Frequency of metabolic syndrome and its components in patients with carpal tunnel syndrome

Objective: To determine the frequency of metabolic syndrome and its components in patients with carpal tunnel syndrome

Study Design: Case-series

Place and Duration of Study: Department of Neurology, Mayo Hospital, Lahore, from January to June 2012

Methodology: Seventy-five [64 females and 11 males] patients with clinically diagnosed and electrodiagnostically confirmed carpal tunnel syndrome were inducted. Their waist circumference, blood pressure, fasting blood glucose, fasting triglycerides and high density lipoprotein cholesterol levels were recorded. Patients were categorized having metabolic syndrome according to Adult Treatment Panel III criteria, if any 3 were present out of hypertension, elevated fasting triglycerides, reduced high density lipoprotein cholesterol, elevated fasting blood glucose, and elevated waist circumference

Results: Mean age of the patients was 42.04 +/- 9.31 years, mean waist circumference was 95.32 +/- 9.03 cm, mean systolic blood pressure was 134.13 +/- 13.72 mmHg, mean diastolic blood pressure was 89.13 +/- 8.83 mmHg, mean fasting blood glucose was 94.35 +/- 21.81 mg/dl, mean fasting triglycerides was 177.48 +/- 48.69 mg/dl, and mean high density lipoprotein cholesterol was 41.95 +/- 11.17 mg/dl. Metabolic syndrome was found in 54 [72%] patients including 9 [16.7%] males and 45 [83.3%] females. Out of 75 patients, 54 [72%] had elevated waist circumference, 52 [69.3%] had elevated blood pressure, 19 [25.3%] had elevated fasting blood glucose, 53 [70.6%] had elevated fasting triglycerides and 54 [72%] had reduced high density lipoprotein cholesterol. Highest frequency of metabolic syndrome was found in age range of 40 - 49 years in both genders

Conclusion: Metabolic syndrome is frequently found in the patients with carpal tunnel syndrome

Clinical features, role of mobile plasmapharesis unit and outcome in patients with acute inflammatory demyelinating polyradiculoneuropathy [Guillain-Barr‚ syndrome]

To study the clinical features, role of mobile plasmapharesis unit and outcome in patients with acute inflammatory demyelinating polyradiculoneuropathy [AIDP]. Retrospective Cross Sectional Study. This study was conducted at Neurology Department, KEMU, Lahore from July 2008 till June 2012. Patients from various hospitals [both public and private] fulfilling the Ashbury and Cornblath's Clinical Diagnostic Criteria for GBS and requiring plasmapharesis were included in the study. For this purpose a special proforma was designed to be filled by the primary physician at the time of request for mobile plasmapharesis service. This service was provided by a donor organization namely Pakistan Myasthenia Gravis Welfare Organization [PMWO] based at a public hospital in Lahore. Plasmapharesis was started according to the guidelines, as soon as possible after admission, if patient had history of progressive weakness. The protocol of this treatment was to exchange 200 to 250 ml of plasma per kilogram of body weight in five sessions within 7 to 10 days. The replacement fluids most often consist of 0.9% normal saline, haemaccel and/or albumin. Recovery was assessed by modified Hughes Guillain-Barr‚ syndrome disability scale. A total of 152 patients were included in the study with 94 [61.8%] males and 58 [38.2%] females and M: F ratio of 1.62:1. The mean age was 32.66 [SD 15.89] with range from 7-80 years. One hundred and nine [72%] cases presented between 11-40 years of age. All patients were treated with five sessions of plasmapharesis. Drop out rate for plasmapharesis was 1.5% implying its good tolerability. Out of the total of 152 cases, 149 [98%] cases presented with progressive areflexic weakness and 3 [2%] patients with bilateral external Ophthalmoplegia, areflexia and ataxia [Miller-Fisher variant]. Sensory symptoms were present in 31[20.4%], bulbar weakness in 29[19.1%], and bilateral facial weakness in 25[16.4%] cases. Severe respiratory distress requiring ventilatory support occurred in 36[23.7%] cases. Pearson's correlation revealed that gender and age were not risk factors for the development of ventilatory failure [p=0.354; 0.803], bilateral facial weakness [p = 0.121; 0.473] or bulbar weakness [p= 0.383; 0.745] respectively. Overall mortality was 5% and all these cases developed severe respiratory distress and needed ventilatory support. Complete recovery occurred in 90% cases and 5% had residual deficit [Hughes disability scale severity 1 and 2] at mean follow up of six months. Our study showed that GBS is statistically more frequent in males than females in our local population with maximum frequency between 11-40 years of age range. However, the two factors i.e. gender and age has no significant association with the development of ventilatory failure, bilateral facial weakness and bulbar weakness. Areflexic motor weakness was the commonest presenting feature. Plasmapharesis remained very effective therapeutic option which is cheaper and affordable in our poor socio-economic setting. Mobile unit service provided an excellent opportunity to treat most of these patients at their native hospitals. We recommend that government and donor organizations should develop more mobile plasmapharesis services in all major cities which can cover nearby district and tehsil hospitals

study of chronic inflammatory demyelinating polyneuropathy [CIDP] in diabetics: clinical features, laboratory findings and response to treatment

