI) is the most decisive factor in determining the outcome following a cardiac arrest. After an arrest, neuronal death may be early or delayed. The aim of our study is to determine the prevalence and predictors of HIBI on autopsy following an in hospital cardiac arrest. We retrospectively reviewed the medical records of patients who sustained an in hospital cardiorespiratory arrest and underwent autopsy following in hospital mortality at our tertiary care medical center from January 2004-June 2012. These patients were identified from the autopsy registry maintained by the Department of Pathology and were classified into two groups based on the presence or absence of HIBI on autopsy. We compared the baseline demographics, risk factors, total duration of cardiopulmonary resuscitation, number of resuscitative events and survival time between both groups. Multivariate logistic regression analysis was performed to identify predictors of hypoxic ischemic injury following cardiac arrest. Out of 71 patients identified during this study period, 21% had evidence of HIBI on autopsy. On univariate analysis, predictors of HIBI were prolonged hospital stay, prolonged survival time following an arrest and a slight increased trend following multiple resuscitative events. On multivariate analysis, prolonged survival time was the only significant predictor of HIBI. Similar to other prognostication cardiac arrest studies, there were minimal predictors of early neuronal injury even on autopsy.

A winged scapula and dropped wrist: an unusual manifestation of copper deficiency

Myelopathy due to copper deficiency closely resembles myelopathy due to vitamin B12 deficiency. This is a treatable form of myelopathy and was recognized for the first time in 2001 [1]. The deficiency of copper may lead to a length-dependent axonal neuropathy, myelopathy, and myelodysplastic syndrome [2]. Due to the concomitant involvement of spinal cord and peripheral nerves in copper deficiency, the disorder is sometimes called as myeloneuropathy. To the best of our knowledge, we are reporting a first case of copper deficiency leading to radiculomyeloneuropathy manifesting as winged scapula, wrist drop, axonal neuropathy, and myelopathy. Case report

Objective measures of gait and balance in healthy non-falling adults as a function of age

BACKGROUND Neurodegenerative diseases increase in incidence with age. Prior studies using differing populations and gait paradigms have reported various parameters changing with age, some of which correlate with falls and mortality. Here we use three different paradigms to evaluate gait and balance in healthy non-fallers. RESEARCH QUESTION What objective gait and balance parameters are correlated with aging. METHODS Healthy subjects aged 21-79 years without histories of falls, lower extremity orthopedic procedures or chronic pain were included. Subjects walked on a 20 × 4 foot pressure sensor mat (Zeno Walkway, Protokinetics, Havertown, PA) under three different gait paradigms, (i) steady-state gait, (ii) dual-task while texting on a cellular phone and (iii) tandem gait. Data was collected and analyzed using PKMAS software (Protokinetics). Linear regression analysis, stepwise multivariate analysis, and grouped analysis of gait parameters was performed using SPSS 24 (IBM). RESULTS Seventy-five subjects were enrolled. Grouped analysis and linear regression analysis showed differing significance in parameters tested. Step-wise multivariate analysis of all 31 parameters assessed from three different gait paradigms, showed weak but significant correlations in age with (i) stride-to-stride variability in (i) integrated-pressure of footsteps and (ii) stride-length during steady-state gait, (iii) mean stride-length on dual-task, and (iv) mean step-width on tandem gait (R2 = 0.382, t = 2.26, p = 0.026). SIGNIFICANCE In a population of healthy subjects without prior history of falls or medical illness that should affect gait, there were weak but significant age-related changes in objective measures of steady state gait and balance. Future prospective longitudinal data will help predict the relevance of this in relation to falls in the elderly.BACKGROUND Neurodegenerative diseases increase in incidence with age. Prior studies using differing populations and gait paradigms have reported various parameters changing with age, some of which correlate with falls and mortality. Here we use three different paradigms to evaluate gait and balance in healthy non-fallers. RESEARCH QUESTION What objective gait and balance parameters are correlated with aging. METHODS Healthy subjects aged 21-79 years without histories of falls, lower extremity orthopedic procedures or chronic pain were included. Subjects walked on a 20 × 4 foot pressure sensor mat (Zeno Walkway, Protokinetics, Havertown, PA) under three different gait paradigms, (i) steady-state gait, (ii) dual-task while texting on a cellular phone and (iii) tandem gait. Data was collected and analyzed using PKMAS software (Protokinetics). Linear regression analysis, stepwise multivariate analysis, and grouped analysis of gait parameters was performed using SPSS 24 (IBM). RESULTS Seventy-five subjects were enrolled. Grouped analysis and linear regression analysis showed differing significance in parameters tested. Step-wise multivariate analysis of all 31 parameters assessed from three different gait paradigms, showed weak but significant correlations in age with (i) stride-to-stride variability in (i) integrated-pressure of footsteps and (ii) stride-length during steady-state gait, (iii) mean stride-length on dual-task, and (iv) mean step-width on tandem gait (R2 = 0.382, t = 2.26, p = 0.026). SIGNIFICANCE In a population of healthy subjects without prior history of falls or medical illness that should affect gait, there were weak but significant age-related changes in objective measures of steady state gait and balance. Future prospective longitudinal data will help predict the relevance of this in relation to falls in the elderly.

