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 partial sequence of lipoxygenase gene from genomic DNA of aromatic rice (Oryza sativa L.)

Aromatic (Bas-370, PB-1) and non-aromatic (Pusa-677, Pusa-834) rice were selected for the characterization and for distribution of lipoxygenase (Lox) genes. Polymorphism was observed when genomic DNA of rice varieties was hybridized with a heterologous lipoxygenase probe. A distinct polymorphic fragment (approximately 1.2 kb) was found in Bas-370. Sub-genomic library of Bas-370 was constructed and screened with LoxA probe. The smallest putative clone (pBas-14) of approximately 1.2 kb was sequenced. Complete nucleotide and deduced amino acid sequence showed the clone was 1134 bp long and comprised of 378 amino acid residues. PCR amplification of genomic DNA from four rice varieties with a soybean Lox primer also showed a polymorphic fragment of size approximately 600 bp (amplicon) in aromatic varieties that was sequenced directly. Nucleotide sequence alignment between pBas-14 and amplicon concluded that the amplicon was a part of the insert pBas-14.

Unusual haematological alterations in rheumatoid arthritis

Three cases of rheumatoid arthritis (RA), presenting with refractory anaemia, thrombocytopenia and peripheral lymphocytosis respectively, were observed. In all the cases haematological manifestations were unrelated to disease activity or drug toxicity. These patients were detected to have pure red cell aplasia (PRCA) (normocytic normochromic anaemia, reticulocytopenia and absence of erythroid precursors in the bone marrow), immune thrombocytopenia (IT) (absence of splenomegaly and presence of increased megakaryocytes in the bone marrow) and multiple myeloma (MM) (lytic lesions on skull, paraproteinaemia and bone marrow plasmacytosis) respectively. PRCA and IT responded to glucocorticoids. Association with these three haematological alterations has rarely been reported. Our report highlights the need to regularly monitor blood counts in patients with RA.

Decompressive shunts and hepatic encephalopathy

Encephalopathy is a major complication of all decompressive procedures done to reduce portal pressure. There are two major groups of decompressive procedures: surgical portosystemic shunts and transjugular intrahepatic portosystemic shunts (TIPS). Surgical decompressive shunts are of three types: total, partial and selective, depending on the amount of hepatopetal flow that is maintained in each of them. Encephalopathy with these shunts occurs because of reduction in hepatopetal flow. These shunts have failed to reduce mortality; in fact, some studies have shown an increase in mortality following shunts. TIPS has more or less replaced the need for surgical shunts, but their risk to cause encephalopathy is almost equivalent to that of selective shunts and in some series is even more. Lactulose, antibiotics and protein restriction can easily control severe encephalopathy as a consequence of decompressive shunts.

Helicobacter pylori and hepatic encephalopathy

Several extra-intestinal diseases have been associated with Helicobacter pylori infection. Hepatic encephalopathy has been linked to H. pylori infection because of the ammonia produced by the organism in the stomach. H. pylori infection is commoner in cirrhotic patients with hepatic encephalopathy than in those without. Increased ammonia levels have been observed in the gastric juice and blood more commonly in cirrhotics with H. pylori infection than in those without. Though the amount of ammonia produced by H. pylori may be too small to contribute to hepatic encephalopathy, eradication of H. pylori has been shown to improve the blood ammonia levels and hepatic encephalopathy.

Autoimmune hemolytic anemia associated with benign ovarian cyst: a case report and review of literature

A 28-years-old female presented with severe autoimmune hemolytic anemia (AIHA), warm antibody mediated, and right side tubo-ovarian (TO) mass. There was sub-optimal response to immunosuppressive therapy (IST). Eight months later she underwent ovarian cystectomy which resulted in complete remission of AIHA without the need for IST. Pathological examination of the TO mass revealed benign ovarian cyst. Our case highlights the need to search for ovarian cyst/mass in females presenting with AIHA. Since immunosuppressive therapy is usually ineffectual in AIHA associated with ovarian cyst, it may be appropriate to contemplate surgery before embarking on IST in such cases.

