This case summary describes a 4-year-old male child who presented with cough, cold, fever, and seizure followed by altered sensorium for 15 days prior to admission. He had been hospitalized for 15 days at a private hospital where he was on mechanical ventilation for 10 days and received a tracheostomy tube. Testing showed normal CBC, SE, CSF study, viral markers, CSF NMDA receptor study, and MRI. He received multiple antiepileptics and steroids with some improvement in condition but remained dependent on the tracheostomy tube. The summary discusses various types and causes of encephalitis including autoimmune encephalitis such as anti-NMDA receptor encephalitis, LGI1 encephalitis
Anti-NMDA receptor encephalitis: Psychiatric presentation and diagnostic chal...Pawan Sharma
Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, only recently first described, is an increasingly well-recognized inflammatory encephalitis that is seen in children and adults. The highlights: Pychiatric manifestations in encephalitis and the need for the psychiatrist to a have high index of suspicion when atypical symptoms (e.g., dyskinesia, seizure, fever etc.) present in acutely psychotic patients.
By Dr. Usama Ragab Youssif
Definitions & Nomenclatures
Structure of immunoglobulins
Immunoglobulins in our bodies
Physiologic actions of immunoglobulins
The Idea behind use of immunoglobulins
Uses: indications, mechanisms, preparation, posology, administration
Adverse effects
Safe practice
Final bottom-line
Anti-NMDA receptor encephalitis: Psychiatric presentation and diagnostic chal...Pawan Sharma
Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, only recently first described, is an increasingly well-recognized inflammatory encephalitis that is seen in children and adults. The highlights: Pychiatric manifestations in encephalitis and the need for the psychiatrist to a have high index of suspicion when atypical symptoms (e.g., dyskinesia, seizure, fever etc.) present in acutely psychotic patients.
By Dr. Usama Ragab Youssif
Definitions & Nomenclatures
Structure of immunoglobulins
Immunoglobulins in our bodies
Physiologic actions of immunoglobulins
The Idea behind use of immunoglobulins
Uses: indications, mechanisms, preparation, posology, administration
Adverse effects
Safe practice
Final bottom-line
Autoimmune Encephalitis is a particularly intimidating entity, as recognition of this disease can be delayed because diagnosis can involve ambiguous neurological symptoms, leading to detrimental long-term consequences. Auto-anti-bodies (NMDA,VGKC) can be found through serum lab tests, and magnetic resonance imaging can show inflammation, and spinal tap can reveal auto antibodies and other biomarkers in the cerebrospinal fluid that point to autoimmune encephalitis. Being that autoimmune encephalitis is a recently described diagnosis, there is still a tremendous amount of investigation to be done to discover the root causes of the disease, more anti-body essays need to be developed to discover all of the phenotypes, and the best most effective treatments need to be found to treat this mysterious disease.
Autoimmune Encephalitis is a particularly intimidating entity, as recognition of this disease can be delayed because diagnosis can involve ambiguous neurological symptoms, leading to detrimental long-term consequences. Auto-anti-bodies (NMDA,VGKC) can be found through serum lab tests, and magnetic resonance imaging can show inflammation, and spinal tap can reveal auto antibodies and other biomarkers in the cerebrospinal fluid that point to autoimmune encephalitis. Being that autoimmune encephalitis is a recently described diagnosis, there is still a tremendous amount of investigation to be done to discover the root causes of the disease, more anti-body essays need to be developed to discover all of the phenotypes, and the best most effective treatments need to be found to treat this mysterious disease.
ABSTRACT:
Nocturnal enuresis or night time urinary incontinence, commonly called bedwetting or sleep wetting, is involuntary urination while asleep after the age at which bladder control usually occurs. Bedwetting is a common childhood urologic complaint and one of the most common pediatric health issues. Enuresis is notoriously difficult to treat and is frequently related to psychological factors. The emotional impact of enuresis on a child and family is considerable. Children with enuresis are commonly punished and are at risk for emotional and physical abuse. Numerous studies of children with enuresis report feelings of embarrassment and anxiety, loss of self-esteem, and effects on self-perception, interpersonal relationships, quality of life, and school performance. The condition can be successfully treated with homoeopathic medicines but require a long term follow – up. The present article focuses on management of this medical condition with our medicines.
Dr. john millichap kcnq2 Cure summit professional track learn more at kcnq2cu...scottyandjim
Dr. John Millichap speaking at 2014 Denver KCNQ2 Cure summit professionals track at Children's Hospital of Colorado. More information at www.kcnq2cure.org
SSPE, dr. amit vatkar, pediatric neurologistDr Amit Vatkar
Subacute sclerosing pan encephalitis (SSPE) also known as Dawson Disease, Dawson encephalitis, and measles encephalitis is a rare and chronic form of progressive brain inflammation caused by a persistent infection with measles virus.
