A Double-Blind, Placebo-Controlled Study of Appropriate Site of Botulinum Toxin Therapy in Hemifacial Spasm.

INTRODUCTION: Hemifacial spasm (HFS) is a condition causing poor quality of life. Treatment with botulinum toxin A (BTX) injection is effective. Only one randomized controlled trial with a single-blind fashion has evaluated if oral injection is needed in HFS. The present study aimed to evaluate the necessity of oral BTX injection in HFS by a randomized, double-blind, placebo-controlled method. METHODS: We conducted a double-blind, placebo-controlled trial in patients with HFS who never received BTX treatment. Eligible patients randomly received either 15 units of BTX around the eye and normal saline around the mouth (group A) or 15 units of BTX around both the eye and the mouth (group B). The primary outcomes were self-reported symptoms and observed frequency of spasms, while the secondary outcome was the duration of improvement or the time between the injection and the recurrence of symptoms to the same condition as before treatment. Student t test and survival analyses were used to compare the duration of symptoms between both groups. The mean changes were compared to secondary outcomes between the two groups. RESULTS: There were 60 patients enrolled, half in each group. Baseline characteristics between both groups were similar. The mean (SD) of the duration of improvement in group A and B was 22.97 (18.85) and 17.53 (14.90) weeks, respectively (p = 0.220). There was no difference between both groups by survival analysis. Group B had a higher percentage of mouth improvement but there was no difference in the percentage of eye improvement, visual analog scale of eye and mouth spasm, or frequency of eye and mouth spasm. Group B had a higher incidence of side effects particularly mouth drooping (30% vs 10%) than group A (p = 0.053). CONCLUSION: The mouth injection of BTX may not be necessary for HFS. It may be beneficial to reduce mouth symptoms with a higher rate of mouth drooping.

A Real Life Clinical Practice of Neurologists in the Ambulatory Setting in Thailand: A Pragmatic Study.

The burden of neurological disorders is high in developing countries. Real life data from neurologists as to how they practice in Thailand are limited in literature. Practices of neurologists in a university hospital clinical setting in Thailand were studied. A prospective study was performed at the ambulatory neurology clinic, Khon Kaen University Hospital, between 1 February and 31 October 2009. The following data were recorded: numbers of patients, characteristics of patients, consultation notes, and time spent for each patient. There were three neurologists, each of whom ran one afternoon clinic, once a week. There were 6137 visits during the 9 months, with an average of 681 visits per month. The total number of patients was 2834. The three most common diseases were cerebrovascular diseases (33%), epilepsy (16%), and movement disorders (non-Parkinson's disease, 12%). Neurologists spent an average of 6.34 minutes per patient. In conclusion, neurologists in medical schools have limited time to take care of each patient. Several strategies are needed in medical education and neurology training to improve the quality of care.

Cost minimization of HLA-B*1502 screening before prescribing carbamazepine in Thailand.

BACKGROUND: Carbamazepine (CBZ) is broadly used for the treatment of epilepsy, neuropathic pain and other neurological diseases, owing to its effectiveness and low price. CBZ can induce Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). There are several studies that found an association between HLA-B*1502 and CBZ-induced SJS/TEN, especially in people of Thai origin. In Thailand the prevalence of HLA-B*1502 was found to be in the range 8.1-14 %. OBJECTIVE: This study aimed to determine if screening for HLA-B*1502 in Thai patients who were to receive CBZ is cost effective. Setting Srinagarind Hospital, Khon Kaen University, Thailand. METHOD: A comparison between treatment cost of CBZ induced SJS/TEN and the HLAB*1502 screening costs in the Thai population. MAIN OUTCOME MEASURE: Comparison of the costs of treatment of CBZ induced SJS/TEN and costs of HLA-B*1502 screening test. Results When persons having the HLA-B*1502 allele receive CBZ, the chance of developing SJS/TEN is as high as 88.1 %, while persons without the HLA-B*1502 allele do not develop SJS/TEN. Therefore, a model was calculated to compare the cost of treatment between HLA-B*1502 testing before giving CBZ and if the patients were not tested for HLAB*1502. It was found that screening 100 patients before giving CBZ would save an amount of 98,549.94 baht per 100 cases of CBZ-prescribed patients. CONCLUSION: The screening for HLA-B*1502 allele before giving carbamazepine is cost effective. The results of the present study may also apply to other populations if the HLA-B*1502 frequency is high enough.

