Association between Clinical Features and Magnetic Resonance Imaging Findings in Patients with Temporal Lobe Epilepsy

Background: Temporal lobe epilepsy (TLE) is the most common cause of partial seizures. However, there is a paucity of data on the correlation of clinical and semiological features of TLE with specific imaging findings on magnetic resonance imaging (MRI). Objective: In this study, we sought to evaluate the association between the semiology of TLE with specific etiological findings as identified on MRI. Materials and methods: This was a single-center, observational study in which consecutive patients presenting with clinical features diagnostic of TLE underwent a brain MRI on a 1.5 T scanner. The data collected from the various MR parameters were then correlated with history. Results: A total of 90 patients were included in the study. The mean age of the study population was 29.1 years. Females comprised 45% of the study population. Mesial temporal sclerosis (MTS) was the most common imaging finding in about 60% of patients. Four out of five patients had aura whereas 70% had automatisms. The presence of aura in TLE patients was significantly associated with MTS on MRI (p = 0.042). The presence of automatism and history of childhood febrile seizure did not have a significant association with any specific etiological findings on MRI (p = 0.254 and 0.731, respectively). Drug-refractory epilepsy was commonly associated with the presence of MTS on MRI (p = 0.004). The presence of dual pathology on MRI was associated with drug-refractory epilepsy (p = 0.031). Conclusions: The presence of aura and drug-refractory epilepsy point towards the presence of MTS. Dual pathology, on MRI, in TLE patients may be a risk factor for drug-refractory epilepsy.

Depression and diabetes: A tendency or demon of darkness among diabetics? A cross-sectional study among type 2 diabetes mellitus patients attending an “integrated diabetes and gestational diabetes clinic” of Eastern India

Background: Depression is a common comorbid condition found in chronic medical illnesses in general and diabetes mellitus (DM) in particular. Worldwide, more than 365 million people are estimated to have Type 2 DM (T2DM), and almost 300 million people have major depression. Depression can be viewed as a Modifiable independent risk factor for the development of T2DM and for progression of complications from either type 1 or T2DM. Objectives: The aim of the study was to find out the distribution and determinants of depression among T2DM patients attending an integrated diabetes and gestational diabetes clinic (IDGDC) of a tertiary care hospital of West Bengal, East India. Materials and Methods: This cross-sectional, observational study was conducted among T2DM patients who attended IDGDC during May 2017–June 2017. Public Health Questionnaire-9 was used to assess depression and its severity. A total of 196 study subjects participated in the study. Results: The prevalence of depression was found to be 54.6%. About 28.1% of the study subjects had mild depression, 17.9%, 6.1%, and 2.6% subjects had moderate, moderately severe, and severe depression, respectively. Women gender, increasing age, rural residence, low literacy, longer duration of diabetes, and overweight/obesity were significantly associated with high frequency of depression. Addiction was significantly higher among depressed T2DM patients. Mean hemoglobin A1c level was significantly lower among non-depressed T2DM patients. Conclusion: More than half of the T2DM patients are suffering from depression of varying severity. There should be a dedicated counselor in diabetes clinics for routine screening of depression among all T2DM patients to identify the high-risk patients requiring urgent psychiatrist consultation.

Pre-operative hypertension and its risk factors: A cross-sectional study among patients admitted for surgery at a tertiary health care facility of Eastern India