Efficacy of endoscopic wire guided biliary brushing in the evaluation of biliary strictures

Endoscopic brush cytology is a valuable technique for the evaluation of biliary strictures. The sensitivity of this technique varies from 30% to 83%, however, it can have specificity of 100%. We retrospectively evaluated the usefulness of wire-guided biliary brush cytology in biliary strictures in our hospital over a 3 years period from 1997 to 2000. Brushings from 58 biliary strictures were obtained during endoscopic retrograde cholangiography. They were compared with histological proof obtained by surgical biopsy or percutaneous fine-needle aspiration cytology and/or clinical findings. These were reported as benign or malignant. Eleven patients were excluded due to incomplete data. Eighteen patients had benign brushings. Fourteen of the 29 patients in whom histological confirmation of malignancy brushings was obtained were also reported as malignant. The sensitivity of endoscopic brushings was 48.2%, specificity 100% and diagnostic accuracy 55.2%. No major complications were seen in our study group.

Metastasis to thyroid from lung carcinoma

Metastasis to thyroid gland are rare. The primary sites which metastasize to thyroid gland include the breast, lung, kidney and stomach. Among lung cancer metastasizing to the thyroid, adenocarcinomas are the commonest followed by squamous, small cell and large cell carcinomas. The bronchioloalveolar carcinoma has not been reported to metastasize to the thyroid. In this case report we document this rare occurrence.

Circadian pattern in cerebro vascular disorders

Over the last decade, various studies have been reported to evaluate the circadian pattern of cardiovascular and cerebro-vascular diseases. The data from Indian population is lacking. We undertook this prospective observational study to evaluate the circadian variation in disorders like cerebro-vascular accidents and transient ischemic attacks. Total of 146 patients (events) were studied. Only 10 patients had TIA's. 55% had hemorrhage and 45% had infarction. The 24 hours period was divided into 6 equal portions of 4 hours each. The maximum events were seen between 4 am to 8 am and 12 noon to 4 pm (23.28%) each. Minimum events were seen between 12 midnight to 4 am 14/146 - 9.58%). The circadian variation in occurrence of cerebro-vascular disorders was present with two equal peaks.

Wasp sting induced neurological manifestations

Wasp stings generally cause local reactions like pain, wheal, flare, edema and swelling, which are generally self-limiting. Multiple stings can lead to vomiting, diarrhea, generalized edema, dyspnea, hypotension, collapse, renal failure or death. Unusually, they may cause serum sickness, vasculitis, neuritis or encephalitis. We report a case of a 40 year old male who developed focal neurological deficit 10 hours following a wasp sting, which was confirmed to be ponto-cerebellar infarction on MRI scan, and recovered within five days.

Adult onset celiac disease in north India

INTRODUCTION

Informations on celiac disease among Indian adults is scarce. With the availability of improved and more accessible diagnostic tools for celiac disease, the disease is being more frequently recognized among the adults. Therefore, a retrospective analysis of duodenal biopsies were performed to identify adult celiac disease among Indian patients.

MATERIAL AND METHODS

A retrospective analysis of the patients, who had villous atrophy on duodenal biopsy between February, 1997 to June 2001, was performed. The clinical presentation, laboratory parameters, treatment and follow up details of patients diagnosed as adult onset celiac disease were analysed. Diagnosis of celiac disease was established in these patients as per ESPGAN criteria.

RESULTS

There were 68 duodenal biopsies during the study period. Thirteen (10 were under 15 years of age and 3 had followup biopsy) biopsies were excluded. Eleven (20%) out of 55 patients with villous atrophy in their duodenal biopsy satisfied the ESPGAN criteria for the diagnosis of celiac disease. The age at the time of diagnosis ranged from 15-56 years (mean 36.8 years). Male to female ratio was 5:6. Chronic diarrhea (99%) was the most common presentation followed by weight loss (88%) and anemia (66%). Only one patient had refractory iron deficiency anemia (11%). Histopathological examination showed, subtotal villous atrophy in 6 patients and partial villous atrophy in 5. Nine out of 11 patients had raised concentration of IgA antigliadin antibody. Two patients also had raised concentration of antiendomysial antibody. All of them showed favorable clinical response to Gluten free diet.

CONCLUSION

Coeliac disease is considered rare in the tropics. Our study shows that this disease may not be as infrequent as is thought.

