Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : OC06 - OC10 Full Version

CSF Neurofilament-H Levels as a Potential Prognostic Marker in Patients of Guillain-Barré Syndrome- A Cohort Study


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/50049.15186
Tanveer Hassan, Rayees Ahmad Tarray, Tanzeel Ahmad Wani, Mushtaq Ahmad Wani, Zaffar Amin Shah, Imtiyaz Ahmad Bhat

1. Senior Resident, Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India. 2. Senior Resident, Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India. 3. Junior Resident, Department of Emergency Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India. 4. Professor, Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India. 5. Professor, Department of Immunology and Molecular Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India. 6. Senior Resident, Department of Immunology and Molecular Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India.

Correspondence Address :
Dr. Tanveer Hassan,
Rajbagh Extension, Srinagar-190008, Jammu and Kashmir, India.
E-mail: hassan.doc@gmail.com

Abstract

Introduction: The prognosis of Guillain-Barré Syndrome (GBS)at an early stage with explicit biomarkers is critical to distinguish patients with possibility of poor recovery. Cerebrospinal Fluid (CSF) serves as an impending source for biomarkers that portrays the exact biochemical changes.

Aim: To find out if there is any prognostic value of high CSF phosphorylated Neurofilament Heavy subunit (pNf-H) levels, measured during first two weeks of onset of GBS, as assessed by the level of disability at six months after the onset of GBS.

Materials and Methods: The cohort study was conducted in the Department of Neurology and Department of Immunology and Molecular Medicine, at the Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India, over a period of two years from August 2015 to August 2017. Sixty two patients who satisfied the required diagnostic standards for GBS (study group) and 35 patients with tension-type headache (control group) were selected for the study. After clinical and electrophysiological assessment, CSF samples were collected. A commercially available sandwich enzyme immunoassay kit, manufactured by BioVendor-Laboratorní medicína (Czech Republic), was used for measuring human pNf-H quantitatively.

Results: Mean CSF pNf-H level in patients with good outcome was 325.3 pg/mL whereas, in patients with poor outcome it was 3655.2 pg/mL. CSF pNf-H levels were found to be suggestively higher in GBS patients with poor outcome as compared to those with good outcome. Only eight patients in good outcome group had pathologically high CSF Nf-H levels whereas 10 patients in poor outcome group had CSF Nf-H levels ≤730 pg/mL. The odds ratio was 17.1 (95% Confidence Interval (CI) 3.83-76.29). Thus, high CSF Nf-H levels on admission predicted poor outcome in GBS (p-value <0.001). Moderate degree of positive correlation was found between CSF Nf-H levels and outcome (F score) at six months (R=0.684; p-value <0.001).

Conclusion: It can be determined that higher values of CSF pNf-H in GBS (acute stage), could serve as a predictive marker indicative of poor prognosis.

Keywords

Acute motor axonal neuropathy, Axonal degeneration, Biomarker

The GBS is referred to as a disease with a single phase distinguished by acute onset, immune mediated (cellular and humoral) polyradiculoneuropathy that may be axonal or demyelinating. It is clinically characterised as rapidly evolving areflexic weakness and sensory disturbance in the limbs and associated with weakness of facial, bulbar and respiratory muscles (1). GBS can be categorised into:- Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP), Acute Motor Axonal Neuropathy (AMAN), Acute Motor and Sensory Neuropathy (AMSAN), acute sensory neuronopathy, acute pandysautonomia and Miller Fisher Syndrome (MFS) (2),(3). Studies have reported the incidence of GBS is 0.6-4 cases/100000 across the world (4),(5). GBS is commonly seen to be affecting the males more than the females and its incidence rises with age (6),(7).