Background: Hypertension (HTN) is one of the most common diagnoses in a primary health care setting and it is one of the important and preventable contributors to disease and death. HTN is considered as an additional risk factor in anesthesia and HTN is of special importance to the anesthetist for various reasons. Tracheal intubation, surgical incision, recovery from anesthesia, and post-operative pain can increase blood pressure (BP). Objectives: This study aims to find out the burden of pre-operative HTN and its risk factors among patients who were admitted for surgical procedures at a tertiary health care facility of Durgapur, West Bengal, India. Materials and Methods: After obtaining permission from the Institutional Ethics Committee, an institution based, observational, and cross-sectional study was conducted from January 2019 to February 2019. A pre-tested, semi-structured schedule was used to collect Clinic Social data. Anthropometric measurements and BP were taken as per the world health organization STEP-wise approach to surveillance guidelines. BP was classified as per “The eighth joint national committee (JNC-8) guidelines. Results: Data were collected from 150 study subjects and were analyzed using SPSS, version 20.0 for windows. The frequency of pre-operative HTN and pre-HTN was found to be 38.0% and 32.0% respectively. As per JNC-8, 34.7% had Stage-1 HTN followed by 32.0% and 3.3% who had pre-HTN and Stage-2 HTN, respectively. Increasing age, male gender, smoking, increasing body mass index, dyslipidemia, and Type 2 diabetes mellitus (T2DM) were significantly associated with a higher frequency of HTN. Conclusion: There is a very high prevalence of pre-operative HTN and pre-HTN. Increasing age, male gender, smoking, overweight, obesity, dyslipidemia, and T2DM were significant risk factors for HTN. Routine screening of HTN should be done in surgical ward to see if there are cases of “white coat” HTN.

The BDFOOT- IDGDC study: Burden of diabetic foot ulcers and its determinants among type 2 diabetes patients attending an “Integrated Diabetes and Gestational Diabetes Clinic” of Eastern India

Background: Globally, about 425 million people are suffering from diabetes mellitus (DM) which will be about 629 million by 2045. India is popularly known as “World Diabetes Capital” and is presently home of about 72.9 million diabetes patients. Poorly managed DM will increase the burden of both microvascular and macrovascular complications. One of the most common complications among them is diabetic foot ulcer (DFU) which affects about 7%–24% of DM patients. Aims and Objectives: This study was planned to determine the burden of DFU and its determinants among Type 2 diabetes mellitus (T2DM) patients attending integrated diabetes and gestational diabetes clinic. Materials and Methods: An institution-based, observational, cross-sectional study was conducted from July to September 2018. A pre-designed, pre-tested, semi-structured schedule was used to collect clinicosocial data. Blood pressure of the study subjects was measured and classified as per Joint National Committee-8 guidelines. Peripheral vascular assessment of the feet was done by calculating “ankle-brachial index (ABI)” in both lower limbs using “Diabetik Foot Care India Pvt. Limited” vascular Doppler instrument having 8 MHz transducer. ABI ≤0.9 and absence of pulse in dorsalis pedis and/or posterior tibial arteries were considered as peripheral artery disease (PAD). Vibration perception threshold for peripheral sensory neuropathy was tested with the help of Diabetik Foot Care Pvt. Limited Digital Biothesiometer using 50 Hz frequency. Results: Data were collected from 338 study participants. The frequency of DFU was found to be 9.5%. Increasing age, longer duration of diabetes, poor educational status, overweight/obesity, poor glycemic control, treatment with insulin, PAD, diabetic peripheral neuropathy, hypertension, ischemic heart disease, and hypothyroidism were significantly associated with DFU. Conclusion: There is high frequency of DFU among T2DM patients. Most of the risk factors are modifiable and if taken care of the occurrence of DFU can be prevented and/or delayed.

To study the oxidative stress induced by lindane in epileptic rats brains and their modulation by neurosteroids.

