Manejo del estado epiléptico en niños: encuesta en hospitales pediátricos de la Ciudad Autónoma de Buenos Aires / Management of status epilepticus in childhood: a survey conducted at pediatric hospitals in the City of Buenos Aires

Introducción. El estado epiléptico constituye la emergencia neurológica más frecuente. Si bien la mortalidad en niños es baja, su morbilidad puede superar el 20 %. Objetivo. Conocer las pautas de manejo del estado epiléptico referidas por médicos pediatras que atienden esta patología en forma habitual. Población y métodos. Estudio descriptivo, transversal, basado en una encuesta a médicos de tres hospitales pediátricos monovalentes de gestión pública de la Ciudad Autónoma de Buenos Aires. Resultados. Se administraron 292 encuestas (la tasa de respuesta completa alcanzó el 86 %); el 77 % se administró a pediatras y el 16 %, a especialistas en cuidados intensivos. Un 47 % de los participantes refiere indicar la primera benzodiacepina en el tiempo correcto; el 56 % utilizar diazepam intrarrectal en ausencia de un acceso intravenoso; el 95 % elige lorazepam como benzodiacepina inicial en caso de contar con acceso intravenoso; el 58 % refiere iniciar la etapa de fármacos de segunda línea en tiempo adecuado; el 84 % opta por fenitoína como fármaco inicial de segunda línea, un 33 % no cronometra el tiempo durante el tratamiento. La adherencia global a las recomendaciones internacionales fue del 17 %. Conclusiones. Nuestro estudio advierte una baja adherencia referida de los pediatras a las guías internacionales, en particular en las decisiones tiempo-dependientes. También se observó mayor heterogeneidad en las conductas terapéuticas a medida que se avanza en el algoritmo de tratamiento.

Introduction. Status epilepticus is the most common neurological emergency. Although mortality in children is low, morbidity may exceed 20%. Objective. To evaluate the management of status epilepticus by pediatricians who usually treat this condition. Population and methods. Descriptive, cross-sectional study based on a survey administered to physicians from 3 pediatric hospitals in the City of Buenos Aires. Results. A total of 292 surveys were administered (complete response rate as high as 86%); 77% were administered to pediatricians and 16% to intensive care specialists. Forty-seven percent of the participants reported that they administer the first dose of a benzodiazepine within the correct timeframe; 56% use intrarectal diazepam when intravenous access is not available; 95% choose lorazepam as the initial benzodiazepine if an intravenous access is available; 58% initiate the administration of a second-line drug within the correct timeframe; 84% administer phenytoin as the first-choice, second-line drug; and 33% do not measure treatment time. Overall adherence to international recommendations was 17%. Conclusions. Our study highlights poor adherence of pediatricians to international guidelines, particularly in time-dependent decisions. Greater heterogeneity was observed in treatment approaches as the treatment algorithm progressed.

Produção de fumo e insônia: relato de caso sobre os determinantes socioeconômicos para o uso contínuo de benzodiazepínicos em uma zona rural no Sul do Brasil / Tobacco production and insomnia: case report on socioeconomic determinants of the continuous use of benzodiazepines in a rural area in southern Brazil / Producción de tabaco e insomnio: Reporte de caso sobre determinantes socioeconómicos del uso continuo de benzodiacepinas en una zona rural del sur de Brasil

Introdução: A fumicultura concentra-se sobretudo em áreas rurais do Sul do país. Reconhecidamente, as áreas rurais apresentam disparidades socioeconômicas, desigualdades no acesso geográfico, bem como dificuldade de retenção de profissionais na Atenção Primária à Saúde (APS). Apresentação do caso: Descrevem-se, neste artigo, as intersecções de determinantes socioeconômicos de saúde ao se abordar um paciente masculino, de 57 anos, em uso crônico de benzodiazepínicos para o tratamento de insônia. Ao se aprofundar a anamnese, os determinantes socioeconômicos que levaram ao desenvolvimento da insônia foram identificados como: dificuldades financeiras na produção de tabaco, preocupações excessivas com o trabalho e presença de depressão como comorbidade. Nesse sentido, ser produtor de tabaco e a relação com a empresa podem ser considerados determinantes socioeconômicos da saúde para o desenvolvimento de insônia. Conclusões: No contexto deste caso, a rotatividade de profissionais e a falta de criação de vínculo fez com que o paciente permanecesse cronicamente a tratar a insônia como benzodiazepínico, o que é proscrito. Assim, revelam-se a fragmentação do cuidado e a alta rotatividade de profissionais como determinantes socioeconômicos da saúde.

