Extra-pontine myelinolysis secondary to hypernatremia induced by postpartum water restriction.

A young adult female with restricted water intake during the postpartum period presented with history of progressive weakness, dizziness and tendency to fall with generalized slowing of movement. On examination, patient was anaemic, febrile and stuporous. Investigations revealed hypernatremia, delta waves in electroencephalogram (EEG) and features suggestive of extra-pontine myelinolysis on magnetic resonance imaging (MRI) of brain. After correcting hypernatremia and instituting anti-cholinergic therapy, there was a gradual but steady improvement in neurological symptoms of the patient over a period of one week and the patient was discharged in a conscious, oriented and ambulant state. As such, neuroimaging findings can be crucial in diagnosing hypernatremic encephalopathy in the postpartum period.

Lipidomic profiling before and after Roux-en-Y gastric bypass in obese patients with diabetes.

Bariatric surgery is a well-established approach to improve metabolic disease in morbidly obese patients with high cardiovascular risk. The post-operative normalization of lipid metabolism has a central role in the prevention of future cardiovascular events. The aim of the present study therefore was to characterize changes of plasma lipidomic patterns, consisting of 229 lipid species of 13 lipid classes, 3 months after Roux-en-Y gastric bypass (RYGB) in morbidly obese patients with and without diabetes. RYGB resulted in a 15-32% decrease of body mass index, which was associated with a significant reduction of total cholesterol (TC, -28.3%; P=0.02), LDL-cholesterol (LDL-C, -26.8%; P=0.03) and triglycerides (TGs, -63.0%; P=0.05) measured by routine clinical chemistry. HDL-cholesterol remained unchanged. The effect of RYGB on the plasma lipidomic profile was characterized by significant decreases of 87 lipid species from triacylglycerides (TAGs), cholesterol esters (CholEs), lysophosphatidylcholines (LPCs), phosphatidylcholines (PCs), phosphatidylethanolamine ethers (PEOs), phosphatidylinositols (PIs) and ceramides (Cers). The total of plasma lipid components exhibited a substantial decline of 32.6% and 66 lipid species showed a decrease by over 50%. A direct correlation with HbA1C values could be demonstrated for 24 individual lipid species (10 TAG, three CholE, two LPC, one lysophosphatidylcholine ethers (LPCO) (LPC ether), one PC, two phosphatidylcholine ethers (PCO) and five Cer). Notably, two lipid species (TAG 58:5 and PEO 40:5) were inversely correlated with HbA1C. LPCO, as single whole lipid class, was directly related to HbA1C. These data indicate that RYGB-induced modulation of lipidomic profiles provides important information about post-operative metabolic adaptations and might substantially contribute to improvements of glycemic control. These striking changes in the human plasma lipidome may explain acute, weight independent and long-term effects of RYGB on the cardiovascular system, mental status and immune regulation.

Lack of evidence of hepatitis E virus infection among renal transplant recipients in a disease-endemic area.

Persistent hepatitis E virus (HEV) infection has been reported among solid-organ transplant recipients in nonendemic areas. Such chronic infections have all been related to genotype 3 HEV, which is prevalent in these areas. Whether persistent infection occurs with genotype 1 HEV, prevalent in areas where the infection is hyperendemic, is unclear. We therefore tested sera from renal transplant recipients receiving immunosuppressive agents in India, where genotype 1 HEV infection is endemic, for alanine aminotransferase levels, and presence of IgM and IgG anti-HEV antibodies and HEV RNA. Of the 205 subjects studied [aged 16-65 (median, 38) years, 182 male], 46 (22.4%) had abnormal ALT levels (>40 IU/mL). IgG anti-HEV was detected in 52 (20.5%) and IgM anti-HEV was detected in 14 (6.8%) subjects, including four who had IgG anti-HEV; antibody positivity had no relation with serum ALT or serum creatinine. All the sera tested were negative for HEV RNA. These findings suggest that chronic infection with genotype 1 HEV is infrequent.

Why mental health services in low- and middle-income countries are under-resourced, underperforming: an indian perspective.

