Large versus Small Dose Magnesium Sulfate Infusion in Tetanus

INTRODUCTION

Evidence based guidelines regarding the use of magnesium sulfate in tetanus is lacking. Hence, our objective was to compare two infusion doses of magnesium sulfate to control the tetanic spasms.

METHODS

Data of 14 adult male patients admitted in the intensive care unit were retrieved. Twelve adult ventilated patients received magnesium infusion as an adjunct to diazepam therapy to control tetanic spasms. We retrospectively divided them into two groups for comparison. Group 1 patients (n=7) received a smaller dose (<1 g.h(-1)) than group 2 (n=5) (1.5 to 2 g.h(-1)).

RESULTS

The duration of symptoms before arrival to hospital was significantly longer in group 1 than group 2. The Ablett severity grade was II in three patients in group 1 and III in all patients of group 2. In Ablett severity grade III patients, the diazepam dose used was significantly higher in group 1 (n=4) (292±48 mg.d(-1)) than group 2 (n=3) (106±9 mg.d(-1)) as magnesium infusion dose was restricted due to hypotension in group 1. Amongst the patients who received MgSO(4) for ≥10 days, the requirement of diazepam was significantly reduced in the second week (174.1±59.2 mg/d) than the first week (325.4±105.9 mg.d(-1)) of infusion in group 2 (n=4) but not in group 1 patients (n=4).

CONCLUSIONS

The larger dose of MgSO(4) infusion was titrated to control tetanic spasms as an adjunct to diazepam in select group of patients without hypotension. Uncontrolled hypotension, cardiac arrhythmia and renal failure were the factors to limit its infusion dose.

Successful intubation with McCoy laryngoscope in a patient with ankylosing spondylitis

Involvement of cervical spine in ankylosing spondylitis limits neck movement resulting in difficult intubation. We report a case of 45-yr-old lady of ankylosing spondylitis with restricted neck movement planned for emergency laparotomy. Grade 3 Cormack and Lehane laryngoscopic view was observed with Macintosh laryngoscope and gum elastic bougie could not be negotiated. At second attempt with McCoy blade, the posterior commissure of the vocal cord could be visualized and intubation was successful. Thus, in absence of flexible laryngoscopes and when awake intubation is not feasible, McCoy blade should be considered an alternative than Macintosh blade to attempt intubation in patients of ankylosing spondylitis with restricted neck movement.

Chemical reactivity and biological activity of dihydro-1,4-dithiin tetraoxides

Certain dihydro-1,4-dithiin tetraoxides such as dimethipin, a commercial plant growth regulant, have been reported to exhibit highly selective biological activities depending on the type and number of substitutions on the α,β-unsaturated bond in the dithiin ring. Despite the abundant reports on this class of compounds, the study of chemical reactivity of the α,β-unsaturated bond in the dithiin ring has not been reported and the factors governing the biological selectivity of these compounds are still unknown. In this study, the reactivity of eight dithiin compounds substituted in varying degrees at the α,β-unsaturated bond towards biologically important nucleophilic groups at pH 7.4 were investigated using UV-vis, fluorescence, and 1H NMR spectroscopies. Their reactivity towards glutathione correlated strongly with their cell growth inhibitory activity and inhibition of DNA topoisomerase II, an enzyme containing critical sulfhydryl groups. On this basis, the mechanism by which these dithiins achieve the biological selectivity previously reported was proposed. Excellent correlations between glutathione reactivity and Taft’s polar substituent constants or electrostatic atomic charges of the dithiins were also demonstrated, suggesting that these descriptors might be useful for predicting the reactivity of other dithiins towards sulfhydryl nucleophiles.

Perception about the role of anesthesia and anesthesiologist among the paramedical staffs: perspective from a medical college in Nepal

BACKGROUND

Anesthesiologists and anesthesia has been considered behind the scene. The image and status of anesthesiologist in the eyes of the medical and lay communities has always been a problem.

OBJECTIVES

This study was designed to assess the knowledge about the role of anesthesiologist among the paramedical staffs at Kathmandu University Hospital.

METHODS

This prospective questionnaire based study was done at Kathmandu University School of Medical Science, Dhulikhel Hospital for 2nd January 2011 to 30th Jan 2011 among the paramedical staffs working in different department of the hospital.

RESULTS

There were 150 questionnaire distributed out of which 120 responded. Mean Age was 23.33 and most of the respondents were female with majority having education qualification equivalent to intermediate level. Only 49.20 said it to be a different specialty and 72.5% said anaesthesiologist work differently in the theatre where as 70% knew anaesthesiologist did something in the post-operative period too.

CONCLUSION

Anesthesiologists have duty to visit patients pre operatively and post operatively. The role inside the theatre and expanding role outside the theatre is poorly known. The awareness about the role of anesthesiologist in operation theatre, in intensive care unit, acute and chronic pain management and emergency care areas should be highlighted to all the staffs.

Postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block: a randomized study of dexamethasone prophylaxis

BACKGROUND

Postoperative nausea and vomiting is a common distressing problem in patients undergoing gynaecological surgery under anaesthesia including central neuraxial blockade, which requires frequent medical interventions.

OBJECTIVES

We aimed to find out the antiemetic effect of prophylactic dexamethasone for prevention of postoperative nausea and vomiting in patients undergoing total abdominal hysterectomy under subarachnoid block. Influences of dexamethasone on patient satisfaction and postoperative analgesia were also observed as secondary objectives.

