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Epilepsy is one of the most prevalent neurological diseases globally, which causes seizures in the patient. As per a survey done worldwide, it is found that approximately 70 million people are living with epilepsy (~1% of the total population of the world). Effective detection of these seizures requires specialized approaches such as video and electroencephalography monitoring, which are expensive and are mainly available at specialized hospitals and institutes. Hence, there is a need to develop simpler and affordable systems that can be made available to health care centers and patients for accurate detection of epileptic seizures. A wireless remote monitoring system based on a wrist-worn accelerometer is an optimum choice for the same. Sophisticated algorithms need to be developed for effectively detecting seizure events from this accelerometer data with minimal false alarms. This paper presents a Hidden Markov Model (HMM) based probabilistic approach applied to the reduced-dimension feature vector representation of time-series accelerometer data to detect epileptic seizures. The results obtained from the HMM were compared with three commonly used machine learning models viz. support vector machine (SVM), logistic regression, and random forest. The proposed approach was able to detect 95.7% of seizures with a low false alarm rate of 14.8% with a run time of just under 24 seconds.

Background Two randomized, double-blind, sham-controlled trials (ACT1, ACT2) evaluated non-invasive vagus nerve stimulation (nVNS) as acute treatment for cluster headache. We analyzed pooled ACT1/ACT2 data to increase statistical power and gain insight into the differential efficacy of nVNS in episodic and chronic cluster headache. Methods Data extracted from ACT1 and ACT2 were pooled using a fixed-effects model. Main outcome measures were the primary endpoints of each study. This was the proportion of participants whose first treated attack improved from moderate (2), severe (3), or very severe (4) pain intensity to mild (1) or nil (0) for ACT1 and the proportion of treated attacks whose pain intensity improved from 2–4 to 0 for ACT2. Results The pooled population included 225 participants (episodic: n = 112; chronic: n = 113) from ACT1 (n = 133) and ACT2 (n = 92) in the nVNS (n = 108) and sham (n = 117) groups. Interaction was shown between treatment group and cluster headache subtype ( p Conclusions nVNS is a well-tolerated and effective acute treatment for episodic cluster headache. Trial registration The studies were registered at clinicaltrials.gov (ACT1: NCT01792817; ACT2: NCT01958125).

Background andMethodsErenumab, a monoclonal antibody to CGRP, is a new treatment option for preventive treatment of migraine. We audited 3 month outcome data of erenumab for prevention of chronic migraine in Glasgow. Patients are offered erenumab 140mg if they fail 4 migraine prophylactic agents in addition to Botox. Erenumab is continued for a further 9 months if effective at 3 months (≥30% reduction in total headache days or ≥50% reduction in severe headache days, using data from the “best month”). A 3 month extension is occasionally considered if there is a trend for improvement.ResultsData were available for 93 patients (86% female). Previous treatments included: all 4 prespecified prophylactics (76%); flunarizine(63%); GON block(51%); Botox(95%); neuromodulation(25%); dihydroergot- amine infusion (19%). Erenumab was continued in 81% (53% continued for reduction in headache days, 28% for reduced severity/clinical discretion) and discontinued in 19% for dramatic improvement (2%), side effects (2%), and inefficacy (15%). Side effects included constipation(23%), hair loss(3%) injection site reactions, fatigue, cramps, itch (all 2%), itch, blistering, restless legs, rash, nausea, diarrhoea, insomnia, flushes (all 1%).ConclusionA surprisingly high response rate was observed at 3 months. Twelve month data are required to determine if the effect is sustained.krishnadani@icloud.com50

IntroductionNon-invasive vagal nerve stimulation (nVNS) is a novel treatment modality for primary headache disorders. There is some clinical trial evidence to support its use, both as an abortive and pre- ventative treatment, in cluster headache and migraine. We evaluated the use of this novel treatment in a regional tertiary headache service.MethodsA retrospective analysis of case notes of all patients currently using nVNS in our service was undertaken. Other current and previous headache treatments were recorded. A subjective assessment of response to nVNS was made based on available clinical data.Results21 patients currently using nVNS were identified. Diagnoses were chronic cluster headache (n=12), episodic cluster headache (n=1), migraine (n=4), hemicrania continua (n=3) and SUNCT (n=1). All current users reported some degree of positive response to nVNS, with 14 (67%) assessed as having a large improvement. The most frequently reported improvement parameter was reduction in headache frequency (15, 71%). Those reporting a large improvement used significantly fewer concurrent preventa- tive medications (median 0 vs. 2.5, p=0.033).ConclusionsIn this small group of patients with a variety of headache diagnoses nVNS has been an effective treatment; this appears to be due to efficacy as a preventative treatment.michaelcmlowe@gmail.com