Introduction: Tobacco production is mainly concentrated in rural areas of the southern region of the country. Rural areas present socioeconomic disparities, inequalities in geographic access, and difficulties in retaining professionals in primary care. Mental health problems, such as insomnia, are common in clinical practice. Case presentation: This article describes the intersections of the social determinants of health when approaching a patient with chronic use of benzodiazepines for treatment of insomnia. By delving deep into anamnesis, the socioeconomic determinants that led to the development of insomnia were identified as: financial trouble with tobacco production, excessive concern about work and presence of depression as comorbidity. Conclusions: In this context, the turnover of health professionals and lack of doctor-patient relationship meant that the patient continued using benzodiazepines, which are not recommended for long-term treatment. Therefore, fragmented care and high professional turnover stand out as socioeconomic determinants of health.

Introducción: La producción de tabaco se concentra principalmente en las zonas rurales del sur del país. Se reconoce que las zonas rurales presentan desigualdades socioeconómicas, desigualdades en el acceso geográfico, así como dificultad para retener profesionales en Atención Primaria de Salud (APS). Los problemas de salud mental como el insomnio son comunes en la práctica clínica. Presentación de caso: Este artículo describe las intersecciones de los determinantes socioeconómicos de la salud al abordar a un paciente uso crónico de benzodiazepinas para el tratamiento del insomnio. Al profundizar la anamnesis, se identificaron los determinantes socioeconómicos que llevaron al desarrollo del insomnio como: dificultades económicas en la producción de tabaco, excesiva preocupación por el trabajo y la presencia de depresión como comorbilidad. En este sentido, ser productor de tabaco y la relación con la empresa pueden considerarse determinantes socioeconómicos de la salud para el desarrollo del insomnio. Conclusiones: En el contexto de este caso, la rotación de profesionales y la falta de vinculación hicieron que el paciente continuara crónicamente tratando el insomnio como una benzodiazepina, lo que no es recomendable. Así, la fragmentación de la atención y la alta rotación profesional se evidencia como un determinante socioeconómico de la salud.

Síndrome de la persona rígida / Stiff-man syndrome

El síndrome de la persona rígida es un trastorno neurológico infrecuente y desconcertante, caracterizado por contractura progresiva, rigidez y espasmos dolorosos que afectan la musculatura axial, lo que imposibilita la deambulación del paciente. Se presenta un paciente masculino de 22 años de edad con manifestaciones clínicas y electromiográficas compatibles con esta entidad nosológica. El tratamiento descrito para la enfermedad no produjo mejoría de los síntomas. Con respecto a los casos descritos en la literatura científica, es el primer paciente con diagnóstico de síndrome de la persona rígida que ha recibido una dosis de diazepam de 500 mg diarios por vía oral sin efectos adversos y una dosis en bolo de propofol de 800 mg para lograr la relajación muscular(AU)

Stiff-Man Syndrome is an uncommon and disturbing neurological disorder characterized by progressive contracture, stiffness and painful spasms that affect the axial musculature, making it impossible for the patient to walk around. We present a 22-year-old male patient with clinical and electromyographic manifestations compatible with this nosological disease. The treatment described for the disease did not produce an improvement in symptoms. Regarding the cases described in the scientific literature, this is the first patient diagnosed with Stiff-Man Syndrome who has received a dose of diazepam of 500 mg daily orally without adverse effects and a bolus dose of 800 mg of propofol to achieve muscle relaxation(AU)

