MRS in the differential diagnosis of tremors

By the time Parkinson 's disease [PD] symptoms appear, the substantia nigra [SN] already has lost about 60% of dopaminergic neurons. So, with the advent of neuroprotective agents that could slow or prevent disease progression, it reinforces the need to define at-risk patients so that such a disease-modifying therapy could be initiated before the development of clinical dysfunction. However, there is a real clinical diagnostic problem in the differentiation between PD and essential tremor [ET] in the early stages of both disorders. To investigate the use of proton magnetic resonance spectroscopy [[1]H-MRS] as an objective diagnostic index in the differential diagnosis of PD from ET in the early stages of both disorders. This was a cross sectional study in which 20 patients with PD meeting the United Kingdom Brain Bank criteria for the diagnosis of idiopathic PD were recruited. They were Hoen and Yahr stage I to II. In addition, 20 patients with ET meeting the diagnostic criteria were also recruited. All patients underwent a routine MRI brain to exclude underlying pathology. Brain [1]H MRS was performed. The spectroscopic volume of interest was placed in the putamen, the temporal, and the cerebellar cortices. The metabolite ratios NAA/Cr NAA/Cho and Cho/Cr were determined. It was found that in comparison to the ET group, the PD group had significantly lower NAA/Cho ratio and higher Cho/Cr ratio in the putamen, and lower NAA/Cr and NAA/Cho ratios in the temporal region. On the other hand, ET group had significantly lower NAA/Cr and NAA/Cho ratios in the cerebellum than the PD group. The current study protocol that includes muti-regional [1]H-MRS assessment of the putamen, temperoparietal, and cerebellar cortices proved to be of considerable value in the differential diagnosis between PD and ET in the early stages of both disorders

Benign acute myositis in association with acute dengue viruses' infections

Dengue is the most common and widespread arthropod-born arboviral infection in the world today. Early diagnosis and prompt management would help prevent evolution into the more devastating sequelae with hemorrhagic manifestations and dengue shock syndrome. However, the diagnosis of dengue fever in the early febrile phase with undifferentiated symptoms and signs is difficult. The frequent observation of myalgia [sometimes severe] and increased serum CK in patients with dengue fever attending our hospital inspired us the idea of this study. To study myositis associated with dengue viruses' infections. Also, to study if the elevated serum CK levels in the early febrile phase among suspect cases with acute dengue viruses' infections has value in the early diagnosis of dengue fever. This was a prospective study that was carried out on all cases of dengue fever and dengue hemorrhagic fever presented to Hay Aljamea Hospital, Jeddah, Saudi Arabia from January 2006 till December 2006. All clinics in the hospital were alerted and asked to report suspected cases of dengue viruses' infections according to the WHO 1997's case definition. Paired serum samples were collected from 525 patients and MAC-ELIZA was done on them. Patients with positive serological tests for acute dengue viruses' infections were re-examined by the investigators and thorough neurological assessment and EMG studies were performed. Serological tests were positive for acute dengue viruses' infections in 101 patients. One hundred nine patients had elevated serum CK levels in the first serum samples. Among them, 47 patients had acute dengue viruses' infection by testing the first serum sample. The number increased to 92 patients by testing the second serum sample. This gives the elevated CK levels among febrile patients with suspected criteria of acute dengue viruses' infection according to the case definition mentioned above, a positive predictive value of 84% and a negative predictive value of 98% in the diagnosis of dengue fever. If the criteria of patients suspected to have dengue fever had been narrowed to only include those who have elevated CK levels, the pre-test probability for the diagnosis of acute dengue viruses' infection would have been 92.7%. Myalgia was found in 64 patients [63.4%]. However, it was severe in 12 patients only. Mild proximal muscle weakness especially in the lower limbs was found in only three patients and they recovered completely before discharge. Nerve conduction studies were normal in all the patients. EMG showed features of muscle hyperirritabilities in 4 patients only; 3 of them had muscle weakness. Benign acute myositis is a very common manifestation in association with dengue viruses' infection. Serum CK level should be checked in every patient suspected to have dengue fever in the febrile phase and be used as a diagnostic marker till the serology results for dengue viruses are available