The microorganisms contributing to the infectious state include: C jejuni, Cytomegalovirus (CMV), Epstein Barr virus (EBV), M. pneumonia, H. influenza (8),(9). It is also seen to occur after vaccination, surgery and head injuries (10),(11). GBS is characterised by weakness in the lower extremities bilaterally (most commonly), and sometimes the upper limbs (12),(13). The clinical presentation includes paraparesis, muscular pain, bulbar and ocular nerve involvement, respiratory muscle weakness, dysautonomia, hyporeflexia or areflexia (14),(15). Early prognostication of GBS with specific biomarkers is essential to recognise patients with probability of poor recovery (16),(17). CSF is probably an important spring for biomarkers, whose compartment has close proximity with the nerve roots exhibiting meticulous biochemical changes (18). The biomarkers associated with the disease include CSF neurofilaments, 14-3-3 protein, complement components C3a and C5a, tau protein, soluble fractalkine, cystatin C and B, chemokines, antibodies against myelin basic protein and anti-GM1 antibodies (19),(20). Elevated levels of CSF neurofilaments (CSF Nf-H) are observed in several neurodegenerative diseases wherein, few studies have assessed the role of CSF Nf-H as an early prognostic marker (21),(22).

Hence, the present study was conducted with the aim to find out if there is any prognostic value of high CSF pNf-H levels, measured during first two weeks of onset of GBS, as assessed by the level of disability at six months after the onset of GBS.

Material and Methods

The cohort study was conducted in the Department of Neurology and Department of Immunology and Molecular Medicine, at the Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, over a period of two years from August 2015 to August 2017, with a follow-up period of six months. The study was approved by Hospital Ethical Committee (IEC/SKIMS Protocol RP 08/2018) and written informed consent was obtained from all the participants.

Sample size calculation: Using GPower software, it was estimated that a minimum of 90 subjects with 60 cases and 30 controls were needed to be included in present study with 80% power, 5% significance level and an allocation ratio of 2:1.

Inclusion criteria:

• Sixty two participants who fulfilled the diagnostic criteria for GBS, (as compiled by Asbury and Cornblath criteria), with areflexia and progressive motor weakness of more than one limb and those who reported in the first two weeks of the disease onset were included in the study (1).
• MFS, which is not covered by this criteria was diagnosed as a triad of acute onset of ophthalmoplegia, areflexia and ataxia after ruling out other aetiologies (23).
• Patients with past history of GBS, who presented with fresh episode were also included in the study.
• Thirty five patients with tension-type headache with no neurological pathology and who had normal CSF findings, matched for age and gender, were included in the control group.

Exclusion criteria

• GBS patients presenting after two weeks of onset of symptoms.
• Patients having recent history of traumatic brain injury, spinal cord injury, subarachnoid haemorrhage or stroke.
• Patient suspected with underlying condition that alter Nf-H levels in CSF (e.g., Amyotrophic lateral sclerosis, Alzheimer’s disease, Parkinsons disease, etc.).

Clinical Evaluation and Study Protocol

The demographic and clinical data were collected including age, sex, first neurological symptom to present and presence of any previous disease with respect to respiratory tract infection, diarrhoea and influenza like illness. CSF was examined for microscopic and biochemical parameters including total cell count, protein and sugar.

Data regarding day of illness on which patient was admitted, season of presentation (Winter, Spring, Summer, Autumn), duration between preceding illness and onset of symptoms, duration of hospital stay, need for ventilatory support, growth of autonomic dysfunction and time duration to acquire ultimate shortfall were recorded. A thorough motor system assessment was performed comprising of cranial nerve examination, power and reflexes. Complete Blood Count (CBC), blood sugar and biochemical parameters including RFT and LFT were done in all patients as general routing investigative procedures. All patients underwent electrophysiological assessment on admission using Medelec Synergy equipment (Oxford Instruments Medical, UK). Motor nerve conduction evaluation was conducted by exciting the common peroneal nerve, posterior tibial nerve, median and ulnar nerves to examine compound muscle action potentials comprising onset latency, amplitude and conduction velocity. Sensory nerve conduction assessment was performed to measure sural, median and ulnar sensory nerve action potentials. Mean F wave latency was also measured. Albers JW and Kelly JJ had proposed certain criteria for both demyelinating and axonal varieties for the electrophysiological diagnosis of GBS (24). To keep the paper focused on the primary objectives, these data have not been included in this article.

Outcome measure: Hughes functional grading scale to assess the general functioning was used as follows:- 0 (normal health), 1 (minor neurological symptoms or signs, being able to run), 2 (able to walk at least 5 m, but unable to run), 3 (able to walk 5 m with walker or support), 4 (bedridden), 5 (ventilated), to 6 (dead) (25). The F-score was documented at nadir and final follow-up (six months). Outcome was categorized as “poor” (F-score ≥3) if patients were unable to walk independently and “good” (F-score <3) if patients were able to walk independently at follow-up (26).