Equivalencia terapéutica de tabletas de diazepam dispensadas en la ciudad de Ica, Perú / Therapeutic equivalency of tablets of diazepam dispended in the city of Ica, Peru

Objetivos: Determinar la equivalencia terapéutica in vitro de tres formulaciones de diazepam 10 mg tabletas, para establecer su intercambiabilidad con el medicamento de referencia original. Material y métodos: Estudio descriptivo, comparativo, realizado en junio del 2010, utilizando tres medicamentos genéricos dispensados en la ciudad de Ica y el medicamento original de referencia: Diazepam (Valium®) de laboratorios Roche. Se determinaron los perfiles de disolución efectuados en medios similares a pH fisiológicos del organismo según lo señalado por la OMS (Reporte Técnico 937). Para establecer la equivalencia terapéutica se empleó el factor de similitud (f2), considerando que dos formulaciones son equivalentes terapéuticos in vitro si los valores están comprendidos entre 50 y 100. Resultados: Los medicamentos evaluados presentaron a pH 1,2 una disolución muy rápida, sin embargo las tres formulaciones de prueba y el de referencia presentaron a pH 4,5 y pH 6,8 una disolución lenta con valores f2 a pH 4,5: Genérico A (f2 = 76,0); Genérico B (f2 = 68,9); Genérico C (f2 = 30,5); y a pH 6,8: Genérico A (f2 = 60,6); Genérico B (f2 = 78,2); Genérico C (f2 =20,4). Conclusiones: Según los valores f2 encontrados para las tres formulaciones de diazepam el medicamento genérico C (genérico nacional) no es equivalente al medicamento de referencia dado que no se pudo demostrar su intercambiabilidad, la que si se logró establecer para los medicamentos genéricos A y B.

Objectives: To determine the in-vitro therapeutic equivalence of three formulations of diazepam in tablets of 10mg to establish their interchangeability with the original brand name product. Methods: Descriptive and comparative study performed in September 2010 using three generic presentations dispended in the city of Ica compared to the original brand name product Diazepam (Valium®) from Roche Pharmaceutical Laboratories. We determined the dissolution profiles performed in similar media at physiologic pH based on WHO recommendations (Technical report 937). To establish therapeutic equivalence, we used the similarity factor (f2) and considered therapeutic equivalence if values were between 50 and 100. Results: All presentations had a very rapid dissolution at pH=1.2. However, the three generic presentations and the brand name product had slower dissolutions with f2 values at pH=4.5 of 76.0 for Generic A; 68.9 for Generic B; and 30.5 for Generic C, and f2 values at pH=6.8 of 60.6 for Generic A; 78.2 for Generic B and 20.4 for Generic C, respectively. Conclusions: Based on the f2 values found for the three generic presentations of diazepam, only the generic C presentation was not equivalent compared to the brand name product.

Analgesic efficacy of diazepam and placebo in patients with temporomandibular disorders: A double blind randomized clinical trial.

Aim: The aim of the study was to evaluate and compare the analgesic efficacy of placebo and diazepam in patients with temporomandibular disorder. Materials and Methods: Thirty-five patients were recruited with a diagnosis of temporomandibular disorder based on standard clinical diagnostic criteria for temporomandibular disorder. The patients were put in to one of the two groups: placebo or diazepam at random. The average pain intensity was recorded with visual analog scale (VAS) at pretreatment, at weekly interval till the completion of a three-week trial and at post-treatment visit on the eighth week from baseline. The secondary outcome measures were changes in masticatory muscle tenderness, viz. massater muscle, lateral pterygoid muscle, medial pterygoid muscle and temporalis muscle and changes in mouth opening. Statistical Analysis: Intra-group comparison for analgesic efficacy and mouth opening was carried out by Wilcoxon's signed ranked test. Inter-group comparison for analgesic efficacy was also carried out using Mann-Whitney's test. Results: A statistically significant (P<0.01) decrease in temporomandibular disorder pain in the placebo group (65%) and statistically highly significant (P<0.001) decrease in the diazepam group (72%) were observed on VAS after three weeks of treatment. The inter-group comparison demonstrated no statistically significant difference between the groups. Conclusion: This study suggests that the placebo can give near similar results as diazepam can. So the role of placebo should also be considered as one of the important management strategies. In the short term, reduction in the masticatory muscle tenderness and significant improvement in the mouth opening in both the groups were observed.