Background: Lindane is pesticide has been shown to affect the nervous system adversely. Previous work has shown that lindane is proconvulsant and neurosteroids (NS) has been shown to be neuroprotective against lindane-induced convulsions. As the mechanisms of lindane in epileptogenesis is not completely understood. The present study was designed to investigate the oxidative stress parameters of lindane toxicity in epileptogenesis and their modulation by NS like allopregnanolone (AP), and 4ʹ-chlorodiazepam (4ʹ-CD) in pentylenetetrazole (PTZ) kindling methods. Methods: Kindling was induced by injecting PTZ (30 mg/kg; s.c.) on alternate days i.e., 3 times in a week. Lindane was also administered (15 mg/kg p.o) on alternate days for 6 weeks. AP (2.5 mg/kg, intaperitoneal [i.p.]) and 4ʹ-CD (0.5 mg/kg, i.p.) single dose was given in kindled rats before lindane. Results: Following per oral administration of lindane for 6 weeks produced signifi cant oxidative stress in epileptic brain. There was an increase in brain malondialdehyde (MDA) level and decrease in reduced glutathione (GSH) levels. AP (2.5 mg/kg, i.p.) and 4ʹ-CD (0.5 mg/kg, i.p.) single dose administration were not able to reverse the effect of chronic exposure of lindane. Conclusion: The result of the present study provides evidence that oxidative stress produced in the brain after chronic exposure of lindane may be the mechanism of epileptogenesis. Though NS have been shown to be neuroprotective, but they failed to reverse chronic oxidative stress produced by lindane. Further studies are required to demonstrate interaction of NS with lindane in oxidative stress.

Non-haematopoietic malignancies metastasing to the bone marrow: A 5 year record-based descriptive study from a tertiary care centre in South India.

INTRODUCTION: Bone marrow involvement by a non-haematological malignancy gives an opportunity to identify the lodgement, invasion of metastatic cells and the response of the host to the tumor cells. The study was undertaken to assess the involvement of bone marrow with non-haematopoietic malignancies and its significance in establishing primary diagnosis in clinically unsuspected cases. MATERIALS AND METHODS: This was a descriptive study which included record review of the departmental archives for the last five years (January 2007 to December 2011). Eighty four cases were studied; which included clinically diagnosed non-haematological malignancy for staging or symptomatic cytopenias/bony lesions (group 1, n = 63), clinically suspected bone marrow metastasis of unknown primary malignancy due to symptomatic cytopenias/bony lesions (group 2, n = 07) and clinically unsuspected malignancy with incidentally detected bone marrow metastasis (group 3, n = 14). RESULTS: Bone marrow metastases of solid tumors were identified in 23 cases (27.3%) which included 9 cases from group 1, 14 cases from group 3 and nil in group 2. Of the 14 cases in group 3, in 12 cases a definitive diagnosis could be made by correlating clinicoradiological findings with morphology and immunohistochemistry. The most common tumor in pediatric cases were neuroblastoma and Ewing’s sarcoma (40%) and in adult’s adenocarcinoma of gastrointestinal tract (30.7%) was the commonest. CONCLUSION: Bone marrow metastasis can masquerade as a primary haematopoietic disorder; however its detection has both therapeutic and prognostic significance. Immunohistochemistry is a useful adjunct to morphology in reaching a definitive diagnosis.

The First Identification of <i>Rotavirus B</i> from Children and Adults with Acute Diarrhoea in Kathmandu, Nepal

<i>Rotavirus B</i> (RVB) in the genus <i>Rotavirus</i> of the family <i>Reoviridae</i> is known to be a cause of acute gastroenteritis among children and adults in parts of Asia including China, India, Bangladesh and Myanmar. In a 15-month surveillance programme between March 2007 and May 2008, 3,080 stool specimens were collected from children and adults with acute gastroenteritis in an infectious disease hospital in Kathmandu, Nepal. In 25 (0.8%) specimens RVB was detected, for the first time in Nepal, by the use of polyacrylamide gel electrophoresis followed by confirmation with reverse-transcription PCR and sequencing. The strains detected in this study had very similar electropherotypes, and their VP7 sequences were almost identical and phylogenetically belonged to the Indo-Bangladeshi lineage which was distinct from the Chinese lineage. Thus, this study showed the circulation of RVB strains belonging to the Indo-Bangladeshi lineage in a broader region than previously documented, suggesting that this phylogenetic divide corresponded to the geographic divide created by the Himalayan Mountains. Further studies may be warranted to identify and characterize the RVB strains in northern Vietnam which is adjacent to southern China with a long and less mountainous border.