How can clinicians ensure the diagnosis of meningitic angiostrongyliasis?

Meningitic angiostrongyliasis (MA), caused by Angiostrongylus cantonensis, is often diagnosed by clinical criteria alone, because the confirmative serologic tests are not always available in the rural endemic areas. In this study, we evaluated the relationship between various clinical parameters of MA and the sero-positivity to sort out the predictive parameters to ensure the diagnosis. We enrolled consecutive adults in whom MA had been clinically diagnosed, who had serologic results for A. cantonensis, and negative serologic results for Gnathostoma spinigerum. There were 75 eligible patients; 26 (34.7%) and 49 (65.3%) patients who had negative and positive serologic tests for A. cantonensis, respectively. Baseline characteristics and laboratory results were comparable between sero-positive and -negative groups. Only the cerebrospinal fluid (CSF) eosinophil counts of 40% or higher was significantly predictive for positive serologic test with the adjusted odds ratio of 4.970 (95% confidence interval of 1.337-18.477). In diagnostic facilities in the endemic areas with the limited availability of serologic tests, clinicians can ensure the diagnosis of MA by using CSF eosinophil level.

Abdominal epilepsy: an uncommon of non-convulsive status epilepticus.

OBJECTIVE: To recognize abdominal epilepsy in adults. MATERIAL AND METHOD: Case report. RESULTS: Case 1: A 21-year-old woman with DM type I presented with a 2-month history involving four episodes of severe abdominal pain and vomiting, each of which lasted four to five days. She had a recurrence every two weeks. The EEG revealed 'spike and wave ' and she was started an intravenous phenytoin that resolved the symptoms. Case 2: A 20-year-old woman with DM type I was admitted with a 2-month history of recurring severe left upper quadrant pain associated with occasional nausea but no vomiting. She experienced two more episodes of generalized tonic-clonic seizures and was treated with 300 mg phenytoin given orally The abdominal pains gradually subsided and she was symptom-free within two days. An EEG showed frequent sharp waves. She was treated with 10 mg intravenous diazepam and her symptoms and sharp waves disappeared within two minutes. Case 3: A 46-year-old man with DM type I was admitted with a four-month history of recurring severe epigastric pain and vomiting. His physical examination, laboratory tests, and extensive investigation for a primary GI disorder revealed nothing unusual. The EEG revealed spike and wave and he was treated with intravenous AED (phenytoin) loading after which the symptoms disappeared. CONCLUSION: Physicians should consider abdominal epilepsy in diabetics with recurrent, intractable abdominal pain in whom extensive investigations for primary gastrointestinal (GI) disorders are unremarkable.

Peripheral eosinophilia as an indicator of meningitic angiostrongyliasis in exposed individuals.

The diagnosis of meningitic angiostrongyliasis (MA) is based on clinical criteria. A lumbar puncture is used as a diagnostic tool, but it is an invasive procedure. The blood eosinophil levels are also assessed and used in the diagnosis of this disease. We enrolled 47 patients with serologically proven MA and 131 controls with intestinal parasite infections. An absolute eosinophil count model was found to be the best marker for MA. An eosinophil count of more than 798 cells led to sensitivity, specificity, positive predictive and negative predictive values of 76.6%, 80.2%, 58.1% and 90.5%, respectively. These data support the use of testing for high blood eosinophil levels as a diagnostic tool for MA in individuals that are at risk for this disease.

Peripheral eosinophilia as an indicator of meningitic angiostrongyliasis in exposed individuals

The diagnosis of meningitic angiostrongyliasis (MA) is based on clinical criteria. A lumbar puncture is used as a diagnostic tool, but it is an invasive procedure. The blood eosinophil levels are also assessed and used in the diagnosis of this disease. We enrolled 47 patients with serologically proven MA and 131 controls with intestinal parasite infections. An absolute eosinophil count model was found to be the best marker for MA. An eosinophil count of more than 798 cells led to sensitivity, specificity, positive predictive and negative predictive values of 76.6 percent, 80.2 percent, 58.1 percent and 90.5 percent, respectively. These data support the use of testing for high blood eosinophil levels as a diagnostic tool for MA in individuals that are at risk for this disease.

Prediction of seizure control in non-ketotic hyperglycemic induced seizures.