The inadequacies of mental health services in low- and middleincome countries are often attributed to inadequate allocation of resources. This may not be entirely true. The experience in India suggests that a top-down approach to planning, divorced from the ground realities, poor governance, managerial incompetence and unrealistic expectations from low-paid/poorly motivated primary healthcare personnel play an important role and may result in the failure of even adequately funded programmes. The ambitious National Mental Health Programme (NMHP), launched in 1983 and aimed at providing basic mental health services through the existing primary healthcare system, using the Bellary model, failed to achieve any of its targets over the subsequent decades. In early 2001, the NMHP was radically revamped. It was re-launched as part of the Tenth Five-Year Plan (2002-07) and the budgetary allocation was increased more than 7-fold. However, the programme faltered due to techno-managerial underperformance and the initial momentum was lost. The reasons for this failure are analysed and possible remedial strategies suggested. While the experience documented in the paper is country-specific and relates to India, it may hold useful lessons for other low- and middle-income countries.

Overexpression of osmotin gene confers tolerance to salt and drought stresses in transgenic tomato (Solanum lycopersicum L.).

Abiotic stresses, especially salinity and drought, are major limiting factors for plant growth and crop productivity. In an attempt to develop salt and drought tolerant tomato, a DNA cassette containing tobacco osmotin gene driven by a cauliflower mosaic virus 35S promoter was transferred to tomato (Solanum lycopersicum) via Agrobacterium-mediated transformation. Putative T0 transgenic plants were screened by PCR analysis. The selected transformants were evaluated for salt and drought stress tolerance by physiological analysis at T1 and T2 generations. Integration of the osmotin gene in transgenic T1 plants was verified by Southern blot hybridization. Transgenic expression of the osmotin gene was verified by RT-PCR and northern blotting in T1 plants. T1 progenies from both transformed and untransformed plants were tested for salt and drought tolerance by subjecting them to different levels of NaCl stress and by withholding water supply, respectively. Results from different physiological tests demonstrated enhanced tolerance to salt and drought stresses in transgenic plants harboring the osmotin gene as compared to the wild-type plants. The transgenic lines showed significantly higher relative water content, chlorophyll content, proline content, and leaf expansion than the wild-type plants under stress conditions. The present investigation clearly shows that overexpression of osmotin gene enhances salt and drought stress tolerance in transgenic tomato plants.

Natural history of solitary cerebral cysticercosis cases after albendazole therapy: a longitudinal follow-up study from India.

OBJECTIVES: To find out natural course of solitary cerebral cysticercosis (SCC) cases after treating them with 2 weeks albendazole therapy. MATERIAL AND METHODS: All patients with SCC were treated with 2 weeks of albendazole therapy with follow-up radiological scan at 6 months and 2 years. The evolution of lesion was noted as complete resolution, calcification or persistent active. Antiepileptic drugs (AED) prophylaxis was given for 1 year in patients with complete resolution and for 2 years in calcified lesion, respectively. AED was continued in persistent lesion group till it became calcified or resoluted completely. One-year follow-up was done in all after stopping AED. RESULTS: Among 345 cases, 226 (65.5%) had complete resolution with very low seizure relapse rate with 1 year of seizure free period on AED treatment. On the contrary, 105 (30.5%) had calcified lesion with high seizure relapse rate after stopping AED treatment with 2 years of seizure free period. Fourteen patients (4%) could not stop their antiepileptic medication at all because of active lesion. CONCLUSION: Two-third of patients with SCC have favorable outcome with complete resolution and needs short-term AED prophylaxis and the rest one-third requires long AED treatment to prevent seizures.

Prophylaxis of deep-vein thrombosis in fractures below the knee: a prospective randomised controlled trial.

The incidence of deep-vein thrombosis and the need for thromboprophylaxis following isolated trauma below the knee is uncertain. We have investigated this with a prospective randomised double-blind controlled trial using low molecular weight heparin with saline injection as placebo in patients aged between 18 and 75 years who had sustained an isolated fracture below the knee which required operative fixation. All patients had surgery within 48 hours of injury and were randomised to receive either the placebo or low molecular weight heparin for 14 days, after which they underwent bilateral lower limb venography, interpreted by three independent radiologists. Further follow-up was undertaken at two, six, eight and 12 weeks. A total of 238 patients fulfilled all the inclusion criteria, with 127 in the low molecular weight heparin group and 111 in the placebo group, all of whom underwent bilateral venography. There was no statistically significant difference in the incidence of deep-vein thrombosis between those patients treated with low molecular weight heparin or the placebo (p = 0.22). The number of deep-vein thromboses in the two groups was 11 (8.7%) and 14 (12.6%), respectively. Age and the type of fracture were significantly associated with the rate of deep-vein thrombosis (p = 0.001 and p = 0.009, respectively) but gender, comorbidities and the body mass index were not. The overall incidence of deep-vein thrombosis in this series was 11%. There was no clinical or statistical significant reduction in the incidence of deep-vein thrombosis with the use of thromboprophylaxis. However, we accept that owing to a cessation of funding, recruitment to this trial had to be ended prior to establishing the necessary sample size. Our results cannot, therefore, categorically exclude the possibility that low molecular weight heparin treatment could be beneficial. We recommend a further multicentre trial be undertaken to resolve this matter.