Early Resolution of Convergence Spasms Following the Addition of Antipsychotic Medications

We report a case of early resolution of convergence spasms following the addition of antipsychotic medications and present it as a possible alternative to the conventional treatment for convergence spasms. The cessation of atropinization of the eyes and the use of reading glasses was achieved after only 2 months following the initiation of antipsychotic medications for childhood emotional disorder.

Avaliação clínica da ansiedade e dos parâmetros cardiovasculares com o uso de ansiolítico no préoperatório em cirurgia bucomaxilofacial / Comparative study of bone response guided tissue regeneration clinical evaluation of the anxiety and cardiovascular parameters with the use of anxiolitic in the pre-operative in bucomaxilofacial surgery

A ansiedade frente ao tratamento odontológico é um fenômeno comum e geralmente inicia-se na infância ou adolescência. A reversão desse quadro requer intervenções não medicamentosas e medicamentosas, ambas com o intuito de reduzir o estresse e a ansiedade. Os benzodiazepínicos são os fármacos mais utilizados na sedação consciente oral do paciente odontológico. Com o intuito de verificar a efetividade dos ansiolíticos na cirurgia bucal. o presente trabalho tem como objetivo avaliar clinicamente sua ação no pré-operatório, comparando-a com um placebo, em um mesmo paciente, observando os níveis de ansiedade e os parâmetros. Foram incluídos 30 pacientes de ambos os gêneros, entre 18 e 30 anos, nos quais havia a indicação de remoção cirúrgica dos terceiros molares retidos, totalizando 60 procedimentos cirúrgicos. Os pacientes foram divididos em dois grupos experimentais. Concluiu-se que: (a) com relação a ansiedade, não houve diferença estatística entre os dois grupos, no pré-operatório, embora possa ser considerado clinicamente benéfico para os dois grupos; (b) o ansiolítico foi eficiente na redução da pressão sistólica dos pacientes do grupo 1, na sala de espera e após a anestesia na primeira intervenção, assim como da pressão diastólica no pós-cirúrgico do grupo 2, na segunda intervenção; e (c) embora não fosse objetivo deste trabalho analisar a experiência prévia odontológica, notou-se que a mesma contribuiu para a redução dos níveis de ansiedade dos pacientes.

Anxiety dealt in odontological treatment is a regular phenomenon and most often start in childhood or adolescence. Reversion of this picture requires interventions, such as behavioral techniques and medicamental treatment, both of them aiming to reduce stress and anxiety. Benzodiazepines are the most used medicines in pharmacological intervention for oral conscious sedation. This work aims to evaluate anxiolytic effectiveness when administered for the preoperative in oral surgery, compared to placebo, in the same patient, and analyses the anxiety levels and cardiovascular parameters. We evaluated 30 subjects of both genders in this research (18-30 years old), for whom both third molar removal surgeries were recommended, for a total of 60 surgical procedures. Subjects were divided into two experimental groups. We were able to verify: (a) the anxiolytic use was not statistically significant in pre-operative for anxiety, although it was clinically benefic for both groups; (b) anxiolytic was efficient in reducing sistolyc pressure in group 1 patients, at first intervention trans-operative and diastolic pressure in group 2, at second intervention pos-operative; and (c) although we did not mean to analyse previous dental surgery experience, we noticed that it contributed to reduce patient’s anxiety levels.

Guidelines for diagnosis and management of childhood epilepsy.