BACKGROUND: To study the factors predictive for seizure control in non-ketotic hyperglycemic induced seizures (NKHS). METHODS: We studied 21 patients who were clinically diagnosed as NKHS at Khon Kaen University hospital, Thailand. Multiple linear regression analysis was used to identify the factors predictive for seizure control. RESULTS: Most patients had no previous history of diabetes and presented with repetitive partial seizures. The mean number of seizure attacks was 45 times prior to admission. The average duration to terminate seizure was 36 hours and significantly predicted by frequency of seizures (estimate 0.9, p value 0.013). CONCLUSION: Frequency of seizures is the only predictive factor for the success of seizure control in NKHS.

Clinical factors predictive of encephalitis caused by Angiostrongylus cantonensis.

Angiostrongylus cantonensis is mainly caused eosinophilic meningitis in humans, whereas a minority of patients develop encephalitic angiostrongyliasis (EA). EA is an extremely fatal condition, and the clinical factors predictive of EA have never been reported. A comparison study was conducted in a hospital situated in an endemic area of Thailand. We enrolled 14 and 80 angiostrongyliasis patients who developed encephalitis and meningitis, respectively. Logistic regression analysis was used to assess the clinical variables predictive of encephalitis. Age (adjusted odds ratio [OR], 1.22; 95% confidence interval [CI], 1.05-1.42), duration of headache (adjusted OR, 1.26; 95% CI, 1.03-1.55), and fever > 38.0 degrees C (adjusted OR, 37.05; 95% CI, 1.59-862.35) were identified as statistically significant factors for EA prediction. Elderly patients with angiostrongyliasis experiencing fever and prolonged headaches were at the highest risk of developing EA.

Predictive risk factors of seizure-related injury in persons with epilepsy.

OBJECTIVE: The clinical risk factors for seizure-related injuries (SRI) in adult persons with epilepsy (PWE) were studied and analyzed to develop a predictive model. METHODS: We enrolled 300 consecutive cases from three epilepsy clinics in Northeast, Thailand. Subjects were eligible if reported to have at least one seizure attack during the past 12 months. Face-to-face questionnaire was used to evaluate SRI, baseline characteristics and other seizure-related variables. RESULTS: There were 247 and 91 PWE who met a criterion and had SRI, respectively. By multivariate logistic regression method, GTC seizure type, having history of seizure attacks at least 12 times/year, and daytime seizure were significant risk factors of having SRI with odds ratio of 2.376, 2.460, and 3.562, respectively. We developed the predictive model for having SRI in PWE and it gave 90.3% sensitivity and 46.7% specificity on the occurrence of SRI. The estimated probability of SRI can be found online at http://sribykku.webs.com/. CONCLUSIONS: The significant predictive factors for SRI in PWE were the occurrence of GTCs, seizures at least 12 times/year or daytime seizures. Clinicians or PWE can easily evaluate the risk of having SRI in individuals by the online predictive model.

A case of Miller Fisher syndrome with anti GQ1b in Thailand.

Miller-Fisher syndrome (MFS) is a rare variant of Guillain-Barré syndrome (GBS) and is characterized by the clinical triad of ataxia, ophthalmoplegia, and areflexia. The incidence rate in Thailand has not been established but it occurred approximately 1-5% that of GBS. Here, the authors report a Thai patient diagnosed as MFS that had a positive test of antibodies against the ganglioside GQ1b. These antibodies have diagnostic and pathogenic importance to MFS because of high sensitivity and specificity. All other investigations, such as cerebrospinal fluid analysis, electrophysiological studies, and imaging studies had no significant abnormalities. The patient was successfully treated with intravenous immunoglobulin and fully recovered within one month. After eighteen months follow-up, he is still healthy and has had no recurrent symptoms.

Albendazole therapy for eosinophilic meningitis caused by Angiostrongylus cantonensis.

Eosinophilic meningitis in humans is commonly caused by the nematode Angiostrongylus cantonensis. A severe headache is the most common presenting symptom. A prospective, randomized, double-blind, placebo, controlled study was conducted to determine if albendazole was efficacious in relieving such headaches. Seventy-one patients (36 and 35 in the treatment and control groups) were enrolled in the study. Five patients (two and three in the treatment and control groups) were excluded from the study because of being lost to follow-up, and the clinical data were incomplete. Therefore, 34 and 32 patients in the treatment and control groups were studied, respectively. Albendazole was administered at 15 mg/kg/day or identical placebo for 2 weeks. The number of patients with persistent headaches after 2 weeks was 7 and 13 in the albendazole and placebo groups (p = 0.08), respectively. The mean duration of a headache was 8.9 and 16.2 days in the albendazole and placebo groups, respectively (p = 0.05). No serious drug events were observed. A 2-week course of albendazole appeared to reduce the duration of headache in eosinophilic meningitis.