Sample collection and storage: Quincke lumbar needle (22 or 24 gauge) was used to collect the CSF samples through lumbar puncture with the mean time of about 8.9 days (median eight days). The CSF samples were collected in polypropylene tubes, centrifuged, and stored at -80°C within two hours of sampling in 1.5-2 mL Eppendorf tubes until analysis. All tubes were coded, and CSF was analysed blinded to all other information.

Measurement of CSF phosphorylated neurofilament: A commercially available sandwich enzyme immunoassay kit, manufactured by BioVendor-Laboratorní medicína (Czech Republic), was used for the quantitative measurement of human pNf-H.

Statistical Analysis

The standard curve was constructed by plotting the mean absorbance (Y) of standards against the known concentration (X) of standards in logarithmic scale, using the four-parameter algorithm. The measured concentration of samples calculated from the standard curve was multiplied by their respective dilution factor. Continuous variables were summarised as mean±SD (Standard Deviation) and categorical variables were expressed as frequencies and percentages. Graphically the data was presented using scatter plot. Chi-square test or Fisher’s exact test, whichever appropriate, was employed to compare categorical variables. Univariate analysis was used for testing factors potentially associated with outcome. Factors significantly associated with outcome were further tested by logistic regression analysis. Pearson Correlation was used to determine relationship of neurofilament H levels with outcome (F-score). A p-value <0.05 was considered statistically significant. All p-values were two tailed. The recorded data was compiled and final data was exported to data editor of Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS Inc., Chicago, Illinois, USA).

Results

The present study consisted of total 97 adults, 62 subjects were in the study group with GBS and 35 in control group comprising of non GBS headache.

The age distribution, presenting symptom, antecedent illness and CSF cell variation in the study group are given in (Table/Fig 1). The age of the patients ranged from 18-72 years with a mean age of 44.7 years. Out of 62 cases, 35 were males and 27 were females, the sex ratio being 1.3:1. The predominant initial symptom was lower limb weakness seen in 41 (66.1%) patients followed by sensory symptoms in 9 (14.5%) patients, 1 (1.6%) patient was admitted as a case of MFS who presented with diplopia. Respiratory tract illness (19.4%) was the most common preceding illness. 80.6% patients in present study had CSF cell count less than 5 and none of the patients had more than 50 cells/μL in CSF.

In study group, 4 (6.5%) patients died during the follow-up period due to various causes in and outside the hospital. Out of them three died during hospital stay and were on ventilator support. Two of them died as a result of hospital acquired pneumonia and sepsis. One patient died of myocardial infarction. Two of these patients died on 12th day of illness. The third patient died on 84th day of admission. He was on ventilator support for third day of start of illness and had presented as hyperacute GBS. One 55-year-old male patient who was discharged after nine days of hospital stay died four months after discharge. He was bedridden at home (F-score 4) and had developed bed sores. The exact cause of death in that patient was not known. All the four patients who died had CSF Nf-H levels greater than 730 pg/mL. On electrophysiological study two of them had demyelinating and two had axonal type GBS. In present study 49 (79%) patients had a good outcome, whereas 13 (21%) patients had a poor outcome at six months follow-up (Table/Fig 2). A statistically significant association was observed between F-score at peak of weakness in hospital and the functional outcome (F-score) at six months follow-up.

The mean CSF Nf-H levels in control patients was 218.6 pg/mL when compared to 1023.54 pg/mL in the study group and the maximum value was 587.6 pg/mL. The population-based upper limit of normal is <730 pg/mL and has been determined using a reference population of 416 patients with a median age of 41.9 (interquartile range, IQR, 31.2-55.8) years (27). As none of the patients in present control group also had CSF Nf-H levels more than 730 pg/mL, any value above 730 pg/mL was taken as pathological. There was significant difference between mean CSF Nf-H levels between case and control group with p-value 0.025 (Table/Fig 3).