Biliary complications of pancreatic necrosis

BACKGROUND

Involvement of the biliary tract in pancreatic necrosis is rare. The authors are presenting six patients with this unusual complication.

METHODS

Retrospective analysis of a case series.

RESULTS

The necrotic process involved the bile duct in four patients (bile duct alone in two and bile duct with duodenum in two) and the gall bladder in two patients. It was not possible to make a preoperative diagnosis of biliary tract involvement in any of these patients. The lesions in the biliary tract were caused by the direct erosion by the necrotic tissue in five patients, and in one patient with gangrene of the gall bladder, it was a "remote" complication of the necrotizing process. All patients underwent surgery. Necrosectomy and cholecystectomy were performed in patients with gall bladder lesions, and proximal biliary drainage was the method of choice in patients with erosion of the bile duct. One patient died postoperatively. During follow-up, another patient who had bile-duct involvement developed a stricture in the damaged part of the bile duct and needed hepaticojejunostomy

CONCLUSIONS

Necrotizing pancreatitis can involve the biliary tract, both by direct extension and by its secondary effects. Although cholecystectomy is the treatment of choice in the presence of gallbladder involvement, proximal biliary diversion may be indicated in patients with erosion of the bile duct.

Left atrial myxoma presenting as pseudobulbar palsy

A case of left atrial (LA) myxoma presenting as pseudobulbar palsy, due to multiple cerebral infarcts, without any cardiac manifestations, is presented. LA myxoma is rare cause of embolization to CNS causing ischemic infarcts. Due to multiple CNS infarcts patient can present with varied clinical picture and pseudobulbar palsy is not a very common presentation. It was a real diagnostic dilemma before LA myxoma was diagnosed on echocardiography.

Video game epilepsy

Reflex epilepsy is the commonest form of epilepsy in which seizures are provoked by specific external stimulus. Photosensitive reflex epilepsy is provoked by environmental flicker stimuli. Video game epilepsy is considered to be its variant or a pattern sensitive epilepsy. The mean age of onset is around puberty and boys suffer more commonly as they are more inclined to play video games. Television set or computer screen is the commonest precipitants. The treatment remains the removal of the offending stimulus along with drug therapy. Long term prognosis in these patients is better as photosensitivity gradually declines with increasing age. We present two such case of epilepsy induced by video game.

ICU management of severe malaria

Malaria is very common in India. First step in management of malaria is to establish the diagnosis. It is established by using traditional smear or method like dipstick antigen captures assay which is simpler, accurate and doesn't require expertise. Next step is to look for signs and symptoms, which help cases of severe malaria should be admitted in intensive care unit (ICU) and antimalarial chemotherapy should be started through parenteral route. Complications like coma, anemia, renal failure, pulmonary edema, disseminated intravascular coagulation are not very uncommon. These complications should be anticipated and treated in time. There is no role of corticosteroids, mannitol in the treatment of cerebral edema. Therapeutic monitoring of severe malaria should involve quantitative estimation of parasite load.

Management of dengue fever in ICU

Dengue virus infection can cause a wide spectrum of illness. Thrombocytopenia with concurrent haemoconcentration differentiates dengue haemorrhagic fever from classical dengue fever. Only cases with shock or unstable vitals signs need admission in the pediatric intensive care. The management is essentially supportive and symptomatic. The key to success is frequent monitoring and changing strategies. A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock. Patients in grade I and II should be closely monitored for signs of shock. The management of dengue shock syndrome (grade III and IV) is a medical emergency needing prompt and adequate fluid replacement for the rapid and massive plasma losses through increased capillary permeability. Early and effective replacement of plasma losses with plasma expanders or fluid and electrolyte solutions results in a favourable outcome in most cases. The ideal fluid management should include both cystalloids and colloids (including albumin). Cystalloids are given as boluses as rapidly as possible, and as many as 2 to 3 boluses may be needed in profound shock. Colloidal fluids are indicated in patients with massive plasma leakage and in whom a large volume of cystalloids has been given. Frequent recording of vital signs and determinations of haematocrit are important in evaluating the results of treatment. Apart from correction of electrolyte and metabolic disturbances, oxygen is mandatory in all patients of shock. Some patients develop DIC and need supportive therapy with blood products (blood, FFP and platelet transfusions). Polyserositis, in the form of pleural effusion and ascitis, are common in cases of dengue shock syndrome, and if possible, drainage should be avoided as it can lead to severe hemorrhages and sudden circulatory collapse. The prognosis depends mainly on the early recognition and treatment of shock.