The association of chronic inflammatory demyelinating neuropathy [CIDP] in diabetics is a recently recognized form of neuropathy. It is important to recognize CIDP occurring in diabetics because, unlike diabetic polyneuropathy, it is treatable. These patients can respond to immune therapies similar to patients with CIDP without diabetes. To study the clinical, electrophysiological, and laboratory features and response to immune modulating treatments in diabetic patients with CIDP. This was a retrospective cross sectional study from January 2009 till December 2012 carried out at Mayo Hospital and National Hospital, Lahore. The inclusion criteria included proven cases of diabetes mellitus with subacute motor weakness fulfilling the research criteria for diagnosis of CIDP. All patients underwent electrophysiological [EP] studies and cerebrospinal fluid analysis [CSF] especially for proteins. Diagnosed CIDP patients were treated with oral prednisolone 1mg/kg body weight along with azathioprine 50-150mg/day. The steroids were gradually tapered after achieving normal muscle strength or a static phase of one month without further improvement in muscle strength. The maintenance dose of prednisolone was continued to complete two years therapy. A course of IVIg [400mg/kg body weight daily for five days] or plasmapharesis [five sessions on alternate days] were used in patients with severe motor weakness to expedite the initial recovery phase. Follow was done at monthly interval for one year and bimonthly for subsequent years. The Hughes functional grading scale was used to assess the outcome. Treatment was considered effective when the patient's condition improved by 1 or more grade on the Hughes scale. There were 10 patients with 6[60%] males and 4[40%] females and M: F ratio of 1.5:1. The mean age of patients was 63.7 + 7.83 years. Mean duration of diabetes mellitus was 11.3 +3.77 years. All patients had Type 2 diabetes mellitus with six patients on Insulin and 4 on oral hypoglycemic agents. Mean duration of motor weakness before treatment was 5.30 + 1.16 months. Mean power as assessed by medical research council [MRC] grading in upper limbs was 3/5 [range 1-5] and lower limbs 1/5[range 0-2]. Seven [70%] patients had mixed demyelinating and axonal picture on EMG, and 3[30%] patients showed predominantly demyelinating type of neuropathy. CSF protein was high in all patients with mean CSF protein of 208.4 + 93.07 mg/dl. Mean duration of follow up after treatment was 25.10 + 15.82 months. Attempt was done to stop immunotherapy after 2 years but relapse occurred in 3 [30%] patients which again responded to steroids. Outcome was assessed by Hughes functional grading scale. Mean Hugh's functional severity grade before treatment was 4.10 + 0.316 and after treatment was 1.30 + 1.16. We conclude that CIDP in diabetics is potentially reversible type of neuropathy and needs careful evaluation for its recognition. The classical demyelinating pattern on EMG may be lacking because of coexistent axonal neuropathy but clinical history of subacute onset predominantly proximal motor weakness [LMN type] and high CSF protein are most sensitive markers to predict response to corticosteroids in these patients. This is more common in males and elderly long standing diabetics. The response to corticosteroids and other immunosuppressive therapies is excellent. The recognition of this entity is important as appropriate management can reverse the disability in these patients

Chronic relapsing inflammatory optic neuropathy [Crion]

This newly recognized entity named chronic relapsing inflammatory optic neuropathy [CRION] is a form of inflammatory optic neuropathy which is frequently bilateral and often painful, and is characterized by relapses and remissions. There is no evidence of acquired demyelinating disorders and systemic collagen vascular or granulomatous diseases. To study the clinical features and response to treatment in patients with recurrent optic neuritis consistent with diagnosis of chronic relapsing inflammatory optic neuropathy [CRION]. Materials and. This is retrospective cross sectional study carried out at department of Neurology, King Edward Medical University, Lahore. Patients with history of recurrent episodes of acute or subacute loss of vision accompanied by pain consistent with optic neuritis, unilateral or bilateral, but, without evidence of an acquired demyelinating disorders, systemic collagen vascular orgranulomatous diseases were included in the study. The response to various treatments was also analyzed.A total of 4 patients were identified. All were females with mean age at presentation 35.50+8.10 years and mean age at onset of first episode was 28+10.92 years. Mean duration of illness was 7. 25 + 4.57 years. The number of episodes varied from 3-6 [mean 4+1.41episodes]. Mean episodes of right optic neuritis were 2.25+0.95 and left side 1.50+ 0.57. Only one patient had an episode of simultaneous bilateral optic neuritis. All patients experienced severe pain with loss of vision to finger counting at less than one meter. MRI brains, detailed vasculitis profile, serum angiotensin converting enzyme [ACE] inhibitor level, and X-ray chests were normal in all patients. The CSF for oligoclonal band was also negative. All patients received pulse therapy with methylprednisolone 1 gm daily for three days followed by two weeks oral taper. Most patients improved after first episode but there was partial recovery after the second and subsequent episodes. Only one patient had complete loss of vision in one eye. Two patients received long term oral steroids and azathioprine with prevention of further relapses. One patient received beta interferonwith complete remission so far. One patient received cyclosporine and oral steroids with remission for 6 years but subsequently relapsed after immunotherapy was discontinued. Chronic relapsing inflammatory optic neuropathy [CRION] should be considered in patients with history of recurrent optic neuritis after exclusion of acquired demyelinating disorders, and systemic collagen vascular or granulomatous diseases