Role of high-resolution sonography in the diagnosis of carpal tunnel syndrome in patients with normal electrodiagnostic studies

Diagnosis of carpal tunnel syndrome [CIS] is based on a combination of symptoms, clinical signs, and abnormal electrodiagnostic [EDX] studies. Although EDX studies are highly specific, however, they have a substantial false-negative rate of between 10% and 20%. High-resolution ultrasonography [US] has received increased attention in the evaluation of CIS. The aim of this study was to prospectively evaluate the accuracy of sonography for the diagnosis of CTS in patients who were clinically suspected of having the disease and have normal EDX studies. This was a prospective cross sectional study. Patients were enrolled in the study if they had the signs and typical history of carpal tunnel syndrome. They were classified into 2 groups: group I [30 patients, 42 hands]: EDX confirmed CTS, group II [30 patients, 39 hands]: normal EDX studies. Also a normal control group [group III] was included [20 volunteers, 40 hands]. All patients underwent standardized EDX studies then sonographic examinations were performed within 2 days. Transverse images of the median nerve were obtained at three levels: proximal to the tunnel, at the level of the pisiform bone and at the level of the hook of the hamate. Then the transverse and anteroposterior diameters were measured and the flattening ratio and the cross sectional area were calculated. The sonographic findings [except for the flattening ratio] had significant differences among the three groups at the level of the pisiform bone only. Using one way analysis of variance, the cross sectional area showed the greatest differences between the three groups. The significant differences were mainly between group III and both group I and II [p < 0.001]. The difference between group I and II was less, but still was also highly significant [P < 0.01]. There was a highly significant positive correlation between the EDX diagnosis of CTS and the cross sectional area [p < 0.001]. A cutoff of 9.89 mm[2] of the cross sectional area that was extrapolated from the receiver operating characteristics curve was found to be highly diagnostic for CTS with sensitivity, and specificity of 100% and 80% respectively. The higher mean amplitude of the sensory nerve action potentials of group II patients was the only significant EDX variance that differentiated this group from the normal control group. In patients with clinical diagnosis of CTS, high resolution sonography is an efficient complementary test to EDX when the latter is normal. These patients have similar sonographic findings to patients with EDX confirmed CTS, suggesting that they also have similar pathology. A cross sectional area of the median nerve at the pisiform bone of >/= 9.89 mm[2] was found highly diagnostic for CTS. It is also concluded that EDX normal CTS patients are mostly patients with dense sensory innervation that might have lead to low pain threshold and buffered the electrophysiological consequences of nerve entrapment in its early stages

Treatment of hypertension in acute ischemic stroke

There has been substantial controversy regarding treatment of blood pressure in the management of acute ischemic stroke. Non-Uniformity of study design and reporting makes it difficult to draw conclusions from previous data. When to treat hypertension in the acute setting is one of the unsettled questions yet. To study stroke outcome in relation to treatment of hypertension in the management of acute ischemic stroke and its impact on the cardiovascular system. This was a prospective study in which all admitted patients for acute ischemic stroke within 24 hours throughout the year 2006 were included. The severity of the stroke was based on the National Institutes of Health Stroke Scale [NIHSS]. The 2005 AHA/ASA guidelines in the management of acute ischemic stroke were followed. We also followed the same guidelines in the treatment of hypertension in adults with acute ischemic stroke in the first 24 hours. However, patients who continued to have hypertension grade II and III after the first 24 hours were also treated. A total of 356 patients were initially included and managed in the acute phase. Only 241 completed the study and attended the clinics for their follow up assessment at 3 months. The majority were males [76%], preexisting hypertension was found in 68.9% and most of the patients had hypertension on admission [87.5%]. In 223 patients [92.53%] no antihypertensive medication was given in the 1[st] 24 hours. In 134 patients [55.6%] the blood pressure continued to be on the hypertensive side after the first 24 hours and they received antihypertensive medications. The 223 patients [92.53%] who did not receive antihypertensive treatment achieved 57.1%, 78.09% and 73.87% of the total reduction in SBP, DBP and MBP respectively at the end of the 1[st] 24 hours. All cardiac complications [ten patients, 4.15%] were reported in the first 24 hours only. The mean NIHSS score on admission was 22.98 +/- 10.38, while the mean score at the 3[rd] month was 9.4 +/- 6.5. The differences were highly significant [p<0.0001]. When the stepwise regression analysis was used, only the increase in stroke severity at the onset [p<0.0001], followed by the decrease in SBP at the 3[rd] day [p<0.001] and lastly the increase in SBP on admission [p<0.05] were predictive for poor stroke outcome. Introducing antihypertensive medications after the first 24 hours of acute ischemic stroke in patients who continued to have hypertension grade II and III has no negative impact on stroke outcome and limits the cardiovascular complications

