Replacement of Percutaneous Endoscopic Gastrostomy Tube with Low Profile Button Percutaneous Endoscopic Gastrostomy: First Indian Experience

Background: Percutaneous endoscopic gastrostomy (PEG) is a common procedure employed for patients with swallowing disorders with a functioning gastrointestinal tract. Replacement of PEG with a conventional PEG tube by ‘pull technique’ is considered to be the standard of care. Low profile or button PEG, an alternative that obviates the need for endoscopy, is less explored in the Indian setting. Methods: Records of all the patients, who underwent PEG replacement with a low-profile PEG (MIC-KEY by Halyard, U.S.A.) for three years, were reviewed. Complications and other relevant details were recorded. Result: Twenty four low profile PEG tubes were placed in 16 patients; [male 12 (75%); median age(range) 67 (25-85) years]. The indications of PEG placement were stroke in 10 patients, other neurologic illnesses in 5 patients and laryngeal malignancy in 1 patient. Perforation peritonitis and skin induration developed in one patient each. None of the patients had any procedure-related fatal complication. Conclusion: Although PEG exchange with low profile PEG is considered safe, it has potential complications. Thus, utmost care is required to recognize and treat them early.

Wake Up and Non-Wake up stroke: A comparative Hospital Based Study.

Background: Almost 25% of all acute ischemic strokes occur during sleep with the patients or relatives become aware of the neurological deficits as they wake up. The present study was conducted with an aim to find out the prevalence of wakeup stroke along with clinical profile and outcome of wake up stroke as compared to non-wake up stroke. Methods: All patients of age group 18 years or more presenting with stroke during the 12-month study period were included. Data was compared with non-wakeup stroke by applying Chi square test, Fischer exact test and Yates corrections was used to evaluate the association between the variables defining the clinical profile and outcome. Results: Patients of non wake-up stroke were higher (63%) as compared to wake-up stroke (37%). Out of 37 wake-up stroke patients, ischemic stroke was found in 23(62.16%) and hemorrhagic stroke in 14(37.83%) patients. Out of 14(37.83%) wakeup strokes; in 8(57.14%) patients lesion was parenchymal and in 5(35.71%) multiple lesions were present. Higher incidence of diabetes mellitus in wake up strokes was found. Atherothrombotic and cardioembolic strokes contribute to majority of the cases of ischemic stroke. Conclusions: The incidence of stroke increases dramatically with advancing age irrespective of gender. .Diabetes mellitus emerged as the main risk factor in wake-up stroke. In wake up hemorrhagic stroke, the higher percentage of thalamic bleed was found. Improvement was appreciated more in non wake-up stroke as compared to wake-up stroke.

Qualitative palmar dermatoglyphic patterns in cases of idiopathic generalized epilepsy.

Background: Genetic etiology has been proposed for both idiopathic epilepsy and dermatoglyphics. Hence, the present study has been undertaken to find out the existence of any correlation between dermatoglyphics and idiopathic generalized epilepsy. Objective of current study was to find out an association, if any, between dermatoglyphic patterns of hands in idiopathic generalized epilepsy of both sexes. Methods: The study was conducted in the department of anatomy and department of neurology, Himalayan institute of medical sciences, Swami Ram Nagar, Dehradun. Fingertip patterns (whorls, loops, arches) and Main line (A, B, C, D) terminations were analysed by utilizing finger and palmar prints. Results: The present study showed a significant decrease in whorls and an increase in arches in both the hands of male and female IGE patients. Loops were increased in both hands of female patients. Main line D was mostly confined to sectors 11, 9 and 7 in both sexes among the cases and controls. Main line C terminated quite often in sectors 9 & 7 in males and females of the case series. Main line B terminated most frequently in sectors 5'' & 7 in control and case groups. Main line A terminated most frequently in sector 5' in males and females. Conclusion: Therefore, we can conclude and hypothesize merely by observing decrease in the whorl and increase in the arch patterns in the fingerprints (as observed in the present study) that persons with high risk of idiopathic generalized epilepsy can be identified early and preventive measures can be taken against serious complications.