First Isolation of Dengue Virus from the 2010 Epidemic in Nepal

Dengue is an emerging disease in Nepal and was first observed as an outbreak in nine lowland districts in 2006. In 2010, however, a large epidemic of dengue occurred with 4,529 suspected and 917 serologically-confirmed cases and five deaths reported in government hospitals in Nepal. The collection of demographic information was performed along with an entomological survey and clinical evaluation of the patients. A total of 280 serum samples were collected from suspected dengue patients. These samples were subjected to routine laboratory investigations and IgM-capture ELISA for dengue serological identification, and 160 acute serum samples were used for virus isolation, RT-PCR, sequencing and phylogenetic analysis. The results showed that affected patients were predominately adults, and that 10% of the cases were classified as dengue haemorrhagic fever/ dengue shock syndrome. The genetic characterization of dengue viruses isolated from patients in four major outbreak areas of Nepal suggests that the DENV-1 strain was responsible for the 2010 epidemic. Entomological studies identified <i>Aedes aegypti</i> in all epidemic areas. All viruses belonged to a monophyletic single clade which is phylogenetically close to Indian viruses. The dengue epidemic started in the lowlands and expanded to the highland areas. To our knowledge, this is the first dengue isolation and genetic characterization reported from Nepal.

Orthopaedic applications of bone graft & graft substitutes: a review.

Treatment of delayed union, malunion, and nonunion is a challenge to the orthopaedic surgeons in veterinary and human fields. Apart from restoration of alignment and stable fixation, in many cases adjunctive measures such as bone-grafting or use of bone-graft substitutes are of paramount importance. Bone-graft materials usually have one or more components: an osteoconductive matrix, which acts as scaffold to new bone growth; osteoinductive proteins, which support mitogenesis of undifferentiated cells; and osteogenic cells, which are capable of forming bone in the appropriate environment. Autologous bone remains the “gold standard” for stimulating bone repair and regeneration, but its availability may be limited and the procedure to harvest the material is associated with complications. Bone-graft substitutes can either substitute autologous bone graft or expand an existing amount of autologous bone graft. We review the currently available bone graft and graft substitutes for the novel therapeutic approaches in clinical setting of orthopaedic surgery.

Prognostic significance of bone marrow histology in multiple myeloma.

BACKGROUND: Bone marrow examination continues to be the cornerstone for establishing the diagnosis of multiple myeloma in association with other clinical and laboratory parameters. Plasma cell morphology has significant correlation with clinical stage and survival. AIMS: To note the bone marrow histology in detail in multiple myeloma and to correlate it with clinical stage and survival. METHODS AND MATERIAL: Fifty-five cases of multiple myeloma diagnosed between January 2001 and December 2006, who had a bone marrow aspiration and biopsy done at the time of diagnosis were included in the present study. STATISTICAL ANALYSIS: SPSS software version 13.0 was used. Clinical stage and plasma cell morphology were correlated using chi square test and Spearman's correlation coefficient. Survival analysis was done using the Kaplan-Meier method. RESULTS: Seventy-six percent patients were in clinical stage III, 17% and 7% were in stage II and I respectively. The clinical stage correlated significantly with plasma cell morphology, percentage of plasma cell infiltration and pattern of infiltration. Plasma cell morphology correlated significantly with bone marrow parameters like percentage infiltrate, pattern of infiltration, degree of fibrosis and mitotic activity. Patients in advanced clinical stage,> 50% plasma cells in the marrow, diffuse pattern of infiltration, high mitosis and increased fibrosis had a shorter median survival than patients with favorable features. CONCLUSIONS: It is recommended that the bone marrow histology be studied in detail in multiple myeloma at diagnosis since it correlates well with the clinical stage and offers useful prognostic information.