Parkinsonism is a commonly seen movement disorder syndrome with neurodegenerative and non-neurodegenerative causes. Presynaptic dopamine transporter (DaT) single‐photon emission computed tomography (SPECT) imaging is the most commonly used imaging technique in clinical practice to differentiate degenerative Parkinson’s disease (PD) and PD plus syndromes from other causes such as essential tremor and drug-induced parkinsonism. This can help identify the patients who would benefit from medical therapy due to underlying pre-synaptic dopaminergic deficits. We report a case of unilateral parkinsonism caused by ipsilateral substantia nigra micro-haemorrhage resulting in disruption of the nigrostriatal pathway. This is an unusual case of a 55-year-old male patient who presented with unilateral Parkinsonism a decade after significant head trauma where MRI plays a critical and complementary role in diagnosing complete interruption of the nigrostriatal pathway due to cerebral micro-haemorrhage. The case also beautifully demonstrates the anatomy of the nigrostriatal pathway where a small lesion in the substantia nigra caused complete loss of radioligand uptake in the ipsilateral corpus striatum. Physicians should be aware of the importance of structural imaging in atypical movement disorder cases and, in particular, the routine use of susceptibility-weighted sequences (SWI).

A 37 year old woman attended the otolaryngology department with episodes of dizziness (“a feeling of swaying”), occasional rotatory vertigo, and unilateral right sided headaches that usually occurred once a week and had been ongoing for six weeks. Her symptoms could last several hours and were sometimes preceded with the appearance of transient flashing lights. Some episodes were associated with short lasting blurred vision and occasional nausea. Her symptoms were unrelated to head or neck movements but could deteriorate with tiredness, bright light exposure, or high coffee consumption. They would improve after several hours if she could lie down in a dark room. The headaches would usually follow the dizziness/vertigo. There was catamenial exacerbation of her symptoms but no phonophobia, hearing problems, or tinnitus. She had a history of similar episodes a few years ago that had gradually settled without medication. Clinical examination was unremarkable. She underwent magnetic resonance imaging (MRI) of the brain and inner ear (fig 1). Fig. 1 Axial fast imaging using steady state acquisition (FIESTA) MRI of the internal auditory meatus and the brain (A) with a focus on the internal auditory meatus (B) Fig. 2 No abnormalities seen on axial FIESTA-MRI. IAM: internal auditory meati. CPA: cerebellopontine angles bilaterally (no vestibular schwannoma). (1) White arrows point to the cochleovestibular nerves in the IAM. (2) Loop of the anterior-inferior cerebellar artery. (3) The labyrinth (in this section with the lateral semicircular canal). (4) Long dotted arrows show the cochlea. (5) White X marks the anterior end of …

Background: Chronic migraine is an under-recognized and under-treated disorder. A greater understanding of the pathophysiology of migraine and transformation to chronic migraine has led to the first targeted treatments for chronic migraine. In this review, we review current approaches to the diagnosis and management of chronic migraine and discuss recent and emerging novel therapies. Objective: The aim of this study was to provide an update on the diagnosis and management of chronic migraine. Methods and Material: The PubMed database was searched for relevant articles published on or before October 2020. Results and Conclusions: Chronic migraine is an under-recognized and under-treated disorder. Prompt diagnosis and appropriate management can lead to a significant improvement in the quality of life with subsequent socioeconomic benefits.

We describe a 39-year-old man who developed thunderclap headaches during a hospital admission for accidental superficial burns. His magnetic resonance brain imaging was normal expect for diffuse segmental vasoconstriction. Prior to admission, he was consuming excessive amounts of caffeine which was restarted and slowly tapered and stopped over weeks. Repeat magnetic resonance angiogram showed resolution of segmental vasoconstriction. The implications of prescribed and non-prescribed drugs on cerebral vasculature have been discussed.