Comparative Efficacy and Tolerability of Sumatriptan, Ergotamine, Naproxen and Rizatriptan in Moderate to Severe Acute Attack of Migraine.

A double-blind, randomized, parallel study was done to compare sumatriptan, ergotamine, naproxen and rizatriptan in 40 outpatients treating a single migraine attack of moderate to severe intensity. Among these groups, significantly more number of patients had headache relief at 2 hours postdose in naproxen and rizatriptan group as compared to ergotamine. Naproxen, rizatriptan and sumatriptan were better than ergotamine in causing freedom from the associated symptoms of nausea, vomiting, photophobia and phonophobia at 2 hour postdose. Naproxen, rizatriptan and sumatriptan were also efficacious in causing functional normalization at 2 hours postdose as compared to ergotamine. The overall results of the study suggest that naproxen is as efficacious as triptan group of drugs but better than ergotamine group in treatment of moderate-severe acute migraine attack. It is more cost effective than triptans and also a well tolerated drug.

Sleep seizures versus wake seizures: A comparative hospital study on clinical, electroencephalographic and radiological profile.

Background: Epileptic seizures, predominantly or exclusively during sleep had been the focus of attention for many electroencephalographers. Though few epileptic syndromes are associated with sleep seizures (SS) its frequencies in Indian patients is still unknown. Aim: To find out the patterns of epilepsies in patients having SS and compare them with patients having wake seizures (WS). Setting and Design : Open label hospital based study. Materials and Methods: One hundred and forty-four (13%) patients having predominantly SS were compared with 976 (87%) patients of WS by various clinical, electrophysiological and radiological factors. Statistical Analysis: Chi square test and student T test, using software SPSS (version 10, 1999) was applied to compare various parameters. Relative risk was calculated by 2 x 2 contingency table. Results: The seizure semiology was better defined in patients with WS and GTCS was more common in SS ( P = 0.001). Wake-electroencephalogram (EEG) was abnormal in significantly ( P = 0.001) higher number of patients with WS. Symptomatic etiologies were found in more than half patients. Left lobe involvement was more common in patients having SS ( P = 0.000). After symptomatic, idiopathic generalized and frontal lobe epilepsy were most frequent with SS. Undetermined epilepsy was found in 37 (25.7%) patients with SS. Conclusion: Epilepsies associated with SS were less frequent and had symptomatic cause in most cases. Left hemispherical and frontal lobe lesion were more commonly associated with SS. Frontal lobe and idiopathic generalized epilepsy was most frequent in patients of SS. Sleep EEG should always be done in patients with sleep seizures.

Extra Pontine Myelinolysis without Striatal involvement Presenting as Pathological Crying, Reversible Parkinsonism and Dystonia.

A case of Central Pontine Myelinolysis and Extrapontine Myelinolysis presented with dystonia, Parkinsonism, and pathological crying that developed few days after gradual correction of hyponatremia. EEG slowing was evident before onset of symptoms, and disappeared with clinical improvement. Thalamic lesions alone produced these features. It dramatically responded to the Trihexyphenidyl therapy. Thus, basal ganglia involvement is not mandatory to produce this clinical picture; early onset of symptoms, resolution of EEG slowing and prompt response to anticholinergics may indicate better prognosis.

Magnetic resonance imaging changes in a case of extra-pyramidal syndrome after acute organophosphate poisoning.

Distal symmetrical polyneuropathy and neuromuscular weakness is common neurological problem in recovery phase of acute organophosphate (OP) poisoning. Various types of extra pyramidal syndromes are uncommon sequel after OP poisoning. These are reported to be reversible within few weeks and characteristically associated with normal magnetic resonance imaging (MRI). In this report we are presenting a case with extra pyramidal syndrome after acute OP poisoning with few interesting MRI changes in striatum.