In this presentaion i will a case a sspe and give u some information regarding daignosis and treatment
Maintenance Electroconvulsive Therapy Augmentation on Clozapine-Resistant Psy...Zahiruddin Othman
Case Report: Maintenance electroconvulsive therapy augmentation on clozapine-resistant psychosis with neurosyphilis is effective and safe but has never been reported in the literature to the authors' knowledge. It is hoped that this case report would contribute to the scarce literature on this augmentation strategy
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
2. CASE SUMMARY
• 4 year old male child
• Presented with
oc/o cough , cold for 5 days
oc/o mild grade fever 5 days
oc/o seizure followed by altered sensorium
since 15 days prior to admission
3. • Hospitalization for 15 days in pvt. hosp. prior
to admission in our hospital
• Mechanical ventilation for approx. 10 days
followed by tracheostomy tube insertion.
• Past history: no similar illness in past.
4. • Birth history:
• 2 nd order male child
Delivered at 32 weeks of gestation
Vaginal delivery
B. wt.- 1600gms
8 days of hospitalization in nicu
5. • Developmental history:
developmental milestones achieved
normally as per age.
• Family history:
no h/o similar illness in family
no h/o contact with TB
6. • AT ADMISSION : child was in status epilepticus
oGC very sick
oPR- 148/min
oRR-56/min. Pressure sores over back and
scalp
oSaturation 96% with tracheostomy tube
attached to oxygen @2 l/min
oGCS -6/15
7. • Systemic examinations.
• Resp. system- conducted sounds present b/l
• CVS- s1s2 normal
• Abdominal examination- no organomegaly
• CNS- GCS-6/15 on tracheostomy tube with T
piece
tone –
reflexes- ++
9. • INVESTIGATIONS:
• CBC – wnl
• SE – wnl
• CSF study – normal, viral markers- negative
• CSF NMDA receptor study –negative
• MRI – normal
• EEG – generalized seizures
10.
11. • HOSPITAL COURSE:
• Received IVIG plus steroid from pvt. Hospital
• Multiple antiepileptics (phynetoin,
phenobarbitone, leveteracetam, valproate,
vigabatrine, lacosamide, oxcarbamazepine)
• Ketogenic diet started (? availability)
• Inj. Cyclophoshamide (Day 6 admission)
12. • Condition today :
• Abnormal movements , no seizures
• Tracheostomy tube in situ
• Child able to sit and walks with support
• GCS improved
• Playing with his toys , mobiles recognizes
parents
16. • Exact incidence is not known.
• a multicenter study in the United Kingdom -
4%
• California Encephalitis Project - anti-NMDA
receptor encephalitis surpassed any viral
encephalitis
17. ANTI NMDR RECEPTOR
ENCEPHALITIS
• Leading cause of autoimmune encephalitis in
children and adolescents.
• Stages :
1. Stage1 – prodromal phase
2. Stage 2 – psychiatric and behavioral problems
3. Stage 3 – Decreased level of consciousness
• Behavioral changes included new-onset
temper tantrums, agitation, aggression, and
changes in mood or personality
18. • Ovarian teratoma is associated in up to 50% of
the cases
• Investigations :
oCSF
o lymphocytic pleocytosis,
o elevated protein levels
o oligoclonal bands
• EEG – extreme delta brush
19. o MRI demonstrate medial temporal lobe
attenuated inversion recovery high signal or
focal areas of hyperintensity in the frontal or
parietal cortex
o fluorodeoxyglucose positron emission
tomography (FDG-PET) scan show cortical
hypermetabolism in acute stages, and
hypometabolism in more subacute stages of
the illness.
20.
21. Mechanism for clinical features
NMDAR in inhibitory GABAergic neurons and glutamatergic
synapses
increase of extracellular glutamate
1. frontostriatal syndrome – neuropsychiatric manifestations,
2. disinhibition of brainstem central pattern generators
accounting for the complex movement disorders
3. disruption of the medullary-pontine network accounting for
central hypoventilation
22. • Confirmation of diagnosis –
• Demonstrating NMDA receptor
antibodies in serum or cerebrospinal fluid
• The levels of antibodies in cerebrospinal
fluid correlate better with symptom
outcome
23. • Treatment :
first line of immunotherapies including
corticosteroids, intravenous
immunoglobulin, or plasma exchange
Rituximab and cyclophosphamide, alone
or combined, are often effective in adults
Approximately 80% of patients have
substantial or full recovery.
24. • symptoms 1st to improve:
autonomic instability, dyskinesias, level of
consciousness, and seizures.
• After recovering consciousness, the psychiatric
manifestations can reemerge, and impulsivity,
behavioral disinhibition.
25. • multidisciplinary approach - nursing,
psychiatrists, cognitive rehabilitators,
physiatrists and families.
• clinical relapse in 20% of children with anti-
NMDA encephalitis.
26.
27. LIMBIC ENCEPHALITIS
• Definition:
• characterised by subacute development
of short term memory loss, behavioural
change and seizures involving the
temporomedial lobes , the amygdalae,
and cingulate gyrus with variable
evidence of CSF inflammation and
neuronal antibodies
28. • antibodies against the neuronal secreted
protein called leucine-rich glioma-
inactivated 1 (LGI1)
• LGI1 - secreted neuronal protein that
interacts with the presynaptic and
postsynaptic proteins ADAM23 and
ADAM22 -modulate synaptic
transmission
29. • In 1968 , as Para neoplastic syndrome
• median age of patients is 60 years
• Severe short term memory loss
• hyponatremia and myoclonic-like movements,
described as faciobrachial dystonic seizures
30. • 70% of the patients improve with t/t.
