Repetitive transcranial magnetic stimulation in chronic tension-type headache: A pilot study

Background & objectives: Tension-type headache (TTH) is the most common type of primary headache disorder. Its chronic form is often the most ignored and challenging to treat. Transcranial magnetic stimulation (TMS) is a novel technique in the treatment of chronic pain. The aim of this pilot study was to explore the effect of low-frequency repetitive TMS (rTMS) on pain status in chronic TTH (CTTH) by subjective and objective pain assessment. Methods: Patients (n=30) diagnosed with CTTH were randomized into rTMS (n=15) and placebo (n=15) groups in this study. Pre-intervention detailed history of patients was taken. Numerical Rating Scale (NRS) for Pain and questionnaires [Headache Impact Test-6 (HIT-6), McGill Pain Questionnaire, Pain Beliefs Questionnaire, Coping Strategies Questionnaire, State-Trait Anxiety Inventory Test, Hamilton Rating Scale for Depression and WHO-Quality of Life Questionnaire-Brief version] were filled, and objective assessments such as nociceptive flexion reflex (NFR) and conditioned pain modulation were done. The tests were repeated after 20 sessions (5 days/week). In the rTMS group, 1200 pulses in eight trains of 150 pulses each were given at 1Hz over the right dorsolateral prefrontal cortex (RDLPFC). In the placebo group, the rTMS coil was placed such that magnetic stimulation did not reach the cortex. Results: The NRS score decreased significantly (P<0.001) and NFR thresholds increased significantly (P=0.011) in the rTMS group when compared to placebo group. Interpretation & conclusions: Subjective improvements in the NRS, HIT-6, McGill Present Pain Intensity, trait of anxiety and psychological pain beliefs were observed. The increase in the thresholds of NFR served as an objective marker for improvement in pain status. Further studies need to be done to confirm our preliminary findings.

Retinal nerve fiber layer and ganglion cell layer changes on optical coherence tomography in early multiple sclerosis and optic neuritis cases

Purpose: To study the retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) changes on optical coherence tomography in early multiple sclerosis (MS) patients. Methods: A prospective cohort study was conducted at a tertiary care center. Patients of early MS (expanded disability status scale <3) with or without optic neuritis (ON) and idiopathic ON were included. Twenty age-matched individuals were taken as controls. Changes in RNFL and GCL thickness were evaluated along with the correlation with visual function parameters such as visual acuity, contrast sensitivity, and visual evoked response at first visit and again at six months. Results: Forty-four patients of MS with or without ON (24 and 20 patients respectively), 29 patients with idiopathic ON, and 20 healthy controls constituted the cohorts. Mean LogMAR best-corrected visual acuity was found to be significantly reduced in all groups except fellow eyes (FE) of ON group. Mean values of average RNFL thickness and values in superior, temporal, and inferior quadrant were significantly reduced. Similarly, overall mean values of average GCL-inner plexiform layer (IPL) thickness and values in superior, superonasal, superotemporal, inferonasal, and inferotemporal quadrant were significantly reduced in all groups except FE of ON group (P < 0.05). All the visual parameters significantly correlated with GCL + IPL thickness. Conclusion: GCL + IPL thickness is a more sensitive clinical structural marker than RNFL in early MS with/without ON and ON patients and correlates with all the visual parameters better than RNFL thickness.

Can visceral leishmaniasis be eliminated from Asia?

Data on the burden of visceral leishmaniasis (VL) in Indian sub-continent are vital for elimination programme planners for estimating resource requirements, effective implementation and monitoring of elimination programme. In Indian sub-continent, about 200 million population is at risk of VL. Nearly 25,000-40,000 cases and 200-300 deaths are reported every year, but these are grossly underestimates. Recent well-designed multicentric studies identified VL burden of 21 cases/10,000 among sampled population in Indian sub-continent (Bangladesh, India and Nepal). This estimates 4,20,000 cases per 200 million risk population clearly indicating that the disease is highly under-reported. Chemical and environmental vector control studies show that the indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) are effective and significantly reduce sandfly densities. The findings documented from different sources revealed that some gaps and weakness in existing policies for introducing VL vector control interventions. Our studies emphasize the need of integrated vector management with both IRS and LLIN vector control interventions. Active case detection with rK39 strip test as diagnostic tool is the key element for detection of VL cases. The use of oral drug miltefosine for the treatment after assessing feasibility at community level is important. Kala-azar elimination in Indian sub-continent is possible if elimination programmes ensure access to health care and prevention of kala-azar for people at risk with particular attention to the poorest and marginalized groups. The evidence-based policy should be designed that motivates to implement the programmes, which will be cost-effective. Maintaining the acceptable level of incidence requires public awareness, vector control, appropriate diagnosis and treatment. The five pillars of VL elimination strategies identified are: early diagnosis and complete treatment; integrated vector management and vector surveillance; effective disease surveillance through passive and active case detection; social mobilization and building partnerships; and clinical and operational research which need to be re-enforced to effective implementation.

