Naureen Narula

All Publications

• Indwelling Pleural Catheter (IPC) for the Management of Hepatic Hydrothorax The Known and the Unknown JOURNAL OF BRONCHOLOGY & INTERVENTIONAL PULMONOLOGY Avula, A., Acharya, S., Anwar, S., Narula, N., Chalhoub, M., Maroun, R., Thapa, S., Friedman, Y. 2022; 29 (3): 179-185

  Abstract

  Hepatic hydrothorax (HH) is described as pleural effusion secondary to liver cirrhosis after ruling out other etiologies. We aim to assess the efficacy of an indwelling pleural catheter (IPC) placement in refractory HH in this systematic review and meta-analysis.A comprehensive search of literature was performed from inception to December 2020. The authors reviewed, selected, and abstracted the data from eligible studies into Covidence, a systematic review software. Cochrane criteria was used to rate each study for the risk of bias. The data abstracted were described using a random-effects model. Heterogeneity was evaluated using the I2 test.Ten studies involving a total of 269 patients were included. The studies were analyzed for the proportion of pleurodesis achieved, the average time to pleurodesis, total complication rate, pleural infection rate, and mortality. A proportion of 47% of the total subjects included achieved spontaneous pleurodesis in an average duration of 104.3 days. The frequency of total complication rate was noted to be 30.36%. The incidence of pleural cavity infection was described to be 12.4% and death resulting from complications of IPC was 3.35%.The current management options for the refractory pleural effusion in HH include repeated thoracenteses, transjugular intrahepatic portosystemic shunt, surgical repair of defects in the diaphragm, and liver transplantation. However, the cost, eligibility, and availability can be some of the major concerns with these treatment modalities. With this meta-analysis, we conclude that IPCs can provide an alternative therapeutic option for spontaneous pleurodesis.

  View details for DOI 10.1097/LBR.0000000000000823

  View details for Web of Science ID 000814291600012

  View details for PubMedID 34753862

• Setting Up a Teleneurology Clinic during COVID-19 Pandemic: Experience from an Academic Practice INTERNATIONAL JOURNAL OF TELEMEDICINE AND APPLICATIONS Katyal, N., Narula, N., Govindarajan, R., Sahota, P. 2022; 2022: 4776328

  Abstract

  The declaration of the COVID-19 pandemic necessitated rapid implementation of telehealth across all neurological subspecialties. Transitioning to telehealth technology can be challenging for physicians and health care facilities with no prior experience. Here, we describe our experience at the Neurology and Sleep Disorders Clinic at the University of Missouri-Columbia of successful transition of all in-person clinic visits to telehealth visits within a span of 2 weeks with a collaborative effort of clinic staff and the leadership. Within a month of launch, 18 clinic providers with no prior telehealth experience conducted 1451 telehealth visits, which was the 2nd highest number of telehealth visits conducted by any department at the University of Missouri-Columbia Health Care system. Lack of connectivity, poor video/audio quality, and unavailability of smart devices among rural populations were the important shortcomings identified during our telehealth experience. Our study highlighted the need for expansion of high-speed internet access across rural Missouri. We hope our experience will help other health care facilities to learn and incorporate telehealth technology at their facilities, overcome the associated challenges, and serve patient needs while limiting the spread of the COVID-19.

  View details for DOI 10.1155/2022/4776328

  View details for Web of Science ID 000766192000002

  View details for PubMedID 35058978

  View details for PubMedCentralID PMC8764272

• Adverse Side Effects Associated with Corticosteroid Therapy: A Study in 39 Patients with Generalized Myasthenia Gravis MEDICAL SCIENCE MONITOR Johnson, S., Katyal, N., Narula, N., Govindarajan, R. 2021; 27: e933296