Idiopathic recurrent stupor mimicking status epilepticus.

Stupor is defined as a deep sleep or behaviourally similar unresponsiveness from which the subject can be aroused only by vigorous repeated stimuli. Causes of stupor may be related to brain damage, toxic or metabolic encephalopathies. Idiopathic recurring stupor is a stupurous condition of unknown aetiology, unrelated to structural, toxic or metabolic disturbance. This condition responds to flumazenil, a benzodiazepine antagonist. We describe a 60-year-old man presenting with abnormal jerky movements of the body and who was wrongly treated as status epilepticus. He responded to flumazenil which confirmed the diagnosis.

Two-tier system of epilepsy evaluation: a useful method for developing countries.

PURPOSE: To test the usefulness of a simplified and clinically oriented, the Epidemiological Classification (EC), in determination of seizure types and appropriate drug selection in epileptic patients at the primary care level. METHODS: The EC was applied to all epileptic patients over 5 years then compared with the currently recommended international classifications of seizures and epilepsy (ICES/ICEES). RESULTS: A total of 1176 patients were enrolled with 2:1 male preponderance and 88% had onset of disease below 30 years of age. Based on EC, 682 (58%) had partial, 333 (28.3%) had generalized and 161 (13.7%) had undetermined seizures semiology. When ICES was applied, seizure typing was same in 86.2%, 68.5% and 26.7% patients of partial, generalized and unclassified seizures respectively. About 87% patients in generalized and partial seizure semiology had no change in selected antiepileptic drug even after the ICES, but 53.6% patients in undetermined group had change in selected AED. Only, 146 patients (12.5%) found to have symptomatic cause for seizure(s) on applying the EC system. After utilizing the ICEES on 1030 patients (87.5%) of "unknown etiology" cases after the EC system, almost 86.5% patients could be classified to a definite etiological class. CONCLUSION: The EC was found useful for determination of seizure type and appropriate AEDs selection at the primary care level. The ICES/ICEES works better at the tertiary care level. This "two-tier" system can be more effective for overall epilepsy management in developing countries with limited facilities.

Neurocognitive dysfunction in patients with obsessive compulsive disorder.

OBJECTIVE: Although a dysfunctional prefrontal-striatal system is presupposed in obsessive-compulsive disorder (OCD), this is not unequivocally supported by neuropsychological studies. This study aims to study the neurocognitive dysfunctions in OCD patients, compared to controls; to study the variations in neurocognitive deficits with the duration of illness, as well as, the severity of the disease. METHOD: Thirty OCD patients were compared with thirty, age and education matched control subjects on computer based tests measuring executive functions, vigilance and spatial working memory. RESULTS: OCD patients performed poorly on all the neuro-cognitive parameters as compared to controls. The severity of illness had a positive correlation with poorer performance on CPT. There were no significant correlations between duration of illness and any parameters of cognition. CONCLUSION: The results suggest that OCD patients perform significantly worse on cognitive measures than controls. This is consistent with their poorer functional outcome. The results further indicate that on the basis of severity OCD patients are qualitatively distinguishable in neuropsychological terms, given their difference in the profiles of cognitive impairment.

Intraoperative cytology (squash smear) in neurosurgical practice - pitfalls in diagnosis experience based on 3057 samples from a single institution.