As depicted in (Table/Fig 4), the mean CSF pNf-H level in patients with good outcome was 325.3 pg/mL whereas, in patients with poor outcome it was 3655.2 pg/mL. CSF pNf-H levels were significantly higher in GBS patients with poor outcome as compared to those with good outcome using univariate comparisons. Only 8 (16.3) patients in good outcome group had pathologically high CSF Nf-H levels whereas, 10 (76.9%) patients in poor outcome group had CSF Nf-H levels >730 pg/mL. On analysis, the Odds ratio was 17.1 (95% Confidence Interval [CI] 3.83-76.29). Thus, high CSF Nf-H levels predicted poor outcome in GBS (p-value <0.001). Correlation analysis was performed using Pearson’s correlation (R). Moderate degree of positive correlation was found between CSF Nf-H levels and outcome (F score) at six months (R=0.684; p-value <0.001). High CSF Nf-H levels were found to correlate with poor outcome (Table/Fig 5).

(Table/Fig 6) and (Table/Fig 7) shows that CSF Nf-H levels are not influenced by age or gender of the patient nor by the timing of performance of lumbar puncture or whether patient had any past episode of GBS. Also, there was no statistically significant correlation between CSF protein levels and CSF Nf-H levels.

Discussion

The GBS being an acute immune-mediated peripheral neuropathy has inconstant clinical consequence that is supposedly recognised by the amount of nerve damage during the acute phase and ability to recover during the convalescent phase (26). It is however, imperative to identify the outcome and prognosis of the disease state at an early stage which incorporates the use of various biomarkers as has been reported in several studies. By envisaging the prognostic result of the disease accurately, novel drugs like eculizumab etc could be examined in a limited GBS populace having poor prognosis (12). It has been reported in earlier studies that diarrhoea (C. jejuni infection within four weeks), increased age group (>40 years), fast advancement, nadir disability, and specific electrophysiological features depicted long-term prognosis (28),(29).

A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacological response to therapeutic intervention (30). The plausible and impending use of biomarkers have been documented in limited studies to elucidate the prognosis of GBS (31). Serum, CSF and peripheral nerve tissue serve as the chief source of GBS biomarkers amongst which CSF remains the most important one. Proximal nerve roots in the subarachnoid region moving generously in CSF, hence, the transformed protein content of CSF could mimic the damage in the nervous system tissue (18). The dysfunction of blood-CSF barrier (B-CSF-B) and Blood-Nerve Barrier (BNB) also allows CSF to be essential sources of biomarker (32). Several studies have been conducted to identify specific biomarkers within the CSF for prognosis and diagnostic of inflammatory neuropathies like GBS, amongst which CSF pNf-H has been assessed as a potent prognostic marker (21),(33).

Neurofilaments are obligate heteropolymer, proteins of the neurons and their adjoining axons (34),(35). Axonal degeneration and membrane disintegration leads to the release of the cytoplasmic contents into the Extracellular Fluid (ECF). Neurofilaments diffuse into the fluid compartments like CSF, blood or amniotic fluid from the ECF. The pNf-H are resistant to protease enzymes, hence, pNf-H discharged from disintegrated axons are found un-degraded in the fluid (36),(37). Thus, the recognition of pNf-H in blood and CSF denotes the neuronal damage unequivocally as it is found exclusively in the neurons.

It has been shown in previous studies that an increased level of Nf-H in CSF of GBS patients can be served as a adverse prognostic indicator. Petzold A et al., conducted a prospective study in GBS patients wherein, motor function and disability grades were quantified. They showed that patients with high (>0.73 ng/mL) CSF Nf-H levels were more restricted on both outcome measures at the last follow-up visit (21). Petzold A et al., in a prospective multicentre study, concluded that high Nf-H levels (>0.73 ng/mL) predicted poor outcome (22). In a study conducted by Dujmovic I et al., high and increasing levels of CSF Nf-H in serial CSF samples were correlated with poor clinical and electrophysiological outcome (38). Therefore, these studies suggested that CSF Nf-H could serve to be a prognostic biomarker to indicate retrograde axonal degeneration or any other proximal axonal impairment in GBS.