  Abstract

  BACKGROUND The tolerability of high-dose oral corticosteroids in patients with generalized myasthenia gravis (gMG) has not been systematically assessed. We evaluated adverse side effects (ASEs) of corticosteroid treatment in patients with gMG. MATERIAL AND METHODS Retrospective analysis was conducted of ASEs reported as being related to corticosteroid treatment in 39 patients with gMG who were treated with oral corticosteroids for ≥1 year. RESULTS Median (interquartile range [IQR]) age was 60 (21) years, 53.8% of patients were women, and 66.7% were aged ≤65 years. Median (IQR) prednisone treatment duration was 14 (2) months; median (IQR) daily dose was 40 (15) mg. The median number of ASEs reported as corticosteroid-related was 2/patient (IQR, 1). Pre-diabetes and weight gain were most common (each 43.6% of patients). Bruising, insomnia, and osteoporosis were more prevalent in patients aged >65 years, while irritability, osteopenia, and pre-diabetes were more common in patients aged £65 years, although differences were not statistically significant. Irritability and weight gain were more prevalent in women (P=0.010 for irritability); osteoporosis and pre-diabetes more common in men (P=0.015 for osteoporosis). ASEs were generally more common in the high-dose prednisone group (>30 mg/day), but were only statistically significant for irritability (P=0.001). CONCLUSIONS Corticosteroid-related ASEs were common in patients with gMG. Some of these ASEs can have serious medical consequences, and certain ASEs appeared to be associated with specific patient characteristics. Demographics and comorbidities of patients with gMG must be carefully considered before corticosteroid initiation. Potential ASEs, such as unanticipated osteoporosis in men, require extra vigilance.

  View details for DOI 10.12659/MSM.933296

  View details for Web of Science ID 000712910200001

  View details for PubMedID 34707081

  View details for PubMedCentralID PMC8562011

• Sarcoidosis: Pitfalls and Challenging Mimickers FRONTIERS IN MEDICINE Narula, N., Iannuzzi, M. 2021; 7: 594275

  Abstract

  Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.

  View details for DOI 10.3389/fmed.2020.594275

  View details for Web of Science ID 000610828900001

  View details for PubMedID 33505980

  View details for PubMedCentralID PMC7829200

• Continuous Electroencephalography (CEEG) in Neurological Critical Care Units (NCCU): A Review CLINICAL NEUROLOGY AND NEUROSURGERY Katyal, N., Singh, I., Narula, N., Idiculla, P., Premkumar, K., Beary, J. M., Nattanmai, P., Newey, C. R. 2020; 198: 106145

  View details for DOI 10.1016/j.clineuro.2020.106145

  View details for Web of Science ID 000587346400033

  View details for PubMedID 32823186

• Neuromuscular Complications With SARS-COV-2 Infection: A Review FRONTIERS IN NEUROLOGY Katyal, N., Narula, N., Acharya, S., Govindarajan, R. 2020; 11: 1052

  Abstract

  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases were first reported in Wuhan, Hubei province of China in December, 2019. SARS- COV-2 primarily affects the cardio-respiratory system. Over the last few months, several studies have described various neurological sequelae of SARS-COV-2 infection. Neurological complications are more frequent in patients with severe respiratory infections. In this review, we have analyzed the current literature on neuromuscular complications associated with SARS-COV-2 and highlighted possible mechanisms of neuromuscular invasion. We reviewed 11 studies describing 11 cases of Guillain Barre syndrome (GBS), and 1 case each of Miller Fisher syndrome, Polyneuritis Cranialis, Acute myelitis, Oculomotor paralysis and Bell's Palsy associated with SARS-COV-2 infection. Mean age of patients with GBS was 61.54 years, with standard deviation (SD) 14.18 years. Majority patients had fever and cough as the first symptom of SARS COV-2 infection. Mean time for onset of neurological symptoms from initial symptoms in 11 patients was 8.18 days, with SD of 2.86 days. Mean time to performing electrodiagnostic study from onset of neurological symptom was 6 days with standard deviation of 3.25. Six patients had demyelinating pattern, three had acute sensory motor axonal neuropathy, and one had acute motor axonal neuropathy on electrodiagnostic studies.