• Other antibodies associated- antibodies
against intracellular antigens (eg, Hu, CRMP5,
Ma2) or against cell surface or synaptic
proteins (eg (AMPA) [GABA(B)] [mGluR5])
• Ophelia syndrome
31. HASHIMOTO
ENCEPHALOPATHY
• Previous steroid responsive encephalopathy
associated with autoimmune thyroiditis.
• Now encephalopathy associated with
autoimmune thyroid disease
• 52% hypothyroid , 48% normal thyroid
function
32. • Clinical features : non specific
Stroke like symptoms, tremors ,myoclonus,
transient aphasia, sleep and behavior
abnormality, hallucinations, seizures.
• CSF- protein elevated
• EEG- generalized slowing
• MRI- normal
34. RASMUSSEN ENCEPHALITIS
• Progressive refractory partial seizures,
cognitive deterioration and focal deficit occurs
with gradual atrophy of one hemisphere.
• AMPA, munc 18-1.
• High dose methylprednisolone and ivig.
• Tacrolimus.
35. BASAL GANGLION
ENCEPHALITIS
• specifically affecting the basal ganglia
• isolated subcortical features including
movement disorders such as parkinsonism,
dystonia, or chorea.
• hypersomnolence and psychiatric features
such as attention deficit, emotional lability,
obsessive-compulsive disorder, and psychosis
36. • Investigations :
oinflammatory CSF (lymphocytic pleocytosis
and oligoclonal bands) and lymphocytic
cuffing in histopathology of the basal
ganglia,
oFDG-PET scan demonstrates basal ganglia
hypermetabolism.
37. • MRI reveals basal ganglia swelling and T2-
weighted hyperintensity and sometimes
brainstem signal change, with follow-up scans
showing basal ganglia atrophy and gliosis.
38.
39. Therapeutic strategies and
outcomes
• no consensus guidelines
• pulsed steroids followed by high dose oral
prednisone, and IVIg and/or plasmapheresis
as first-line therapy
• DOSAGE:
- 3–5 days of pulsed IV methylprednisolone
(30 mg/kg/day up to 1 g/day) followed by high
dose oral prednisone (1–2 mg/kg/day) and 2
g/kg of IVIg administered over two to five doses
40. • Non response:
• within 1–2 weeks should lead to
consideration of three to five exchanges
with plasmapheresis, or commencement
of second-line therapy such as
cyclophosphamide or rituximab
• respond slowly to immune therapy
(weeks rather than days).
41. Therapeutic challenges
• What defines failure of first-line treatment?
• At what stage is it reasonable to escalate therapy to
second-line agents?
• Do patients who have a particularly significant
clinical episode warrant second-line therapy despite
improvement with first-line therapy?
• To what degree does second-line therapy reduce the
relapse rate?
• What role does maintenance immunosuppression
have?
42. Case senarios
• Treatment of antibody negative patients:
An 8-year-old boy presented with a 3 week history of focal
seizures, a hyperkinetic movement disorder, and mutism,
requiring a 2 month intensive care unit and hospital admission.
CSF showed 20 106/L monocytes but viral studies, and serum
and CSF anti- NMDAR, VGKC complex, and D2R antibody testing
was negative. Given this was a severe presentation and the
clinical phenotype was reminiscent of autoimmune encephalitis,
he was treated with first-line therapy in the form of IV steroids
and IVIg. Ten days after first-line therapy there was no
improvement so second-line therapy with rituximab was
commenced. Within 5 days of rituximab he began improving and
subsequently made a good clinical recovery over 6 weeks,
returning to baseline function.
43. • Role of second-line therapy:
A 4-year-old girl presented with a 2 week history of focal seizures
and psychosis. CSF analysis revealed 12 106/L monocytes and
was positive for anti-NMDAR encephalitis. She was treated with
first-line therapy in the form of IV steroids and IVIg. She started
to improve rapidly within 2 weeks of therapy, and returned to
baseline by 8 weeks. Her serum anti-NMDAR antibody status
remained positive 1 year after presentation although the patient
was clinically well.
44. • Management of relapsing anti-NMDAR encephalitis:
Focal seizures, speech disturbance, chorea, and agitation. CSF
oligoclonal bands were positive. This presentation was prior to
the initial descriptions of anti-NMDAR encephalitis, however
given the high index of suspicion for autoimmune encephalitis,
she was treated with IV steroids and IVIg. Her diagnosis was
confirmed as anti- NMDAR encephalitis in 2009 with
retrospective testing of acute serum and CSF samples. She has
had three subsequent relapses which were treated successfully
with IV and oral steroids. Given the relapsing course and steroid
responsiveness, she was started on oral mycophenolate mofetil
and has been free of relapses for the last 2 years.
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