OBJECTIVES: The smear technique is challenging for a neuropathologist where rapid and accurate diagnosis is to be given on small biopsies. The present study, a large retrospective analysis of squash smears in neurosurgical practice, was conducted to assess the usefulness, accuracy and the diagnostic pitfalls of smear diagnosis. METHODS: The authors analysed 3057 central nervous system (CNS) lesions sent for intraoperative cytology (IC) during the years 1988-2005. The stain used was 1% alcoholic toluidine blue. The smear diagnosis was compared with the histological diagnosis to evaluate the diagnostic accuracy. RESULTS: Diagnostic accuracy irrespective of lesion and site ranged from 83.0% to 86.0% per year (mean=85%). The highest rate of correlation among common brain tumours was noted in schwannoma (96.6%) and pituitary adenoma (92.2%), followed by meningiomas (88.9%), astrocytomas (88.4%), chordomas (86.4%) and neurocytomas (86.9%). Infections as a whole contributed 380 cases. The most common infection was tuberculosis. CONCLUSION: This is the largest series reported from India to the best of our knowledge. Squash smear technique is a very reliable and rapid method of intraoperative diagnosis. Knowledge of clinical and neuroimaging details helps the experienced neuropathologist to improve the diagnostic accuracy.

Leptin improves pulmonary bacterial clearance and survival in ob/ob mice during pneumococcal pneumonia.

The adipocyte-derived hormone leptin is an important regulator of appetite and energy expenditure and is now appreciated for its ability to control innate and adaptive immune responses. We have reported previously that the leptin-deficient ob/ob mouse exhibited increased susceptibility to the Gram-negative bacterium Klebsiella pneumoniae. In this report we assessed the impact of chronic leptin deficiency, using ob/ob mice, on pneumococcal pneumonia and examined whether restoring circulating leptin to physiological levels in vivo could improve host defences against this pathogen. We observed that ob/ob mice, compared with wild-type (WT) animals, exhibited enhanced lethality and reduced pulmonary bacterial clearance following Streptococcus pneumoniae challenge. These impairments in host defence in ob/ob mice were associated with elevated levels of lung tumour necrosis factor (TNF)-alpha, macrophage inflammatory peptide (MIP)-2 [correction added after online publication 28 September 2007: definition of MIP corrected], prostaglandin E(2) (PGE(2)), lung neutrophil polymorphonuclear leukocyte (PMN) counts, defective alveolar macrophage (AM) phagocytosis and PMN killing of S. pneumoniae in vitro. Exogenous leptin administration to ob/ob mice in vivo improved survival and greatly improved pulmonary bacterial clearance, reduced bacteraemia, reconstituted AM phagocytosis and PMN H(2)O(2) production and killing of S. pneumoniae in vitro. Our results demonstrate, for the first time, that leptin improves pulmonary bacterial clearance and survival in ob/ob mice during pneumococcal pneumonia. Further investigations are warranted to determine whether there is a potential therapeutic role for this adipokine in immunocompromised patients.

Mental health legislation in contemporary India: the need for inter-sectoral dialogue.

It is said that war is far too serious a matter to be left to the generals alone. The same could be said for the interface between law and mental health. With our narrow, and sometimes myopic, treatment-centric vision we are ill equipped to claim hegemony over the complex domain of legislation as it relates to mental health, even more so in the multicultural Indian subcontinent, where the medieval exists alongside the modern and where abject poverty jostles with ostentatious wealth.

Psychological effects of low intensity conflict (LIC) operations.

BACKGROUND: A burgeoning clinical and empirical literature has provided incontrovertible evidence that combat operations exact a heavy toll in terms of human suffering not only on combatants but also military support personnel. Though the Indian army is engaged in low intensity conflict (LIC) operations for over five decades, the psychological effects of LIC deployment on soldiers have not been adequately studied. AIMS: To evaluate the psychological effects of deployment in LIC operations on service personnel. METHODS: Five hundred and sixty-eight servicemen engaged in LIC operations and equal number of age- and rank-matched personnel in adjoining peace areas were evaluated with a self-made questionnaire, General Health Questionnaire (GHQ), Carroll Rating Scale for Depression (CRSD), State-Trait Anxiety Inventory (STAI), Michigan Alcoholism Screening Test (MAST), Impact of Events Scale (IES), Perceived Stress Questionnaire (PSQ), Multidimensional Fatigue Inventory (MFI), Hindi PEN inventory, Satisfaction With Life Scale (SWLS) and Locus Of Control (LOC) scale. RESULTS: Respondents from LIC area had significantly higher scores on CRSD, MAST, GHQ, IES, and general fatigue, physical fatigue, and mental fatigue subscale of the MFI in comparison to those located in other areas. Significantly higher number of respondents from highly active LIC and with more than one-year service in LIC scored above cut-off levels on CRSD, MAST and GHQ. CONCLUSIONS: The psychological status of troops was directly related both to the duration of stay and the nature of LIC area.