Basic knowledge of epilepsy among medical students.

BACKGROUND: The medical students' knowledge about basic medical neuroscience in the preclinical level may be fragmented and incomplete. OBJECTIVE: Evaluate the knowledge of students prior to a lecture on epilepsy in clinical level. MATERIAL AND METHOD: One hundred ten fourth-year medical students' knowledge was accessed by a self-administered questionnaire. RESULTS: The presented results revealed that 91.8% of respondents knew that epilepsy arose from a transient dysfunction in the brain. Generalized tonic-clonic seizures (GTCs) were the most common type (91.5%) they knew and absence seizures were the least common type (33.6%) they knew. All of them knew that eating pork and punishment of gods did not cause epilepsy. However 50% thought that genetics was a cause and 80.3% did not know that stroke and sleep deprivation (92.7%) cause epilepsy. About treatment and prognosis, only 28.2% of respondents thought epilepsy can be cured and patients should take antiepileptic drugs (AEDs) for seizure free 2-5 years (48.2%), life long (33.6%). They knew that the patients should be prohibited from driving (80%), working on machinery (74.5%), and (27.3%) avoid drinking. However, they knew that the patients could marry (100%), get pregnant (98.2%), and lactate (91.9%). Regarding the first aid management, 50.9% of them recommended that placing a piece of wood between the teeth during a seizure and perform chest compressions (20.0%). Means knowledge scores is about 60%, the highest score is the definition of epilepsy (90.2%) and the lowest is type of seizure (43%). CONCLUSION: The findings indicated that lecturers should review aspects ofpathophysiology and emphasize on type of seizure, cause, consequences, and prognosis including first-aid management.

Very high dose phenobarbital for refractory status epilepticus.

BACKGROUND: Refractory status epilepticus (RSE), defined as status epilepticus that fails to respond to first, second and third-line therapy. The RSE is associated with high morbidity and mortality. Treatment guidelines of RSE give a spectrum of options, such as, continuous intravenous (i.v.) midazolam (MDL), or continuous i.v. propofol (PRO) as alternatives to phenobarbital (PB) or continuous i.v. pentobarbital (PTB). OBJECTIVE: To study the efficacy of very-high-dose phenobarbital (VHDPB) for treatment RSE. STUDY DESIGN: Retrospective study MATERIAL AND METHOD: The authors collected and analyzed data from adult patients who were diagnosed with RSE. RESULTS: The authors present 10 patients with RSE who were treated with VHDPB. All of them were generalized convulsive status epilepticus (GCSE). Ages ranged from 16-86 years old (mean.: 43 years). PB dosage ranged 40-140 mg/kg/day (mean: 70 mg/kg/day). The duration of status epilepticus (SE) varied widely, ranged 1-44 days (mean: 7 days). PB level ranged 35.29-218.34 ug/mL (mean 88.1 ug/mL). RSE was controlled by VHDPB 70%, 30% were not controlled. CONCLUSION: VHDPB were considered as alternative treatment for RSE.

Communicating hydrocephalus as a complication of eosinophilic meningoencephalitis.

The authors reported an adult patient with communicating hydrocephalus in eosinophilic meningoencephalitis. He presented with localized peritonitis and then developed eosinophilic meningoencephalitis. Angiostrongylus cantonensis was the causative agent. This was confirmed by the positive serology test. His consciousness did not recover after supportive treatment. The MRI of the brain showed diffuse enlargement of the ventricular system two weeks after the diagnosis was made. The parameters for hydrocephalus were measured and were compatible with the Gyldensted's criteria.

Acetylcholine receptor antibody in Thai generalized myasthenia gravis patients.

The authors studied acetylcholine receptor antibody (AChR Ab) in twenty-six Thai patients diagnosed as having generalized myasthenia gravis and fifteen control cases. AChR Ab assay was done by radio-immunoassay technique and reported by titer in nmole/L. The positive result was defined by titer more than 0.5 nmole/L. In the myasthenia gravis group, age ranged from 18 to 64 years old with mean of 34 years old. The female: male ratio was 4.2:1. Duration of disease before taking blood sample ranged from 1 month to 14 years with a mean of 3.9 year The AChR Ab could be detected in 21 out of 26 patients (80.7%). In the control group, tests were all negative. The results of the test made the sensitivity of 80.7% and specificity of 100%. The positive predictive value was 100%, the negative predictive value was 75%, and the prevalence was 60.3%. There was no correlation between AChR Ab titer and clinical features. This test is a very valuable test in case of uncertainly in the diagnosis of myasthenia gravis.