As mentioned previously, the results of present study were in accordance to studies conducted by Petzold A et al., (21), Petzold A et al., (22) and Lee Y et al., (33) who demonstrated that elevated Nf-H levels in CSF of GBS patients indicated adverse prognosis of the disease. These findings could be justified by the apparent anatomic source for Nf-H. The proximal axonotmesis near the motor nerve root causes release of axonal proteins into the CSF. The identification of the protein biomarkers in the CSF thus, permits the estimation of proximal axonal damage in the acute phase of GBS. Proximal axonotmesis is likely to be more relevant for prognosis than distal axonal damage, because recovery needs axonal regrowth over a long distance along with losing chemical and anatomical guidance signals. In distal axonal damage, detection of biomarkers in CSF sample, shows less prognosis due to axonal sprouting, providing potential for recovery (22).

In India, there are no reported studies that have evaluated prognostic role of CSF Nf-H levels in GBS patients. The biomarker pNf-H levels were measured during the acute stage of GBS and 35 patients were considered as controls who were discharged with the diagnosis of tension type headache. The mean CSF Nf-H levels in the control group was 218.6 pg/mL compared to 1023.54 pg/mL in the study group.

In present study, 49 patients (79%) had a good outcome, whereas 13 patients (21%) had poor outcome at at six months follow-up. This was similar to the results of studies which depicted approximately 20% GBS patients were unable to walk after six months (39),(40). The mean CSF pNf-H level in patients with good outcome in present study was 325.3 pg/mL whereas the mean level in patients with poor outcome was 3655.2 pg/mL. In GBS patients, levels of CSF Nf-H (>730 pg/mL) measured in the sample taken within two weeks of the onset of symptoms prophesied incapability to walk independently at six months (F-score ≥3) with an odds ratio of 17.1 (Table/Fig 4). Moderate degree of positive correlation was found between CSF Nf-H levels and outcome (F score) at six months (R=0.684; p-value <0.001).

Present study has shown a male:female ratio of 1.3:1, signifying male preponderance, which was similar to few other reported studies (6),(7). Analysis was done to determine any correlation of CSF pNf-H (pg/mL) levels with other variables.

Correlation analysis of CSF pNf-H levels with age, time to lumbar puncture and CSF protein was done and no significant correlation was established. The mean time of lumbar puncture in patients of present study was 8.9 days, so owing to the Ethical Committee restraints, CSF analysis was done only once in these patients. Lumbar puncture was done during second week except in one patient who had presented as hyperacute GBS. Hence, it would be advisable to evaluate CSF Nf-H levels before first week of onset of symptoms so as to correlate with outcome. This would help to prognosticate patients earlier during the course of disease. Six patients in present study had past episode of GBS with complete recovery which had no significant association with CSF pNf-H levels.

The GBS usually follows a monophasic course and does not recur. Kuitwaard K et al. (41) in their study have reported two or more episodes in 7% of patients which had no significant association with poor outcome.

A statistically significant association also exists between F-score at nadir and F-score at six months follow-up. Mean time required to reach peak disability in this study was 8.4 days which was comparable to the studies described by Paul BS et al., (42) and Verma R et al., (43).

Limitation(s)

• A high age has consistently been related to poor prognostic outcome in GBS patients (26),(44). Its lack of association in the present study may be because of small sample size for brevity of paper this data has not been included in the results section.
• The mean time of lumbar puncture in patients of present study was 8.9 days, owing to the Ethical Committee restraints. It would be advisable to evaluate CSF Nf-H levels before first week of onset of symptoms so as to establish its correlation with outcome at earlier stage. This would help to prognosticate patients earlier during the course of disease, at which time early institution of therapy would be beneficial.

Conclusion

The present study hence, delivers an indication that high CSF pNf-H levels in acute stage of GBS could serve to be a prognostic marker, with high levels representing a poor prognosis. This is important as GBS patients with suspected poorer prognosis might benefit from more aggressive initial treatment or transfer to specialised centres.

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DOI and Others

10.7860/JCDR/2021/50049.15186

Date of Submission: Apr 24, 2021
Date of Peer Review: Jun 01, 2021
Date of Acceptance: Jul 05, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 26, 2021
• Manual Googling: Jun 30, 2021
• iThenticate Software: Jul 23, 2021 (23%)

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