  View details for DOI 10.3389/fneur.2020.01052

  View details for Web of Science ID 000576373700001

  View details for PubMedID 33041989

  View details for PubMedCentralID PMC7527465

• COVID-19 presenting as stroke BRAIN BEHAVIOR AND IMMUNITY Avula, A., Nalleballe, K., Narula, N., Sapozhnikov, S., Dandu, V., Toom, S., Glaser, A., Elsayegh, D. 2020; 87: 115-119

  Abstract

  Acute stroke remains a medical emergency even during the COVID-19 pandemic. Most patients with COVID-19 infection present with constitutional and respiratory symptoms; while others present with atypical gastrointestinal, cardiovascular, or neurological manifestations. Here we present a series of four patients with COVID-19 that presented with acute stroke.We searched the hospital databases for patients that presented with acute stroke and concomitant features of suspected COVID-19 infection. All patients who had radiographic evidence of stroke and PCR-confirmed COVID-19 infection were included in the study. Patients admitted to the hospital with PCR- confirmed COVID-19 disease whose hospital course was complicated with acute stroke while inpatient were excluded from the study. Retrospective patient data were obtained from electronic medical records. Informed consent was obtained.We identified four patients who presented with radiographic confirmation of acute stroke and PCR-confirmed SARS-CoV-2 infection. We elucidate the clinical characteristics, imaging findings, and the clinical course.Timely assessment and hyperacute treatment is the key to minimize mortality and morbidity of patients with acute stroke. Stroke teams should be wary of the fact that COVID-19 patients can present with cerebrovascular accidents and should dawn appropriate personal protective equipment in every suspected patient. Further studies are urgently needed to improve current understandings of neurological pathology in the setting of COVID-19 infection.

  View details for DOI 10.1016/j.bbi.2020.04.077

  View details for Web of Science ID 000542965400036

  View details for PubMedID 32360439

  View details for PubMedCentralID PMC7187846

• Trends and Outcomes of Gastrointestinal Bleeding Among Septic Shock Patients of the United States: A 10-Year Analysis of a Nationwide Inpatient Sample CUREUS JOURNAL OF MEDICAL SCIENCE Siddiqui, A., Ahmed, M., Khan, T., Abbasi, S., Habib, S., Khan, H. M., Rajdev, K., Narula, N., Siddiqui, F. 2020; 12 (5): e8029

  Abstract

  Introduction Gastrointestinal bleeding (GIB) complicating septic shock (SS) presents a therapeutic challenge in intensive care units. Large-scale data regarding utilization, length of stay, and cost outcomes of this association are lacking. Methods We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2003 to 2012, and identified all adult patients aged ≥18 years hospitalized for SS by the International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for SS and GIB. We compared the baseline characteristics and outcomes among patients with SS plus GIB to patients with SS without GIB. Results The weighted sample size from 2003 to 2012 was 119,684 admissions for SS. Among them, 6,571 (5.4%) patients were found to have a GIB. The mean age of the SS population with and without GIB was (mean/standard error of mean) [70.85 (0.43) vs. 67.43 (0.13) P < 0.001, respectively]. The incidence of GIB over the course of 10 years has remained stable; however, the mortality associated with GIB among SS patients is found to be declining especially from 2008 (59.2%) to 2012 (45.1%) (P < 0.01). Patients with SS and GIB compared to patients with SS and no GIB were found to have a longer length of stay [20.56 (0.61) vs. 15.76 (0.13) P < 0.001], higher mortality [54% vs. 45% P < 0.001], and higher admission costs in United States dollar ($) (mean/SEM) [$192,524.89 (7,378.20) vs. $142,688.55 (1,336.65) P < 0.001]. Univariate analysis demonstrated that comorbid conditions like peptic ulcer disease and cirrhosis had significant odds ratios {1.56 and 1.709, P = 0.016 and 0.046 respectively} for the occurrence of GIB with SS. Gastroesophageal reflux disease was found to be associated with a lower incidence of GIB [odds ratio: 0.57, P = 0.0008]. The cause of sepsis (pneumonia, urinary tract infection, or abdominal infections) was not a significant distinguishing factor for the incidence of GIB in SS. Conclusion GIB continues to affect the patients with SS admitted in intensive care units in the United States. We found an incidence of 5.4% of GIB in patients with SS, and it was associated with worse outcomes.

