Homocysteine--risk factor for ischemic stroke?

The present study was undertaken to compare the homocysteine levels in patients of ischemic stroke with controls. Our study included 117 patients of ischemic stroke and 101 controls. The mean homocysteine levels in patients with ischemic stroke were 16.80 +/- 6.71 micromol/L while in controls it was 12.30 +/- 4.68 micromol/L, the difference being statistically significant (P < 0.01). The increased homocysteine levels in patients with ischemic stroke are independent of diabetes mellitus, age and sex. The homocysteine levels were higher in hypertensive subjects than non-hypertensive (P < 0.05).

Epidemiologic classification of seizures associated with neurocysticercosis: observations from a sample of seizure disorders in neurologic care in India.

AIMS: To determine the etiologic role of neurocysticercosis (NC) in a hospital-based sample of epilepsies divided according to International League Against Epilepsy (ILAE) epidemiological criteria and number of seizures prior to presentation. METHODS: A sample comprising 1026 consecutive patients with either definite seizures or epilepsy attending a Neurology Outpatient Service was divided into four subgroups: single seizure (n = 314), incident epilepsy (n = 127), prevalent epilepsy (n = 398) and recurrent acute symptomatic seizures (RASS) (n = 175). The etiologic contribution of NC to each of the subgroups was examined with imaging studies. RESULTS: Neurocysticercosis was diagnosed on imaging studies in 34.6% of patients with seizure disorder of any type, 59.2% of those with a single seizure, 23.7% of those with recurrent seizure disorder, 92.0% of those with RASS, none of cases of incident epilepsy and 2.0% with prevalent epilepsy. A diagnosis of NC was significantly associated with single seizures (P < 0.001). CONCLUSIONS: Imaging abnormalities consistent with NC are frequently noted in persons presenting with a single seizure in neurologic care in NC-endemic countries like India. The probability of diagnosing NC diminishes with increasing numbers of seizures. Among samples of individuals with recurrent-unprovoked seizures, it is rare for imaging to demonstrate lesions of NC.

Syncope in a middle aged male due to acute rheumatic fever.

Rheumatic fever is a multi system disease which occurs following infection with group A beta hemolytic streptococcus. It is commonest in the age group of 5-15 years but can occur in adults also. First degree atrioventricular block is a common manifestation of acute rheumatic fever and is included in the Jones criteria but Wenckebacks phenomena and complete heart block are relatively rare manifestations of rheumatic fever. Syncope occurring in acute rheumatic fever is also infrequently reported. We report the case of a 38-year-old male with rheumatic carditis who had advanced atrioventricular block which resulted in syncope and required a temporary pacemaker insertion.

Incidence and prevalence of ulcerative colitis in Punjab, North India.

INTRODUCTION: Ulcerative colitis occurs worldwide. It is considered common in most of Europe and North America and uncommon in most of the developing Asian countries. The incidence/prevalence of ulcerative colitis varies not only according to geographical region but also with race and ethnicity. There are no reported data from India on the incidence of the disease and its prevalence. MATERIAL AND METHODS: A house to house survey was conducted by questionnaire, formulated to enquire about symptoms that are suggestive of ulcerative colitis. Those with prolonged diarrhoea with or without rectal bleeding were considered as suspected cases. These suspected cases were subjected to video sigmoidoscopy/colonoscopy and rectal biopsy. In addition, patients already diagnosed and receiving treatment for ulcerative colitis, encountered during the survey, were reviewed. Resurvey of the same areas was conducted after a one year interval to detect new cases. Using direct methods, standardised rates were calculated using world standard population weights 22, 18, 16, 12, 12, 9, 7, 3, and 1 for each 10 year age group. Standardised rates were also obtained separately for males, females, and combined populations, using the Punjab state 1991 population census data. Rates were also estimated according to UK 2000 population data. Ninety five per cent confidence intervals (95% CI) of prevalence and incidence rates of ulcerative colitis were estimated under the assumption that the distribution of cases followed a Poisson probability model. RESULTS: A total population of 51 910 were screened from January to March 1999. We identified 147 suspected cases and of these 23 were finally established as ulcerative colitis cases, giving a crude prevalence rate of 44.3 per 100 000 inhabitants (95% CI 29.4-66.6). A second visit to the same areas after one year identified 10 suspected cases in a population of 49 834. Of these, three were confirmed as "definite" ulcerative colitis giving a crude incidence rate of 6.02 cases per 100 000 inhabitants (95% CI 1.2-17.6). CONCLUSIONS: This is the first population based study from India reporting on the incidence and prevalence of ulcerative colitis. The disease frequency is not much less than that reported from Europe and North America.