Background: This was a prospective, descriptive study performed by collecting and analyzing the results of vestibular exams, evoked myogenic potential tests, pure tone audiometry test and impedence test performed in the Otorhinolaryngology Department of Sri Aurobindo Institute of Medical Sciences, Indore.Methods: This was a prospective, descriptive study performed by collecting and analyzing the results of vestibular exams, evoked myogenic potential tests, pure tone audiometry test and impedence test performed in the Otorhinolaryngology Department of Sri Aurobindo Institute of Medical Sciences, Indore. Results: In age group of 20 to 60, maximum number of patients were in group of 31-40 (16), followed by 51-60 (15), followed by 20-30 (24.) Maximum positive seen in Romberg (07), followed by nystagmus (06), followed by Dix-Hallpike (06). The patients in our study (30 out of 50) were suffering from hypertension. Two patients were of Meniere’s disease and rest 16 were of SNHL, 08 were of SNHL and BPPV combined. The rest of the cases were of mixed hearing loss and other central hearing loss causes will have be ruled out.Conclusions: The main aim of study is to study clinicopathological aspects in patients with vertigo. We also studied incidence of SNHL in our study. It has been established by this study that hypertension is one the major causes of vertigo in patients whereas VEMP has not proven to be very beneficial in our study to see peripheral vertigo patients. Most of the patients with BPPV also had a normal cVEMP which showed that it was not a very reliable instrument in BPPV.

A 41-year-old man presented with a 3-year history of unilateral pulsatile headaches associated with nausea, vomiting, photophobia, and 1 to 2 episodes per day of red, burning, itchy, and painful left pinna, lasting 4 hours, triggered by touch, increased temperature, and sun exposure (figure). The migraine headaches and the red pinna were temporally associated. His brother has migraines only. Examination was normal. MRI of the head and cervical spine including angiogram was unremarkable. Blood and CSF analyses were normal. Ear symptoms were worse with steroids. Beta-blockers and amitriptyline were unhelpful. Gabapentin has shown some benefit in reducing the frequency of attacks. This condition is called red ear syndrome and its pathophysiology is unclear. Secondary causes such as thalamic syndrome, temporomandibular joint dysfunction, carotid body adenoma, upper cervical spine lesions including Chiari I malformations, and vertebral artery compression at C3 need to be ruled out and migraine prophylaxis considered in migraine-related attacks.1,2

Intracranial hypotension from a spontaneous dural CSF leak is being diagnosed more frequently. Patients can present acutely with characteristic orthostatic headaches and with exertional or thunderclap headaches. Often the diagnosis is delayed and the headache disorder can evolve into a ‘chronic daily headache’ pattern. MR brain imaging can show classical features of intracranial hypotension such as subdural collections, pituitary hyperaemia, brain sagging, engorged venous sinuses with pachymeningeal enhancement with contrast being the hallmark finding. The MR brain scan is normal in up to 20% cases1 and a lumbar puncture or an MR scan of spine may be needed to confirm the diagnosis. CT or MR myelography can identify the site of CSF leak, though none is found in half of cases.2 For those with a fast CSF leak and large spinal CSF collection, dynamic CT and digital subtraction myelography may help. Intracranial hypotension often resolves spontaneously and needs no further treatment. Strict bed …

Background Chronic daily headache is a major healthcare problem, with significant resource implications for specialist services. Since 1999, GPs in Greater Glasgow have had direct access to computerised tomography (CT) for investigation of chronic daily headache. Aim The purpose of this study is to assess the significance of pathology, impact of the service, and GP satisfaction. Method The direct-access CT findings in patients between 1999 and 2007 were reviewed. Radiological reports were reviewed for abnormal findings by a radiologist. A neurologist reviewed those cases with abnormalities to assess their potential causation in presenting symptoms. A questionnaire was sent to the referring GP for every patient referred for direct-access CT. Data from the Information Services Division of NHS National Services Scotland was used to estimate potential cost benefits. Results A total of 4404 CT scans were performed. Abnormal findings were reported in 461 (10.5%), and the reported abnormalities were considered a potential causative factor for the presenting symptoms in 60 patients (1.4%). Other abnormalities mostly resulted from established cerebrovascular disease and atrophy; 986 GP questionnaires were analysed. The major body of GP opinion ( n = 460, 47%) indicated that direct-access CT was their preferred choice for referral of chronic daily headache. If direct-access CT was not available, neurology ( n = 448, 45%) and general medicine ( n = 379, 38%) would be the commonest referral choices. This study also reveals that 86% did not require further specialist referral. Projecting the GP questionnaire data to the study group gave an approximate cost saving of at least £86 681.81. Conclusion Direct-access CT is now the preferred choice of management for patients with chronic daily headache in primary care. Patients and GPs are reassured by a normal scan in the majority of cases. There may be cost savings, although confirmation of cost-effectiveness would require further study.