  View details for DOI 10.7759/cureus.8029

  View details for Web of Science ID 000531232400010

  View details for PubMedID 32399377

  View details for PubMedCentralID PMC7212718

• Endobronchial aspergilloma-a comprehensive literature review with focus on diagnosis and treatment modalities EUROPEAN JOURNAL OF CLINICAL MICROBIOLOGY & INFECTIOUS DISEASES Ngu, S., Narula, N., Abureesh, M., Li, J., Chalhoub, M. 2020; 39 (4): 601-605

  Abstract

  Endobronchial aspergilloma (EBA) is a rare manifestation of pulmonary infection with Aspergillus spp. Comprised of hyphae, mucus, and cellular debris, the massive fungus overgrowth can lead to obstructive pneumonitis in large airways, manifesting as cough, dyspnea, hemoptysis, or weight loss. The aim of this paper is to review the literature on endobronchial aspergilloma to further elucidate this disease entity and to classify it as a non-invasive form of pulmonary aspergillosis. A descriptive analysis was performed on articles on PubMed database that contained the key word "endobronchial aspergilloma." A total of 28 cases were obtained. Four articles were excluded as they were not available in the English format. Although EBA is extremely rare, it should be considered in the differential diagnosis of endobronchial masses in immunocompromised patients. There is a potential for the disease entity to progress to tracheobronchitis and fulminant respiratory failure. As such, early detection with bronchoscopy, biopsy, and culture is required to confirm pulmonary aspergillosis. Current treatment regimens remain to be optimized, though piecemeal resection of the mycetoma with bronchoscopic techniques with the addition of systemic antifungals and their combinations has been reported as efficacious.

  View details for DOI 10.1007/s10096-019-03726-5

  View details for Web of Science ID 000520706000001

  View details for PubMedID 31741102

• Placental transmogrification of the lung associated with unilateral pleural effusion: A case report with a comprehensive review of the literature RESPIRATORY MEDICINE CASE REPORTS Narula, N., Ngu, S., Sharma, D., Siddiqui, F., Chalhoub, M. 2019; 26: 161-164

  Abstract

  Placental transmogrification of the lung (PTL) is a rare benign pulmonary lesion resembling chorionic villi. With fewer than 40 cases reported in literature, associations have thus far been made with bullous emphysema, pulmonary fibrochondromatous hamartomas and adenocarcinoma of the lung. Typically presenting as unilateral solitary cystic or bullous lesion, we report the first case of PTL presenting with unilateral pleural effusion. A 70-year-old male presented with recurrent unilateral pleural effusion that failed to resolve with multiple thoracenteses. He underwent thoracoscopic excision and biopsy of a cystic mass identified on computed tomography (CT) scan which revealed characteristic villous and papillary changes. We describe the case and review the literature on this benign but rare pulmonary disease entity.

  View details for DOI 10.1016/j.rmcr.2018.11.018

  View details for Web of Science ID 000461453000042

  View details for PubMedID 30622891

  View details for PubMedCentralID PMC6319187

• Cracking the Crack Dance: A Case Report on Cocaine-induced Choreoathetosis CUREUS Narula, N., Siddiqui, F., Katyal, N., Krishnan, N., Chalhoub, M. 2017; 9 (12): e1981

  Abstract

  Movement disorders represent one of the less common presentations of cocaine toxicity observed in clinical practice. Given the magnitude of crack cocaine use, it is vital to understand the underlying pathogenesis. We present a case of a patient who clinically exhibited cocaine-induced choreoathetosis. The diagnosis was confirmed after ruling out all other organic causes of de novo choreoathetoid movement. This case highlights the association of cocaine with choreoathetoid movements. We propose a preliminary understanding of the underlying pathogenesis, which may help intensivists better recognize this uncommon phenomenon.

  View details for DOI 10.7759/cureus.1981

  View details for Web of Science ID 000453652000079

  View details for PubMedID 29503775

  View details for PubMedCentralID PMC5826744