Coexistence of celiac disease and ulcerative colitis.

Coexistence of celiac disease and ulcerative colitis has been reported from Western countries. We report two patients, a 30-year old man and a 16-year old boy, who presented initially with features of celiac disease and later developed ulcerative colitis.

Focal cortical-subcortical calcifications (FCSCs) and epilepsy in the Indian subcontinent.

PURPOSE: A focal cortical-subcortical calcification (FCSC) is a common finding on computed tomography (CT) in individuals with focal or generalized seizures in the Indian subcontinent. We sought to determine the relation of FCSCs to epilepsy by comparing the lobe of seizure origin by electroclinical and CT evaluations and to study the nature and severity of epilepsy associated with FCSCs. METHODS: The relation of these FCSCs to epilepsy/seizures was studied in 40 patients, seen for the first time to the neurology outpatient department of a tertiary care hospital. An attempt was made to classify seizures and determine their lobe of origin based on clinical-electroencephalographic (EEG) criteria of the International League Against Epilepsy (ILAE). The clinical lobe of origin was compared with the location of the FCSC on CT scan. In addition, records of the CT unit of the same hospital were reviewed retrospecitvely, to identify cases with an FCSC and their referral diagnoses. RESULTS: Thirty-one (77.5%) patients with FCSCs were considered to have localization-related epilepsy (frontal lobe epilepsy, 20; temporal lobe epilepsy, three; parietal lobe epilepsy, one; occipital lobe epilepsy, three; and definitely localization related but having ambiguous localization features, four) based on ictal semiology and EEG studies. Other ILAE categories in the cohort included epilepsy without unequivocal focal or generalized features (four patients; 10%), isolated seizures (one patient; 2.5%), juvenile absence epilepsy (one patient; 2.5%), and insufficient data to classify epilepsy (three patients; 7.5%). Radiologic sites for FCSCs included frontal (20; 50%), temporal (six; 15%), parietal (seven; 17.5%), and occipital (seven; 17.5%). Electroclinical and radiologic data were congruent in localizing and lateralizing seizures in 22 (55%) patients. The FCSC was truly incidental in one patient with juvenile absence epilepsy. Discordance between the clinical and radiologic localizations was noted in five (12.5%) instances. Magnetic resonance imaging (MRI) did not reveal additional lesions corresponding to lobes of origin as determined by electroclinical analysis. Discordance was surmised to be a result of seizure spread from a silent region to symptomatic cortex. In 12 (30%) patients, electroclinical and radiologic congruence could not be ascertained because ictal descriptions were either inadequate or ambiguous, and EEG findings were noncontributory. Review of 4,452 CT scans of brain performed in the CT unit revealed 29 (0.65%) cases with FCSCs in individuals with nonseizure disorders, that could be labeled as incidental. CONCLUSIONS: An FCSC is an important radiologic finding in localization-related epilepsy in the Indian subcontinent. The severity of epilepsy ranges from asymptomatic cases to daily seizures.

Phrenic nerve conduction studies in acute organophosphate poisoning.