Oromandibular dystonia and persistent psychiatric symptoms in extra-pontine myelinolysis.

A 32 years female presented with gradually progressive dysarthria, dysphagia, oromandibular dystonia and mild generalized weakness. She had several episodes of acute psychotic behavior. She had abnormal saccadic eye movements, generalized hypertonia and exaggerated jerks in upper limbs. She was previously treated in a peripheral hospital for severe vomiting and diarrhea. MRI of brain revealed symmetrical T-2 weighted hyperintensities in bilateral putaminal and caudate region along with pons and midbrain suggesting demyelination due to a metabolic insult. Her power improved gradually over days and the dysarthria, dysphagia and oromandibular dystonia improved gradually over several weeks with supportive measures but the psychiatric manifestations are still persisting.

Attenuation of the effect of lindane on immune responses and oxidative stress by Ocimum sanctum seed oil (OSSO) in rats.

Present study was done to evaluate the effect of Ocimum sanctum seed oil (OSSO) on the immunotoxicity and oxidative activity of lindane in rats. Rats were divided into four groups (n = 8) and were treated with lindane (10 mg/kg, po) and/or OSSO (1 mg/kg, po) during the study period. Humoral immunity was assessed by measuring haemagglutination titre to sheep red blood cells (SRBC) and delayed type hypersensitivity (DTH) was assessed by measuring foot pad thickness. Lindane showed significant decrease in anti-SRBC antibody titre and also decreased percentage change in foot pad thickness in DTH response as compared to control group. OSSO per se produced significant increase in anti-SRBC antibody titre, but did not produce significant change in the foot pad thickness as compared to control group. However, it significantly antagonized the effect of lindane on the anti-SRBC antibody titre and foot pad thickness parameters. Lindane produced oxidative stress as indicated by increase in the levels of MDA and decrease in GSH levels. Treatment with OSSO per se showed antioxidant activity and also reversed the oxidative stress produced by lindane. The results suggest that OSSO can attenuate the immunotoxicity and oxidative stress produced by lindane.

Hepatopulmonory syndrome--an uncommon and severe complication of certain liver diseases.

Hepatopulmonary syndrome (HPS) is charaterised by arterial hypoxaemia found mainly in association with chronic liver disease (most commonly cirrhosis of liver) but also rarely with acute liver diseases like fulminant hepatic failure or Budd-Chiari syndrome. The purpose of this article is to present an uncommon but grave complication mostly associated with cirrhosis of liver and to differentiate this entry from cyanotic heart diseases or certain lung conditions. Investigations include history and physical examination, certain biochemical tests, upper gastro-intestinal (GI) endoscopy, abdominal ultrasonography, liver biopsy and venacavography in appropriate cases. Finally, the suspected cases underwent arterial blood gas (ABG) analysis and contrast enhanced echocardiography (CEE) for confirmation of the diagnosis of HPS. Of the 123 cases of cirrhosis of liver, three cases of HPS (2.4%) were found-all of them being males. Also one male patient with inferior vena cava (IVC) obstruction amongst other causes presenting with HPS was encountered. As of now, no medical treatment has been proved to be useful and liver transplant remains the only hope for this disorder.

Substance-dependent women attending a de-addiction center in North India: sociodemographic and clinical profile.