Reversible neurologic manifestations after glycerol: a short report

A 46 year old male inadvertently consumed 500 ml of glycerol and presented with altered sensorium, focal neurologic signs and generalised seizures. He was managed conservatively and recovered fully within 48 hours. The case highlights the rare presentations of overdosage and neurologic effects with glycerol, an otherwise safe drug used in neurology.

Prescribing patterns and cost of antihypertensive drugs in an internal medicine clinic

BACKGROUND

Antihypertensive agents are selected primarily for their ability to prevent morbidity and mortality related to hypertension.

METHODS AND RESULTS

Prescribing trends and the cost of antihypertensive drugs were studied in 300 patients attending an internal medicine clinic. Beta-blockers were the most frequently used group of drugs (46.7%), followed by calcium-channel antagonists (34.3%) and angiotensin-converting enzyme inhibitors (30%). Diuretics were used in only 13.2% of the prescriptions. Atenolol (36%), amlodipine (29.3%) and enalapril (19%) were the most frequently used individual drugs. Propranolol, furosemide, amlodipine and atenolol were the least expensive drugs used, with annual drug acquisition costs of Rs 80, 102, 182 and 318, respectively. Benazepril (Rs 1778), diltiazem SR (Rs 1777), lisinopril (Rs 1660), prazosin (Rs 1416) and losartan (Rs 1365) were the most expensive drugs in terms of annual drug acquisition costs.

CONCLUSIONS

The results of our study emphasize the need to encourage frequent use of diuretics. Since the costs of different antihypertensives vary considerably, newer and relatively expensive antihypertensives should be prescribed only when clearly indicated.

Gastric outlet obstruction in carcinoma gall bladder

BACKGROUND

Gastric outlet obstruction is occasionally reported to occur in advanced gall bladder malignancy and may require palliative surgery. A review of 39 patients who required gastroenterostomy for symptomatic or incipient gastric outlet obstruction in carcinoma gall bladder is presented.

METHODS

This retrospective review included 24 women and 15 men over nine years who underwent gastrojejunostomy for locally advanced neoplasms of the gall bladder.

RESULTS

Twenty two patients with carcinoma gall bladder had symptomatic gastric outlet obstruction whereas in 17 patients gastrojejunostomy had been performed for intraoperatively assessed impending obstruction. Thirty-four patients had concomitant jaundice. In most cases, there was obstruction of the first two parts of the duodenum, mostly by direct tumoral infiltration (64%). All patients underwent anterior gastrojejunostomy, with billoenteric bypass in 15 patients. There were two postoperative deaths. Eight patients developed postoperative delayed gastric emptying; all settled on conservative management, though two patients had recurrent refractory vomiting. Thirty patients had no vomiting till a follow up ranging from 36 days to 11 months.

CONCLUSIONS

Gastric outlet obstruction may frequently complicate gall bladder cancer and a satisfactory palliation can be achieved in most patients by gastrojejunostomy.

Hypokalaemic paralysis

Hypokalaemic paralysis is a relatively uncommon but potentially life-threatening clinical syndrome. If recognised and treated appropriately, patients recover without any clinical sequellae. The syndrome of hypokalaemic paralysis represents a heterogeneous group of disorders characterised clinically by hypokalaemia and acute systemic weakness. Most cases are due to familial or primary hypokalaemic periodic paralysis; sporadic cases are associated with numerous other conditions including barium poisoning, hyperthyroidism, renal disorders, certain endocrinopathies and gastrointestinal potassium losses. The age of onset, race, family history, medications, and underlying disease states can help in identifying the cause of hypokalaemic paralysis. Initial therapy of the patient with hypokalaemic paralysis includes potassium replacement and search for underlying aetiology. Further management depends on the aetiology of hypokalaemia, severity of symptoms, and duration of disease. This review presents the differential diagnosis for hypokalaemic paralysis and discusses management of the syndrome.