Phrenic nerve conduction studies were performed within 48 h of admission and subsequently in 29 patients (14 of whom required mechanical ventilation) with acute organophosphate (OP) poisoning. The mean (+/-SD) amplitude of the diaphragmatic compound muscle action potential (CMAP) in patients requiring mechanical ventilation (119.09 +/- 173.85 microV) was significantly lower than in those not requiring mechanical ventilation (461.63 +/- 138.69 microV) (P < 0.0001). Diaphragmatic CMAP amplitudes in ventilated patients increased with time during the course of hospitalization and were normal in 5 (36%) patients and only mildly reduced in another 6 (43%) patients prior to discontinuation of mechanical ventilation, which was undertaken 4-18 days (mean 7 +/- 3 days) after poisoning. Eleven patients (79%) were successfully weaned from mechanical ventilation at the first attempt. In the 3 (21%) remaining patients, mechanical ventilation had to be reestablished because of weaning failure. The mean (+/-SD) diaphragmatic CMAP amplitude, prior to discontinuation of ventilatory assistance, was 242.6 +/- 94.1 microV in these 3 patients. After ventilatory discontinuation, it fell to 95.5 +/- 105.8 microV. Thus, reduced diaphragmatic CMAP amplitudes correlate with the need for mechanical ventilation in acute OP poisoning.

Serial neuro-electrophysiological studies in acute organophosphate poisoning--correlation with clinical findings, serum cholinesterase levels and atropine dosages.

OBJECTIVES AND METHODS: A prospective evaluation of the correlation between the serial clinical findings, serum cholinesterase levels, electrodiagnostic abnormalities and the daily atropine requirement was undertaken in 29 patients with confirmed acute organophosphate poisoning (OPP). RESULTS: Clinical weakness conforming to the pattern found in 'Intermediate Syndrome' was noted in 19 patients (65.55%). It was associated with all types of organophosphate compounds and occurred in all patients in whom the serum cholinesterase on admission was less than 200 units. Three types of electrodiagnostic abnormalities were noted: single supramaximal electrical stimulus induced repetitive response, a decrement--increment response to 30 Hz repetitive nerve stimulation (RNS) and a decremental responses to 30 Hz RNS. The 30 Hz decremental response correlated best with the presence of clinically detectable weakness (sensitivity = 61.72%; specificity = 81.54%; positive predictive value = 73.91%; negative predictive value = 71.62%). Time trends evaluation revealed that the peak daily atropine dosages were given at a mean of 1.76 +/- 0.83 days in comparison to a mean nadir of serum cholinesterase of 2.48 +/- 1.97 days and a mean nadir of 9:1 ratio of 2.65 +/- 1.76 days. The 2-tailed correlation coefficient analysis and simple regression analysis revealed a positive correlation between serum cholinesterase levels and the 9:1 ratios (correlation coefficient: 0.59). A negative correlation was observed between the 9:1 ratios and the daily atropine requirement (correlation coefficient: -0.57) and between serum cholinesterase levels and daily atropine requirement (correlation coefficient: -0.49). CONCLUSIONS: At admission, level of serum cholinesterase of less than 200 units is a predictor and the 30 Hz RNS decremental response could be a useful marker for the 'Intermediate Syndrome'.

Neurophysiological monitoring of pharmacological manipulation in acute organophosphate (OP) poisoning. The effects of pralidoxime, magnesium sulphate and pancuronium.