Prevalence of obesity and overweight in affluent adolescents from Ludhiana, Punjab.

The objective was to study the prevalence of obesity among adolescents in public schools of Ludhiana, catering to the affluent segment of population. We selected 1000 students from these schools by random, purposive sampling. Their anthropometry was taken. Students also filled-up a prevalidated questionnaire regarding dietary habits and lifestyle. Overweight/Obesity was defined using age and sex specific Body mass index (BMI) cut off points. Incidence of obesity was 3.4% and overweight was 12.7%. A significantly greater number of boys (15%) were overweight as compared to girls (10%).

Role of temporalis muscle over activity in chronic tension type headache: effect of yoga based management.

The role of central versus peripheral mechanisms has always been questioned while explaining the etiopathogenesis of chronic tension type headache (CTTH). The following study was done to study the role of muscle spasm in CTTH. 15 patients of CTTH and 7 age matched controls were included in the study and their m. temporalis EMG was recorded for one minute each during rest, mental activity and maximal voluntary contraction and subjective pain scoring was done by visual analogue scale. The results revealed significant overactivity of m.temporalis in CTTH patients at rest when compared with control subjects (P = 0.01 and 0.03 left and right side respectively). After respective interventions namely non steroidal anti inflammatory drugs, botulinum toxin injections and yogic life style course, the EMG records revealed decrease in the mean EMG amplitude of m. temporalis during rest and mental activity more significantly after yoga based interventions (P = 0.03) and subjective pain scores decreased from 7.00 +/- 2.10 to 2.00 +/- 1.26 (P = 0.02) supporting the beneficial effect of such non invasive techniques.

Hyperacute thrombolysis with IV rtPA of acute ischemic stroke: efficacy and safety profile of 54 patients at a tertiary referral center in a developing country.

BACKGROUND: Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries. Prothrombin time (PT), platelet count and activated partial thromboplastin time (aPTT) may not be feasible within the time window. AIM: To evaluate the safety and efficacy of thrombolysis in selected patients without the coagulation profile. DESIGN: Open, nonrandomized, observational study. MATERIALS AND METHODS: Fifty-four stroke patients were classified using TOAST criteria (large artery atherosclerotic = 13; cardioembolic = 12; small vessel occlusion = 22; other determined etiology =three; undetermined etiology = four). The mean time to reach emergency was 2.4h (1.15-3.4), the mean door to CT, 24 min (10-47) and the door to recombinant tissue plasminogen activator (r-tPA) injection, 26.8 min (25-67). The NIHSS scores ranged from 11 to 22 (mean = 15.5 +/- 2.7). Patients with history of liver or renal disease or those on anticoagulants were excluded. The PT, aPTT and platelet count were not done. Recombinant tissue plasminogen activator was administered at a dosage of 0.9 mg/Kg. RESULTS: Thirty-five patients (65%) significantly improved on NIHSS at 48 h (> or =4 points) (mean change = 10; range= 4-17). At one month, 43 (79%) improved on Barthel Index (mean change = 45%). One each developed small frontal lobe hemorrhage and recurrent stroke; one died of aspiration; and eight showed no improvement. CONCLUSIONS: Hyperacute thrombolysis was found useful and safe in selected patients with AIS even without the coagulation studies.

A clinical profile of shock in children in Punjab, India.

This prospective study was conducted to determine the frequency, etiology, type and outcome of shock in hospitalized children in the age group of 1 month to 15 years. There were 98 cases of shock, constituting 4.3% out of total admissions. Mean age was 2.8 +/-3.4 years. Maximum number of patients (39) was seen in infancy. Hypovolemic shock due to acute diarrheal disease was the commonest type (45.9%) followed by septic, cardiogenic and distributive shock. Compensated stage was common in hypovolemic shock (88.9%) whereas majority of patients with septic shock (73.5%) presented in decompensated stage. Overall survival was 73.6%. The survival rate was best in hypovolemic shock (97.7%;) followed by septic(53.3%) and cardiogenic shock(43.7%). Inotropes and ventilatory support were required in 46% and 23% patients, respectively. Diagnosis and management of shock in compensated stage carried better prognosis than in uncompensated shock irrespective of the age of the patient.

Predictive value of routine hematological and biochemical parameters on 30-day fatality in acute stroke.