Cognitive impairment in patients with heart failure: the role of the inflammatory cytokines

Increasing age and lower indices of left ventricular function were associated with worsening cognitive performance in patients with congestive heart failure [CHF]. However, patients with CHF have also evidence of inflammatory cytokine activation which recently, has also been associated with cognitive disorders and dementia. The aim of this study was to investigate the relationship between inflammatory cytokine levels and cognition in patients with CHF. This was a prospective cross sectional study done on 40 consecutive patients with CHF. New York heart association [NYHA] criteria were used to evaluate the degree of heart failure. Accordingly the patients were classified into two groups, group A [20 patients] included NYHA class I and II, and group B [20 patients] included NYHA class III and IV. Cognitive function was assessed using the Hodkinson Abbreviated Mental Test [AMT]. Serum IL-6 and TNF- ? were measured. the serum levels of IL-6 and TNF-? were significantly higher in group B than in group A. Bivariate correlation analysis revealed the presence significant negative correlations between AMT scores and the serum levels of IL-6 and TNF-? and there were significant positive correlations between the AMT scores and the LVEF and systolic blood pressure. However, stepwise linear regression analysis showed that only the serum IL-6 level could significantly predict the AMT scores. [AMT score =11.839 ?0.439_ serum IL-6]. The current study showed that patients with heart failure had cognitive impairment that worsened with the severity of heart failure. It also showed that the serum levels of IL-6 and TNF-? were significantly elevated in severe cases with heart failure [NYHA classification III and IV] more than in milder cases [NYHA classification I and II]. Both cytokine levels were negatively correlated with the cognitive impairment, however, only serum IL-6 levels could predict the degree of cognitive impairment in patients with heart failure

Seroprevalence of herpes simplex and Varicella zoster virus among diabetic and non-diabetic patients with acute peripheral facial palsy

The aim was to study the prevalence of herpes simplex virus [HSV] and varicella zoster virus [VZV] seropositive patients among diabetic patients with acute peripheral facial paralysis [APFP] as compared to non-diabetics with APFP and a healthy control group. Participants consisted of 40 diabetic patients and 40 non-diabetic patients with APFP from Hai Al-Jamea Hospital, Jeddah, Kingdom of Saudi Arabia studied over a period from July 2000 to December 2001. In addition, 20 age and sex matched healthy volunteers were included as a control group. Paired sera were obtained from all participants within the first 4 days of the illness [acute phase] and 2-3 weeks later [convalescent phase]. Paired sera were also obtained from the control group within an equivalent period. Detection of immunoglobulin [Ig] M and IgG class antibodies to HSV and VZV in these sera was carried out using enzyme-linked immunosorbent assays kits. The demonstration of IgM antibodies, 2-fold elevations of IgG antibodies or both was considered positive evidence for virus infection. The present study has shown that there was no statistically significant difference in the prevalence of HSV-seropositive patients in the diabetic and non-diabetic patients with Bell's palsy; however, it was significantly higher in both groups than in the healthy control group. There were no statistically significant differences in the prevalence of VZV-seropositive patients among the 3 groups. The significantly high prevalence of HSV-seropositive patients among the diabetic as well as the non-diabetic patients with Bell's palsy suggests an equally important role of HSV infection in the pathogenesis of Bell's palsy in the diabetic as in the non-diabetic patients