Software projects are failing because of the poor project planning and due to this estimation have gained interest in recent times. Estimation process reduces the risk around schedule and cost. Effective software project estimation is one of the most challenging activities in software development that software industries are facing. Proper project planning and control is not possible without a reliable estimate. Top down and bottom up are traditionally the most commonly used techniques to estimate the effort of the software project. Studies suggest that the software companies should use Bottom up approach unless they have a vast experience from the similar projects. The goal of this research work is to extend the existing bottom up approach to achieve greater precision in the estimates. This work proposes the use and concepts of fuzzy set theory to extend the Bottom up approach to Fuzzy bottom up approach. With the productivity rate generated by fuzzy bottom up, derived values such as effort of development can be more precisely determined.

The use of herbal remedies and dietary supplements is widespread throughout the world, and use may be increasing. These are taken for a wide range of perceived benefits, such as energy and memory enhancement and treatment of specific conditions. Individuals with and without epilepsy may use these substances and may not inform their treating physician unless specifically asked. Inquiry about herbal medicine and dietary supplement intake should now be part of routine clinical history taking. Anecdotal accounts suggest that some herbal substances may have anticonvulsant effect, but randomised double-blind controlled trails are lacking. Alternatively many herbals and dietary supplements may predispose to seizures in individuals without epilepsy and worsen seizure control in those with epilepsy. In this article, we review the potential anticonvulsant and proconvulsant effects of herbal remedies and dietary supplements and discuss the potential interaction between these herbal substances and conventional anticonvulsant medications.

Epilepsy is a chronic neurological disorder that can have profound physical, social and psychological consequences. We aimed to assess the clinical predictors of quality of life of people with epilepsy. We recruited 31 patients suffering from epilepsy in this cross-sectional study. Their clinical profile was recorded. Quality Of Life in Epilepsy (QOLIE-31) was used to assess quality of life of our patients. Depression was screened by Neurological Disorders Depression Inventory in Epilepsy (NDDI-E). Among all the clinical variables, only seizure frequency significantly correlated with seizure worry (P=0.002), emotional well-being (P=0.026) and social functions (P=0.013) subscales of QOLIE-31. NDDI-E score showed a significant negative correlation with all the subscales of QOLIE-31 except medication effects (P=0.993). A significant positive correlation was also noted between seizure frequency and NDDI-E score (r=0.417, P=0.020). Seizure frequency and depression are the most important predictors of quality of life in epilepsy patients. The management of patients with epilepsy should not only be aimed at just preventing seizures but the treating clinicians should also be cognizant about depression which itself can significantly affect the quality of life of patients.

Alcohol abuse by the husband contributes to poor physical and mental health in the spouse. The aim of the study was to identify the correlation between alcohol consumption in husbands and depression and suicidal ideation, in their wives. Thirty patients who were wives of persons dependent on alcohol were assessed using PHQ-9 for depression and MSSI for suicidal ideation. The husband’s alcohol consumption was graded using the AUDIT scale. We found significant positive correlation between alcohol consumption in husbands and depressive symptoms and suicidal ideation in their wives.DOI: http://dx.doi.org/10.4038/sljpsyc.v4i2.6316

Cluster headache (CH) is a strictly unilateral headache that occurs in association with cranial autonomic features. It is an excruciating syndrome and is probably one of the most painful conditions known to exist, with some female patients describing each attack as being worse than childbirth. CH responds to specific therapies, thereby underlying the importance of distinguishing it from other primary headache syndromes and initiating appropriate treatments. This article reviews the evidence base for the medical treatments used in CH.