Justification: Seizures constitute the most common neurological problem in children and the majority of epilepsy has its onset in childhood. Appropriate diagnosis and management of childhood epilepsy is essential to improve quality of life in these children. Evidence-based clinical practice guidelines, modified to the Indian setting by a panel of experts, are not available. Process: The Indian Academy of Pediatrics organized a consensus meeting on the diagnosis and management of childhood epilepsy on 22-23 of July 2006 at Mumbai. An expert committee was formed consisting of pediatricians, pediatric epileptologists, pediatric and adult neurologists, electrophysiologists, neuroradiologists, neurosurgeons and intensivists. A consensus was reached during the discussion that followed presentation by each of these experts. The process of updating these recommendations and arriving at consensus continued till 2009. Objectives: To develop practice guidelines for diagnosis and management of childhood epilepsy. Recommendations: Recommendations for diagnosis and management of following childhood seizures and epilepsies are given: neonatal seizures, acute symptomatic seizures, neurocysticercosis, febrile seizures, idiopathic partial and generalized epilepsies, first unprovoked seizure, newly diagnosed epilepsy, catastrophic epilepsies of infancy, refractory epilepsies of older children and adolescents, epilepsy with cognitive deterioration and status epilepticus.

Chronic use of diazepam in primary healthcare centers: user profile and usage pattern

CONTEXT AND OBJECTIVE: Chronic use of benzodiazepines is frequent in general practice. The aim of this study was to describe the usage pattern and profile of chronic users of diazepam who had been consuming this drug for a minimum of thirty-six months continuously. DESIGN AND SETTING: This was a descriptive study (survey and clinical assessment) at five primary healthcare centers in Campinas, Brazil. METHODS: Psychotropic drug control books revealed 48 eligible patients. Among these, 41 were assessed by means of the Schedule for Clinical Assessment in Neuropsychiatry (SCAN), the Hospital Anxiety and Depression scale (HAD) and a questionnaire on usage pattern. RESULTS: Most patients were women (85.4 percent). The patients' mean age was 57.6 years, and they were from the social strata C (39 percent), D (54 percent) and E (7 percent). The mean length of diazepam consumption was 10 years. The patients presented a lack of prescription compliance and had made frustrated attempts to stop using the drug. 55.5 percent said their doctor had never given any guidance on the effects of the drug. According to SCAN, 25 patients (61 percent) suffered from depressive disorders; only 12 cases of benzodiazepine dependence were detected by this instrument. CONCLUSION: There is a need to improve the detection and treatment of mental disorders, as well as to prevent inappropriate prescription and use of benzodiazepines. Diazepam dependence has distinctive characteristics that make it undetected by SCAN.

CONTEXTO E OBJETIVO: O uso crônico de benzodiazepínicos é freqüente. O objetivo deste estudo foi descrever o padrão de uso e o perfil dos usuários crônicos de diazepam (uso contínuo por no mínimo 36 meses) atendidos em unidades básicas de saúde. TIPO DE ESTUDO E LOCAL: Estudo descritivo, com inquérito e avaliação clínica padronizada, realizado em cinco unidades básicas de saúde de Campinas, São Paulo. MÉTODO: Os livros de controle de dispensa de psicofármacos revelaram 48 pacientes elegíveis, 41 dos quais foram avaliados por meio do Schedule for Clinical Assessment in Neuropsychiatry (SCAN), pela escala Hospital Anxiety and Depression (HAD) e de um questionário sobre padrão de uso. RESULTADOS: A maioria dos usuários era de mulheres (85,4 por cento), com média de idade de 57,6 anos, pertencentes aos estratos socioeconômicos C (39 por cento), D (54 por cento) e E (7 por cento). O tempo médio de uso de diazepam foi de 10 anos. Havia inobservância em relação à forma aconselhada de se utilizar o diazepam, bem como tentativas frustradas de parar a medicação. 55.5 por cento afirmaram que não receberam orientações de seus médicos sobre os efeitos do medicamento. De acordo com o SCAN, 25 pacientes (61 por cento) sofriam de depressão; apenas 12 casos de dependência a benzodiazepinas foram detectados por tal instrumento. CONCLUSÃO: São necessárias medidas que possam aprimorar a detecção e tratamento de transtornos mentais, assim como prevenir a prescrição e uso inadequado de benzodiazepinas. A dependência de bezodiazepínicos tem características que a difereciam de outras dependências químicas e não é detectada pelo SCAN.