A prospective study of the long-term efficacy of local methyl prednisolone acetate injection in the management of mild carpal tunnel syndrome.

OBJECTIVE: Local glucocorticoid injections are used to treat carpal tunnel syndrome (CTS). However, this treatment is associated with frequent relapses. An important limitation of studies with higher relapse rates is that no attempt has been made to identify patients with mild or severe disease. We evaluated the efficacy of local glucocorticoid injection in patients with mild CTS. METHOD: Mild CTS was defined as intermittent symptoms without absence of sensations, muscle atrophy or weakness of the thenar muscles. Forty-eight patients with idiopathic mild CTS were evaluated before and 3 and 12 months after a single local injection of 40 mg methyl prednisolone acetate. Outcome was assessed by overall satisfaction on a 100 mm visual analogue scale, the Boston self-administered questionnaire for symptom severity and functional scores and improvement in the electrophysiological parameters. RESULTS: At 3 months, 93.7% of the patients reported marked improvement in their symptoms, with significant improvement in the mean values of the nerve conduction parameters distal motor latency at the wrist (DML) (P = 0.00001), distal sensory latency at mid-palm (DSL MP) (P = 0.014) and distal sensory latency at the wrist (DSL W) (P = 0.0003), and symptom severity (P = 4.96 x 10(-8)) and the functional scores (P = 3.56 x 10(-5)). Significant improvement was still present for DML (P = 1.39 x 10(-5)) at 12 months. Almost 50% of the patients achieved normalization in the electrophysiological study. At a median follow-up of 16 months, 79% patients continued to have improvement in their symptoms. Eight patients (16.6%) relapsed following the initial response. CONCLUSIONS: Local glucocorticoid injection results in long-term improvement in nerve conduction parameters, symptom severity and functional scores in patients with mild CTS.

A new homotriterpene from the roots of Marsdenia tenacissima Wight and Arn.

A new homotriterpene isolated from the roots of Marsdenia tenacissima Wight et Arn. has been characterized as 13-(31,32-dimethyl-30-methylene-21alpha-acetoxytetradecanyl)-29-methyl-perhydrophenanthr-1,3-diene on the basis of spectral analyses.

Clinical, radiological and neurophysiological spectrum of JEV encephalitis and other non-specific encephalitis during post-monsoon period in India.

AIMS: To study the spectrum of encephalitis during the post-monsoon period in a tertiary care centre of India. METHODS: Clinical, neurophysiological and radiological features of patients with encephalitis are reported in this communication. The patients were subjected to clinical examination, CT or MRI scan, EEG, motor and somatosensory evoked potentials in both upper and lower limbs bilaterally and concentric needle electromyography. The laboratory studies for Japanese encephalitis (JE) comprised virus isolated, IgM capture ELISA, mercaptoethanol test and hemagglutination inhibition titre in paired sera against JE virus. Patients were classified into JEV encephalitis and non-specific encephalitis. On the basis of radiological features, they were classified into group I (thalamic or basal ganglia involvement), group II (brainstem involvement only) and group III (normal MRI). The outcome was defined into poor (bedridden), partial (dependent for daily activities) and complete (independent) recovery at the end of 3 months. RESULTS: Out of 26 patients (Age 7-70 years, mean 24.8 years), laboratory evidences of JEV infection was present in 14 patients and one patient had herpes simplex encephalitis. The patients with JEV encephalitis had more severe illness as evidenced by lower GCS score, higher frequency of anterior horn cell involvement, movement disorders and more extensive MRI changes. The EEG and MEP changes were also more frequently abnormal in the JEV group. On radiology, 15 patients had thalamic or basal ganglia involvement (group I), 3 isolated midbrain involvement (group II) and 8 had normal MRI (group III). Laboratory evidence consistent with JE were present in 11 out of 12 patients in group I and 3 out of 8 in group III, however, there was no laboratory evidence of JE virus infection in patients with isolated brainstem involvement. There was overlap in the neurologic and systemic manifestations in all the 3 radiological groups as well as in the groups with and without laboratory evidences of JEV infection. CONCLUSION: The observed overlap in neurological and systemic involvement in different subgroups of encephalitis may be due to JE or JE-like viral infection. The possibility of strain variation, change in virulence of organism or immunity of host needs further studies.