OBJECTIVES: The neuromuscular transmission failure in acute organophosphate (OP) poisoning occurs because of the irreversible inactivation of the enzyme acetylcholinesterase located in the neuromuscular junction, and is distinguished neuroelectrophysiologically by single electrical stimulus-induced repetitive responses and either a decremental or a decrement-increment response upon high-rate repetitive nerve stimulation (RNS). Understandably, the administration of pharmacological agents with actions at different sites in the neuromuscular junction would alter the neuroelectrophysiological findings in acute OP poisoning. METHODS: The effect of several pharmacological agents including pralidoxime (10 patients), magnesium sulphate (4 patients) and pancuronium (7 patients) on the neuroelectrophysiological abnormalities was studied in 21 patients with acute OP poisoning. RESULTS: Pralidoxime administration produced neurophysiological amelioration in 11 out of 15 occasions. In those cases where it produced a beneficial effect, pralidoxime administration was continued and its neuroelectrophysiological effects were studied daily. The efficacy of pralidoxime administration was demonstrated by neuroelectrophysiological testing for a maximum of 6 days after poisoning. Three types of neuroelectrophysiological responses to pralidoxime were noted: (i) lack of neuroelectrophysiological improvement (two patients); (ii) initial improvement with subsequent lack of improvement (two patients); and (iii) initial improvement with subsequent normalisation of neuromuscular transmission (5 patients). Normalisation of the electrodiagnostic tests and the failure of pralidoxime to ameliorate the neuromuscular transmission abnormalities were neuroelectrophysiological indications for the discontinuation of pralidoxime treatment. The administration of magnesium sulphate (MgSO4.7H2O, 4 g intravenous) resulted in a decrease in the CMAP amplitude, loss of the repetitive response and conversion of the decrement-increment response at high-rate RNS to an incremental response. Repetitive responses and the decremental response at high-rate RNS also disappeared after the administration of pancuronium (0.5 mg intravenous) to 6 patients. However, in one case where pancuronium administration was preceded by pralidoxime, there occurred a dramatic worsening of the neuromuscular transmission defect. CONCLUSIONS: While the administration of all 3 agents-- pralidoxime, magnesium sulphate and pancuronium-- resulted in the reversion of the neuroelectrophysiological defects, only pralidoxime is contended to be therapeutically useful. The therapeutic benefit due to its administration is limited by a short duration of action, and hence it is recommended that it should be administered for a longer period of time under neuroelectrophysiolgical guidance.

Continuous muscle fibre activity: description of neuroelectromyographic findings including single fibre EMG.

Four patients with continuous muscle fibre activity (Isaacs-Mertens syndrome) are reported in this communication. Electrophysiological evidence of peripheral neuropathy was present in two patients. Impulse induced repetitive CMAPs were noted in two patients. In one case the repetitive activity increased upon proximal stimulation. Single fibre EMG recordings of the spontaneous activity revealed pathological discharges with variable frequencies. Each pathological discharge comprised of a primary discharge and 1-4 extradischarges. There was marked variability of the interval between the primary discharge and subsequent extradischarges.

The Spectrum and clinical correlates of electrodiagnostic abnormalities in acute organophosphorus poisoning : a study of 55 patients.

Electrodiagnostic findings in 55 patients with acute organophosphorus intoxication have been correlated with clinical severity. Patients were assigned 3 grades of intoxication, depending upon the clinical severity of poisoning, muscarinic and nicotinic manifestations, ventilatory failure and altered sensorium. Repetitive responses upon single supramaximal stimulation of the median motor nerve were noted in all three grades of intoxication. In mild intoxication (grade I), low frequency repetitive nerve stimulation (< 3 Hz) produced no change in the amplitudes of the successive compound muscle action potentials. High frequency repetitive nerve stimulation (30 Hz and 50 Hz) resulted in either incremental responses (18 out of 29 cases), decremental responses (5 out of 29 cases) or decremental - incremental responses (6 out of 29 cases). Thirty five electrodiagnostic evaluations were performed in patients with overt neuromuscular weakness but not requiring mechanical ventilation (grade 2). Decremental responses were noted in only 3 instances at low frequency (< 3 Hz) repetitive nerve stimulation and in 34 out of 35 cases with high rates of stimulation. Patients who required mechanical ventilation had decremental responses at high (30 and 50 Hz) (12 out of 12 cases) as well as low rates (3 and 5 Hz) (7 out of 12 cases) of repetitive nerve stimulation. Serial electrodiagnostic evaluations, which were done in 12 patients, revealed that neuromuscular transmission abnormalities were either mild or absent within 24 hours in 9 patients. A deterioration in the neuromuscular transmission studies was noted during subsequent examinations performed, 1- 4 days later in these 9 patients. Electrodiagnostic testing is highly sensitive for establishing a diagnosisof organophosphorus poisoning and correlates well with clinical findings and the severity of poisoning. It may, however be normal in the early stages of intoxication.