BACKGROUND: Treatment-seeking is limited in women substance abusers. Studying the sociodemographic and clinical profile of treatment-seeking substance-dependent women can help us to understand the problem better and respond appropriately in terms of primary and secondary prevention strategies. AIM: To study the sociodemographic and clinical profile of women attending a de-addiction centre in North India. DESIGN AND METHODOLOGY: Retrospective structured chart review of 35 women substance abusers. RESULTS: The results indicated that a typical subject was urban (86%), married (63%), nuclear family (60%), based housewife (57%), educated up to school completion (54%), and having poor social support (57%). The common substances were opioids (60%), followed by alcohol (17%), and tobacco and benzodiazepines (11.5% each). The mean age at onset of substance use was 30.5 years, the mean duration of use was 9 years and mean duration to develop dependence was 5.5 years. The common reasons for initiating use were medical (63%) and curiosity (34%). Comorbidity profile was: physical illness (34%), psychiatric illness (23%) and dependence on another substance (14%). Only 20% had a family history of substance dependence. The social impairment ranged from 77% for social to 40% for financial and none for legal aspects. A typical subject had followed up 4.2 times in 8.4 months, while 54% were abstaining, 40% were continuing their substance dependence at the last follow up. CONCLUSIONS: The results suggest that the development of substance dependence in women is a combination of genetic, personal, and social vulnerability factors, including the drug culture of the social milieu and the poor social support. Comorbidity and impairment are common features.

Unusual presentation of sickle cell anaemia--paraplegia in a fifty year old man.

A fifty-year-old male patient presented with bilateral lower limb paraplegia. He was subsequently found to have sickle cell anaemia. The patient showed good response to treatment. Central nervous system complications in sickle cell anaemia are well known. However paraplegia has rarely been documented in sickling disorders. We report this case because of rarity of sickle cell anaemia presenting in old age with paraplegia.

Ultra-rapid opioid detoxification: current status and controversies.

Opioid dependence is a major health problem and a cause of increasing concern to physicians and other health professionals worldwide. A crucial first step in intervention is detoxification. Recent trends in medical practice have seen the emergence of newer techniques that claim to accelerate the detoxification procedure and ensure prevention of relapse by rapid induction onto maintenance treatment with opioid antagonists such as naltrexone. This review delves into the theoretical and methodological aspects related to ultra-rapid opioid detoxification (opioid detoxification procedure using opioid antagonists, performed under general anaesthesia or heavy sedation) and discusses the status of the same in light of the available evidence regarding its applicability, safety and effectiveness. Although useful in some respects (especially in completion rates for detoxification and subsequent induction onto naltrexone maintenance), the justification of this procedure lies in (a) the resolution of the ethical conflicts surrounding the procedure and (b) conduction of methodologically sound long-term studies to demonstrate greater efficacy over routine/standard detoxification procedures beyond the short-term detoxification period.

Platelet large cell ratio in the differential diagnosis of abnormal platelet counts.

Platelet volume indices, estimated by automated blood cell analyzers, are useful in the diagnosis of various conditions with abnormal platelet counts. Platelet count (PLT), Platelet large cell ratio (P-LCR), Platelet distribution width (PDW) and mean platelet volume (MPV) were studied in 779 patients with normal platelet counts, 74 patients with high platelet counts and 41 cases with low platelet counts. P-LCR was significantly decreased in patients with thrombocytosis than in normal while it was increased in thrombocytopenia. In patients with high counts, P-LCR was significantly decreased in reactive thrombocytosis than neoplastic thrombocytosis. P-LCR was increased in destructive thrombocytopenia than those with hypoproliferative thrombocytopenia though it was not statistically significant. P-LCR was inversely related to platelet count and directly related to PDW and MPV. Platelet large cell ratio if properly utilised can be a good aid in the differential diagnosis of conditions associated with abnormal platelet counts.

Paroxysmal nocturnal hemoglobinuria with onset in childhood: a case report.

A twelve-year-old boy presented with recurrent episodes of anemia. Complete blood counts showed pancytopenia. Bone marrow was hypercellular with erythroid hyperplasia and depleted stores of iron. Positive Ham's test and sucrose lysis test revealed that he had paroxysmal nocturnal hemoglobinuria. There was a delay of nearly two years in the diagnosis in this patient. Paroxysmal nocturnal hemoglobinuria is rare in childhood. It must however be considered in a child who presents with unexplained anemia or bone marrow failure so that an early and accurate diagnosis is reached.