Clinical Reasoning: A 73-year-old man with diplopia and ataxia

A 73-year-old right-handed man with a history of hypertension and hyperlipidemia presented with an 18-month history of diplopia and unsteady gait. He also noted oscillating vision when turning his head to the left. The diplopia was horizontal and was worse looking at objects on his right or at a distance. Over a year, his balance worsened to the point where he required a walker due to recurrent falls. Six months prior to presentation, he developed dysphagia (liquids more than the solids). He was also noted to have short-term memory problems in the last 3 months. On examination, he had moderate cognitive impairment with a Montreal Cognitive Assessment (MoCA) score of 20/30 with predominant deficits in visuospatial functions and language. Glabellar, bilateral palmomental, and snout reflexes were present. The left pupil was surgical and nonreactive to light, and there was mechanical ptosis on the left. He had left exotropia with full eye movements, bilateral horizontal gaze-evoked nystagmus, and upbeat nystagmus on upgaze. Motor strength and tone were normal. He was diffusely hyperreflexic with bilateral extensor plantar responses. Detailed sensory examination was normal. Dysmetria was present bilaterally, more prominent on the left compared to right, with finger to nose testing and finger chase. His gait was ataxic with wide base and a tendency to fall toward the left side. He was unable to tandem walk (video on the Neurology® Web site at Neurology.org). Systemic examination was unremarkable.

A combination of chorea, myoclonus, and dystonia in a patient with pontocerebellar hypoplasia type 2: a video case presentation

An 8-year-old boy was referred to our medical center for the management of involuntary movements. He was born as the second child to a non-consanguineous couple with a normal elder sibling. His birth was via vaginal delivery that was complicated by shoulder dystocia. A prenatal ultrasound had been normal. He demonstrated severe developmental delay and was never able to sit, talk, walk or swallow normally and required the placement of a gastrostomy tube for feeding. He had baseline abnormal movements since around 1 year of age, and he developed seizures at the age of 2 years. On this occasion, he was admitted to our pediatric hospital with hyperthermia (41.5 C), elevated heart rate (147/min), and an elevated white blood cell count. X-ray of the chest was concerning for pneumonia and antibiotics were initiated. He was also found to have rhabdomyolysis with creatine kinase (CK) of 32,000 Units/L, which improved with intravenous hydration. Neurology was consulted for worsening of his movements that consisted of dystonic posturing, choreoathetosis, and myoclonus (please see ESM video). Therapy with tetrabenazine was initiated and the movements ultimately began to improve after about 4 weeks. Brain MRI revealed severe brainstem hypoplasia with flattened belly of pons, hypoplasia of the cerebellar vermis, and thinning of the corpus callosum (Fig. 1). An extensive metabolic evaluation was negative. Genetic testing for pontocerebellar hypoplasia (PCH) was ordered and ultimately revealed c.919G[T (p.Ala307Ser) pathogenic sequence change in exon 8 in the homozygous state which confirmed the diagnosis of PCH type 2. Electronic supplementary material The online version of this article (doi:10.1007/s13760-015-0461-9) contains supplementary material, which is available to authorized users.