Should beta-blockers be withdrawn in post-myocardial infarction patients before treadmill test?

In most patients of myocardial infarction, beta-blockers are used for secondary prophylaxis and a treadmill test is required for risk stratification. To study the effect of oral beta-blockers on interpretation of treadmill test, 54 consecutive patients were subjected to treadmill test four to six weeks after myocardial infarction. Fourteen patients with strongly positive treadmill test were referred for coronary angiography. Treadmill test was repeated in 37 patients 72 hours after withdrawal of beta-blockers. The peak exercise heart rate was significantly different while off and on beta-blockers (148 +/- 13 bpm vs 124 +/- 14 bpm, respectively; p < 0.01). The test was negative on both the occasions in 17 patients. On stopping beta-blockers, the negative test became mildly positive in five and strongly positive in six patients. The mildly positive test became strongly positive in four patients and remained almost unchanged in five. In 10 patients there was conversion of negative or mildly positive treadmill test into strongly positive result after withdrawal of beta-blockers. Thus the risk stratification changed significantly in 27 percent patients. It is suggested that beta-blockers can and should be withdrawn in post-MI patients before doing treadmill test.

Circulating anticoagulant phenomenon manifesting as isolated intracranial hypertension.

A 28 years old male developed headache and bilateral papilloedema. Cerebrospinal fluid revealed increased opening pressure, but was otherwise unremarkable. Magnetic Resonance (MRI) imaging of the brain was normal; MRI of the neck disclosed thrombosis of the right internal jugular vein. Russel viper venom test revealed the presence of a circulating anticoagulant.

Diagnostic and prognostic significance of lactate dehydrogenase in cerebrospinal fluid in patients of meningitis.

Activity of lactate dehydrogenase was measured in cerebrospinal fluid in 60 cases of meningitis (35 pyogenic, 18 tuberculous and 7 viral). Thirty age and sex matched healthy controls were taken to find out its diagnostic and prognostic significance in meningitis. The cerebrospinal fluid lactate dehydrogenase activity was significantly higher (p < 0.001) in cases of pyogenic meningitis and tuberculous meningitis as compared to the control group. The maximum elevation was seen on the 1st day in all types of meningitis but the activity declined significantly thereafter in patients of pyogenic meningitis who recovered without complications. However, in 2 cases of pyogenic meningitis and 5 cases of tuberculous meningitis who survived with complications, the lactate dehydrogenase activity on subsequent estimations increased serially. Further, the basal lactate dehydrogenase activity in 9 cases of pyogenic meningitis (who expired) was higher than those who survived without complications. The basal lactate dehydrogenase activity in pyogenic meningitis was significantly higher (p < 0.05) as compared to tuberculous meningitis and viral meningitis patients (p < 0.02) in this study.

Feasibility of thrombolytic therapy--a one year prospective study.

A one year prospective study was conducted on all the patients admitted with clinical diagnosis of acute myocardial infarction (AMI) to determine the proportion of patients who can be given thrombolytic therapy. Factors responsible for non-administration were analysed. 213 patients with AMI entered the study. Standard inclusion criteria for thrombolytic therapy were used. 101 (47%) patients failed to meet the inclusion criteria. This included 7 (3.3%) who failed to satisfy the electrocardiographic (ECG) criteria. Nine patients with atypical symptoms were unable to reach within the stipulated 6 hours while the remaining 85 (40%) patients were delayed inspite of typical features due to inability of the patient to attribute the symptoms to the heart, lack of proper transport facility and self medication. 112 patients (53%) met the inclusion criteria but 7 patients were excluded because of age (> 70 years), and another 8 because of contraindications. Of the remaining 97 patients, 47 failed to receive thrombolytic therapy due to lack of awareness of the benefits of thrombolytic therapy by the first treating physician, misinterpretation of ECG, inability to afford and refusal to give consent. Only 50 patients (23%) received thrombolytic therapy. This low figure can be easily improved upon by the correction of a number of remediable factors.