Introduction Headache is the most common neurological symptom with which patients attend their GPs and is also the commonest reason for referral to neurology outpatient clinics. The Neurological Services Task and Finish Group in Scotland have developed various pathways for headache using SIGN and NHS Quality Improvement Scotland headache standards. Since 2011 management of chronic headache is also a QOF/QP criteria for general practitioners in Greater Glasgow & Clyde health board. Despite the wide distribution of pathways and the presence of QOF guidelines in primary care, referral practice would appear to be unchanged. The aim of this audit was to look at headache referrals to a specialist headache unit in Greater Glasgow and Clyde and compare it to available local QOF guidelines. Methods From the 1st June 2012–30th June 2012, data was collected from GP referral letters to obtain the number of referrals for headache, reason for referral, gender, duration of headache, acute treatments given for headache and investigations carried out prior to referral. Data collected was compared to current local QOF guidelines and referral pathways. Results A total of 133 patient referral letters were received from primary care during the four week period. Most referrals were routine (122; 91.7%) and there were 11 (8.3%) urgent referrals. Majority of the referrals were for treatment 65 (48.9%) of the headache disorder. The commonest referral diagnosis was migraine 73 (54.9%). There were more females 99 (74.4%) compared to males 34 (25.6%). Patients had complained of headaches for more than 2 years (60; 45.1%), Conclusion The majority of referrals to the regional specialist headache service in Glasgow do not follow the referral guidelines. Following this audit an ‘enhanced vetting’ process has been put into place for headache referrals to the unit. The results of this audit was presented at QOF meetings for primary care in August–September 2012 and a repeat audit would be conducted in June 2013.

Introduction Cluster headache is a severe primary headache disorder characterised by a strictly unilateral pain in the distribution of the trigeminal nerve and associated autonomic symptoms such as redness or tearing from the eye or eyelid drooping. The pathophysiological basis for the autonomic symptoms in cluster headache is unclear although the trigeminal autonomic reflex is thought to contribute to their development. Greater occipital nerve blocks are sometimes used for managing cluster headaches as a transitional prophylactic while awaiting response from oral preventive medications. The anatomical and functional convergence of the trigeminal spinal nucleus and the 2nd and 3rd cervical roots is thought to be the basis for the therapeutic response obtained in patients with headache disorders who undergo this procedure. Methods We report two patients with cluster headaches and prominent eyelid drooping, who received a greater occipital nerve block during a headache bout. In each of the patients the eyelid drooping dramatically resolved within minutes of the procedure being carried out. This was observed by the injector, rather than being self reported. One of the patients has chronic medically intractable cluster headache and the eyelid drooping was more or less constant prior to the nerve block being carried out. Conclusion In our view the resolution of eyelid drooping within minutes of the greater occipital nerve block being carried out is evidence to support the presence of a trigeminal autonomic reflex and its importance in the pathophysiological basis of cluster headaches. We also believe that this observation confirms the anatomical and functional convergence of the trigeminal and the cervical neural pathways and helps to understand the mechanisms by which greater occipital nerve blocks lead to substantial improvement in symptoms reported by patients with headache disorders who undergo this procedure.

The acute medical services cannot exist without blood transfusion - life savers in many situations. Usually, giving blood is generous. Sometimes, however, it is lethal. In countries where blood donors get paid by the pint, drug addicts, street dwellers & others who have little to sell except their bodies flock to for - profit blood centers. Many of these people carry AIDS virus. If one blood bank tests for AIDS antibodies & defers the HIV positive volunteers away - forget about treating them - those poor and desperate enough can often find another ,less scrupulous blood bank or a hospital that doesn't do the testing properly. Such hospitals continue to flourish and nobody knows from whose veins the blood is flowing from. The inevitable result is a frightening rate of contamination. Infection through blood is a major issue in all countries but practically in those with economic constraints with limited safety. The present study was conducted to find out the seroprevalence of HIV antibodies in 6000 donors in a tertiary medical centre. The screening was done by ELISA third generation microelisa kit. Seroprevalence of anti - HIV in 6000 donors was 0.1833% Males show higher incidence and no female donor was found to be HIV seropositive in this study. Also, no voluntary donor was found to be positive for HIV. Blood group A negative showed higher positivity (1.075%) followed by blood group B positive (0.2545%) Age group 41-50 years showed highest positivity (0.3048%) followed by 21-30 yrs (0.2087%).

Blood transfusion is an effective mode of transmission of hepatitis C infection. In developed countries various measures have been taken to reduce the spread of infection through this route. In India, mandatory screening for HCV was introduced as late as 2002 though it was started in Japan & US in 1990. Still, the studies all over India suggest that despite testing of blood units HCV infection is still a significant problem.