OBJECTIVE: This prospective study was planned to study the prognostic value of routine clinical, hematological and biochemical parameters, including platelet aggregation in patients of acute stroke, on fatality occurring during the first 30 days. MATERIAL AND METHODS: In this study 116 consecutive patients (77 males and 39 females) of stroke (within 72 hours of onset) were included. After clinical evaluation and neuroimaging, blood investigations, hemoglobin, total leukocyte count, platelet count, platelet aggregation, erythrocyte sedimentation rate (ESR), blood sugar, urea, creatinine, sodium, potassium, serum cholesterol, serum bilirubin, aspartate aminotransferase (SGOT), alanine aminotransferase (SGPT), albumin, and globulin estimations were performed. The patients were followed up for a maximum period of 30 days from the onset of stroke, and patients who expired were grouped as 'expired' and the rest as 'survivors'. Logistic regression analysis was carried out among the significant parameters to identify independent predictors of 30-day fatality. RESULTS: Univariate analysis demonstrated that among hematological parameters, high total leukocyte count and ESR, at admission, correlated significantly with an undesirable outcome during the initial 30 days. Among biochemical parameters, elevated urea, creatinine, serum transaminases (SGOT and SGPT) and globulin levels correlated significantly with death. Logistic regression analysis demonstrated that a low Glasgow Coma Scale (GCS) score along with biochemical parameters such as high serum creatinine, SGPT, ESR and total leukocyte count correlated with death. CONCLUSION: Impaired consciousness, high total leukocyte count, raised ESR, elevated creatinine and SGPT levels, estimated within 24 hours of hospitalization, are the most important indicators of 30-day mortality in patients with first-time ischemic stroke.

Insulin resistance, insulin sensitization and inflammation in polycystic ovarian syndrome.

It is estimated that 5-10% of women of reproductive age have polycystic ovarian syndrome (PCOS). While insulin resistance is not part of the diagnostic criteria for PCOS, its importance in the pathogenesis of PCOS cannot be denied. PCOS is associated with insulin resistance independent of total or fat-free body mass. Post-receptor defects in the action of insulin have been described in PCOS which are similar to those found in obesity and type 2 diabetes. Treatment with insulin sensitizers, metformin and thiazolidinediones, improve both metabolic and hormonal patterns and also improve ovulation in PCOS. Recent studies have shown that PCOS women have higher circulating levels of inflammatory mediators like C-reactive protein, tumour necrosis factor-alpha, tissue plasminogen activator and plasminogen activator inhibitor-1 (PAI-1). It is possible that the beneficial effect of insulin sensitizers in PCOS may be partly due to a decrease in inflammation.

Sensitivity index of antimicrobial agents: A new treatment criteria proposed for rational use of antimicrobials.

The treatment guidelines are generally decided on the basis of either percent resistant (%R) or percent sensitive (%S) bacterial population tested with a given antimicrobial that vary geographically and represent only a part of total bacterial population existing in response to the antimicrobial used. The isolates with intermediate sensitivity (%I) are either not reported or clubbed with resistant isolates though the two may differ in clinical response. Sensitivity Index (SI) of an antimicrobial is sensitive to change in any of the three co-existing bacterial population and may be a better criterion for rational use of antimicrobial.

Management of agitation and convulsions in hepatic encephalopathy.

Hepatic encephalopathy represents a reversible decrease in neurological function caused by liver disease. Overall incidence of seizures in hepatic encephalopathy varies between 2% and 33%. Non-convulsive status epilepticus may be particularly common in these patients. Psychiatric disturbances manifest as agitation, personality change, delusions, etc. Aims of seizure management include treatment of basic disease, correction of precipitant factors, imaging of head, and choice of a pharmacologically safe agent. It is important to consider non-convulsive status epilepticus and rule it out by an EEG. Absolute data for safety profile of drugs in liver disease is still not clear, as changes of pharmacokinetics make choice of drugs difficult. Free drug concentrations may be higher, making plasma concentration monitoring essential in such circumstances. A single seizure may not require therapy. However when started, antiepileptic drugs are usually discontinued early. Drugs with sedative effects are best avoided because of a risk of precipitating coma. Phenytoin and gabapentin are relatively preferred drugs; however, monitoring of drug levels is desirable. Management of agitation includes physical restraint and medication. Benzodiazepines are best avoided. Haloperidol is a safer choice in the presence of liver disease. Overall management of neuropsychiatric state aims at management of underlying pathology, the resolution of which leads to improvement in the clinical symptomatology.

Vulnerable plaques, inflammation and newer imaging modalities.

Currently, inflammation is considered to be the central player in the pathogenesis of atherosclerosis. It leads to the formation of multiple plaques in the arterial beds including coronary vasculature. Recent studies using the latest imaging techniques have shown that in patients with acute coronary syndromes (ACS) multiple plaques are ruptured and have thrombus formation on them. Various factors make these plaques unstable, these include structural components of plaque like thin fibrous cap, high lipid content of the plaque core and inflammation, both localized and generalized. It has been shown that most of the ACS are caused by plaques causing non-critical stenosis as seen on traditional X-ray angiography. Also, the phenomenon of remodelling makes angiography a poor technique for plaque visualization. Hence newer modalities are required to identify these "vulnerable plaques". Intravascular ultrasound (IVUS), thermography and Magnetic Resonance Imaging (MRI) are a few such promising techniques. Here we review the invasive and non-invasive modalities that can be helpful in the identification of these plaques before they become unstable and cause ACS, and also the available therapies to stabilize these plaques.