Funny turns in an elderly man

A 74-year old man presented with recurrent attacks of altered sensorium, sometimes with abrupt falls, against the background of a long history of chronic obstructive airways disease and ischaemic heart disease. Investigations revealed evidence of significant cardiac conduction abnormalities and this led to the insertion of a permanent pacemaker. However, he continued to have recurrent 'syncopal'attacks. He was hospitalized to clarify the nature and aetiology of these attacks. Multiple stereotyped events were observed by different medical personnel, lasting up to two hours in duration. An attack was terminated by the administration of intravenous diazepam. Subsequent initiation of anti-epileptic drugs led to the complete abolition of these episodes. He has remained event-free since then ie two years. Because of multiple co-morbidities, the elderly present a greater diagnostic challenge in the evaluation of paroxysmal alterations in sensorium. It is essential that epilepsy, particularly with non-convulsive seizures, be included in the differential diagnosis whenever evaluating these patients.

Eclampsia : before and after magnesium sulphate.

This study was done to see the incidence and impact of changes in the intervention strategy for the management of eclampsia in a maternity hospital on maternal and perinatal outcome. Analysis of case records of all eclampsia cases over two different study periods designated as study period A (April, 1994 to Oct, 1996) and study period B (April, 2000 to April, 2001) were done. Total number of eclampsia cases who received intervention over two different study period (46 in study period A and 47 in study period B) were comparable despite the difference in the duration of study period. During study period A, diazepam was used as anticonvulsant, whereas magnesium sulphate was used to control fits during study period B. Incidence of eclampsia has markedly increased in this hospital (0.12% vs 0.29%). Epidemiology and clinical profile of eclamptic patients do not show remarkable change. There was no maternal death in study period B (April, 2000 to April, 2001) whereas there was one maternal death in the study period A (April, 1994 to October, 1996). Marked improvement was noticed in terms of recurrence of fit (19.13% vs 73.91%) with change in the intervention strategy. Perinatal deaths were fewer in study period B (20% vs 33%). Overall, it seems that care of eclamptic patients and use of magnesium sulphate as anticonvulsant has resulted in positive impact on maternal outcome.

Effect of 7-nitroindazole alone and in combination with phenobarbitone and diazepam on picrotoxin-induced convulsions in rats.

There are no reports on the effect of 7-nitroindazole (7-NI) on chemically-induced convulsions. Hence, in the present study, its (100 and 200 mg/kg) action was tested alone and in combination with phenobarbitone (20 mg/kg) and diazepam (0.25 mg/kg) on picrotoxin (PCT)-induced convulsions in rats. The changes produced by 7-NI on nitric oxide synthase (NOS) activity and nitric oxide (NO) concentration were determined in the brain. The effect of 7-NI was tested in L-arginine (1000 mg/kg) pretreated (30 min) animals. The smaller dose (100 mg/kg) of 7-NI did not alter NOS activity and NO concentration, but inhibited PCT-induced convulsions indicating that its anticonvulsant action was devoid of an involvement of NO. But, an inhibition of NOS activity, by a larger (200 mg/kg) dose of it, resulted in a promotion of the convulsant action of PCT and in an impairment of the anticonvulsant effect of both phenobarbitone and diazepam. The proconvulsant action of 7-NI was reverted by L-arginine. These results suggest that 100 and 200 mg/kg of 7-NI produce distinguishable action on PCT-induced convulsions because NOS activity is inhibited by 200 mg/kg and not by 100 mg/kg of it. The results further suggest that NO acts as anticonvulsant and that the NOS inhibitors, like 7-NI, cannot be used as an anticonvulsant either alone or in combination with other anticonvulsants.