Kluver-Bucy syndrome after mycoplasmal bronchitis.

Kluver-Bucy syndrome is a rare neurobehavioral condition characterized by visual agnosia, excessive oral tendencies, hypermetamorphosis, placidity, altered sexual behavior, and changes in dietary habits. This description of a 14-year-old boy presenting with complete Kluver-Bucy syndrome after Mycoplasma pneumoniae bronchitis is the first such case report. MRI revealed left temporal horn dilation and asymmetry of both temporal lobes. We hypothesize that the pathophysiology of our case is immune-mediated damage by M. pneumoniae resulting in vasculopathy.

MR imaging findings in cauda equina gnathostomiasis.

We report a case of cauda equina syndrome caused by Gnathostoma spinigerum, which was confirmed by an immunoblotting test. MR imaging of the lumbosacral spine showed long, segmented hyperintensity along the cauda equina with irregular enhancement on the postcontrast study. The conus medullaris was slightly enlarged with abnormal enhancement. The patient was treated with corticosteroids, and her clinical condition improved. MR imaging, 9 months after treatment, showed the condition to be completely resolved.

Knowledge of epilepsy among teachers in Khon Kaen Province, Thailand.

INTRODUCTION: Epileptic patients face social stigmatization due to negative attitudes and incorrect knowledge on epilepsy. OBJECTIVES: To evaluate knowledge of epilepsy among teachers in Khon Kaen province. MATERIAL AND METHOD: A self-administered questionnaire distributed to 102 teachers who attended the training lectures on epilepsy. The number of correct responses for each item were collected. The statistical analysis included the percentage of correct response and the means of the total scores. RESULTS: Most (78.4%) respondents understood that a seizure is an abnormal electrical discharge in the brain, while 54.9% thought it included a form of abnormal movement and 1% demonic possession. The generalized tonic-clonic seizure (GTCs) was the type of seizure with which most respondents were familiar (90.2%), while 23.5% had knowledge of absence seizures. The respondents identified the following as causes for epilepsy: 1) head injury (84%); 2) genetic disease (74.5%); 3) high fever (68%); and, 4) brain tumor (57%). A small minority associated epilepsy with eating pork (11%) and even fewer (2%) with a non-organic/non-physical cause. Only 16% of respondents thought epilepsy was incurable, and a quarter (27%) of the teachers thought epileptics required anti-epileptic drugs (AEDs) life long, while 20 and 9 percent believed patients would take AEDs for 3-6 months and only for episodes, respectively. About 57% of the teachers thought epileptics needed AEDs for 2-5 years. Most (77-79%) respondents thought epileptics were prohibited from using machinery or driving, and 63% thought alcohol would be prohibited. Almost two-thirds of the teachers (64%) thought they should try to place an object between the teeth of a person having an episode in order to prevent a biting injury to the tongue and 27% would restrain the person and perform chest compressions (CPR). The average total score for correct answers on the questionnaire was about 60% (29.26/50). Respondents generally understood that epilepsy is controllable (82%) and were able to identify a seizure (78.4%). The lowest scores were found in the section on identifying the types of seizures (37.8%). CONCLUSION: Teachers' knowledge of epilepsy was incomplete; thus, an epilepsy education campaign is needed and should emphasize the types of seizures, the causes of epilepsy, and management.

Appropriateness of intravenous loading dose of phenytoin treatment in Srinagarind Hospital.

Intravenous loading dose of phenytoin treatment (ILP) is a useful treatment but may cause serious adverse events. The present study assessed the appropriate use of ILP in Srinagarind Hospital. The authors reviewed all charts that ILP was ordered between January 1st, 2000 and December 31st, 2001, about indication, the infusion rate, and side effects. There were 206 cases treated with ILP Thirty-two cases (15.7%) received inappropriate treatment by ILP The most common indication was primary prophylaxis before brain surgery. There were 7 cases that developed side effects with 5 cases of high blood phenytoin level. These data showed that physicians should consider more carefully the use of ILP.