Assessment of cardiovascular parameters during dental procedures under the effect of benzodiazepines: a double blind study

A finalidade desse estudo foi avaliar os parâmetros cardiocirculatórios, pressão arterial sistólica, diastólica e média e freqüência cardíaca, durante procedimentos clínicos odontológicos. Dezenove pacientes, com idade entre 18 e 56 anos, normotensos, receberam tratamento restaurador em 3 dentes molares superiores. Foram monitorados nos períodos pré, trans e pós-operatórios, para a pressão arterial e freqüência cardíaca, de modo contínuo, a cada minuto. Os valores dos parâmetros foram obtidos nas fases: 15 minutos antes da anestesia; durante a anestesia tópica; durante a anestesia; por 5 minutos após; durante o preparo cavitário; durante o procedimento restaurador; por 10 minutos após o término. Os pacientes foram divididos em 3 grupos: A (sem pré-medicação); B (precedidos de diazepam - 10 mg) e C (precedidos de placebo). Todos receberam anestesia infiltrativa, contendo 1,8 mL de xilocaina (36 mg de lidocaina a 2 por cento mais 18 µg de epinefrina 1:100.000). Não foram encontradas alterações dos parâmetros cardiovasculares durante os procedimentos clínicos. Quando comparados entre si, os grupos apresentaram diferenças estatisticamente significantes na pressão arterial diastólica, durante a anestesia.

Paradoxical Therapy in Conversion Reaction

Paradoxical therapy consists of suggesting that the patient intentionally engages in the unwanted behaviour such as performing compulsive ritual or wanting a conversion attack. In this study, the subjects were selected by the emergency unit psychiatrist from patients who were admitted to the emergency unit with pseudoseizure. The diagnoses was based on DSM-IV criteria. Paradoxical intention was applied to half of the 30 patients with conversion disorders; the other half were treated with diazepam in order to examine the efficiency of the paradoxical intention versus diazepam. In both groups the differences of the anxiety scores at the beginning of the study were found to be insignificant (z=1.08, p=0.28). Of the 15 patients who completed paradoxical intention treatment, 14 (93.3%) responded favorably to paradoxical intention. On the other hand of 15 patients who completed diazepam therapy, 9 (60%) responded well to therapy and 6 patients carried on their conversion symptoms at the end of 6 weeks. Paradoxical intention-treated patients appeared to have greater improvements in anxiety scores (z=2.43, p<0.015) and conversion symptoms (t=2.27, p=0.034) than the diazepam-treated patients. The results of the present study are encouraging in that paradoxical intention can be effective in the treatment of conversion disorder.

Stiff person syndrome and myasthenia gravis.

Association of stiff person syndrome, an immune related disorder of anterior horn cells and myasthenia gravis an endplate disorder with similar pathogenesis, is rare. This communication documents this association in the Indian literature for the first time.

A Case of Maternal Tetanus in Korea

Tetanus is uncommon in Korea due to the introduction of vaccination programs and advances in public health. A case of maternal tetanus occurred on the 9 day postpartum in a 29-yr-old woman, who had not received a 10-yr-booster of tetanusdiphtheria toxoid after receiving the primary series of tetanus-toxoid-containing vaccine. There has hitherto been no reports on maternal tetanus in Korea. This case illustrates that tetanus remains a medical problem, principally among nonand underimmunized adults. The only way to fully prevent this disease is to ensure adequate immunization in all adults.

Seizures in the newborn.

Seizures in the newborn period constitute a medical emergency. Subtle seizures are mild paroxysmal alterations in motor or autonomic activity and are unique to the neonatal period. They are likely to be missed or confused with benign movements observed commonly in preterm children. Focal clonic seizures have a better prognosis as compared to myoclonic seizures for long-term neuro-developmental outcome. Seizures due to sub-arachnoid hemorrhage and late onset hypocalcemia carry a better prognosis as compared to seizures due to hypoglycemia, meningitis and cerebral malformations. Hypoglycemia and hypocalcemia are common causes and should be excluded in all neonates with seizures. Multiple etiologies can co-exist in neonatal seizures and a comprehensive approach for management of neonatal seizures has been described.