METHODS

This was a prospective, randomized, double blind, placebo controlled study conducted in BPKIHS, from January 2009 to April 2009. This study involved 80 American Society of Anaesthesiologist Physical Status I and II patients undergoing total abdominal hysterectomy under subarachnoid block. Patients were divided into two groups of 40 each to receive either 4 mg of dexamethasone (group D) or normal saline (group N) in volume of 2 ml intravenously 1 hour prior to subarachnoid block. Surgery was allowed to start with block height of at least T8 dermatome. Intraoperative and postoperative nausea and vomiting was observed using nausea and vomiting scale every 4 hour for 24 hours.

RESULTS

Seven (17.4%) patients in group D and 11 (27.5%) patients in group N had nausea and vomiting in the intraoperative period (P=0.284). Sixteen (40%) patients in group D experienced nausea and vomiting in the postoperative period as compared to 27 (67.5%) in group N (P =0.0136). Accordingly, the mean requirement of rescue antiemetic was less in group D compared to Group N (P=0.042). Further, only 15 (37.5%) patients in group D required postoperative supplemental analgesic as compared to 23 (57.5%) in group N (P=0.058). After 24 hrs of surgery, 26 (65%) patients expressed satisfaction in group D as compared to 16 (40.0%) in group N (P =0.025).

CONCLUSIONS

Use of dexamethasone prior to subarachnoid block in patients undergoing total abdominal hysterectomy significantly reduces the incidence of nausea and vomiting and the requirement of antiemetic in the postoperative period, with better patient satisfaction.

Propofol sedation during spinal anaesthesia- a dose finding study

BACKGROUND

It is important to be able to measure and maintain a specific sedation level to compare outcomes of different levels of sedation during anesthesia and the aims include general patient comfort, freedom from specific discomfort, and some amnesia for both the block procedure and the surgical operation, in order to meet the patient preference and safety. In this prospective randomized clinical study, we compared the three different infusion doses of propofol.

OBJECTIVE

To find out the appropriate infusion dose of propofol for optimal sedation without causing undue side effects in patients undergoing spinal anaesthesia.

METHOD

One hundred twenty patients ASA PS I-II were randomly allocated to three groups 1, 2 and 3 receiving propofol infusion at the rate of 25, 50 and 75 microgram/kg/min with concentration of (0.5%), (1%) and (1.5%) respectively. They were observed for sedation score, hemodynamic parameters and satisfaction level. The adverse effects like respiratory depression, nausea and vomiting score were assessed.

RESULT

Median sedation score increased in a dose dependent manner, with significantly higher scores in group 2 and 3 compared with group 1. Hemodynamic parameters were better in group 1 and 2 as judged by mephentermine requirement. The awakening time after stoppage of infusion was significantly delayed in group 3 (p < 0.001). Respiratory depression, nausea and vomiting were comparable clinically. Almost three fourth of the patients were satisfied with the techniques used.

CONCLUSION

Propofol infusion at the rate of 50 mcg/kg/min for sedation in spinal anaesthesia provides optimal sedation, early awakening and excellent satisfaction level in the postoperative period.

Incidence of hypertension in patients undergoing surgery at Dhulikhel Hospital-Kathmandu University Hospital

BACKGROUND

Hypertension is an important public health challenge worldwide and is most important modifiable risk factor for cardiovascular, cerebrovascular and renal disease. Blood pressure determination forms an integral part of anaesthesiologist evaluation of his patient condition prior to and during surgery. Data are not available which indicate changes in blood pressure occurring preanaesthetically in hospitalized patients. There are several risks from untreated preoperative hypertension in perioperative and postoperative phase.

OBJECTIVE

To know the incidence of hypertension in preoperative patients undergoing major surgery.

METHODS

This retrospective observational study was based on the data collected from preanaesthetic checkup record book from January 2010 to December 2010.

RESULTS

A total of 955 patients were studied and analyzed in terms of hypertension and demographic characteristics. The total incidence of hypertension in preoperative phase was 10.16%. Among them 64.9% being male and 35.1% female. Maximum incidence was found in age group 50-59 years i.e. 26.6%. Among the case detected maximum patients i.e. 52% were patients with newly diagnosed hypertension and among those under medications 61.1% were using calcium channel blockers.

CONCLUSION

Knowing the incidence will help in proper preoperative optimization of the hypertensive patients and also help in decreasing the incidence of postoperative complications.

Negative pressure pulmonary edema--case series and review of literature

Post obstructive pulmonary edema (POPE) also known as negative pressure pulmonary edema (NPPE) is potentially life threatening complication. It occurs in about 0.1% of anesthetics and is related to upper airway obstruction. Two types have been described in literature. Different etiology has been attributed to development of Negative pressure pulmonary edema. Early identification and treatment of predisposing factor along with proper monitoring of this complication early treatment should be instituted because resolution is also fast and in most cases without residual effects.

Comparison of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy

Background The ability of good glottis visualization during direct laryngoscopy is major determinant of easy tracheal intubation. Sniffing position for laryngoscopy is considered as gold standard and ideal position. Several studies have questioned the validation of sniffing potion. Objectives This study aims to compare relative efficacy of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy. Methods Four hundred patients undergoing elective surgery under general anesthesia requiring endotracheal intubation were randomized into two groups and study was concluded. Glottic visualization was assessed using modified Cormack and Lehane classification. After laryngoscopy, tracheal intubation was performed and intubation difficulty scale was noted. Results Both the groups were comparable regarding glottis visualization. Both the groups were comparable in demographic profiles. All the intubation difficulty scale variables were comparable in both the groups except N3. Total Intubation Difficulty Score was better in sniffing position than in simple head extension group. Conclusion Glottic visualization and intubation difficulty score was better in sniffing position as compared to simple head extension.http://dx.doi.org/10.3126/kumj.v9i1.6265 Kathmandu Univ Med J 2011;9(1):58-63

Surgical site fire: a case of evil spirit or lapsed communication?

Electrocautery has become an indispensable tool in the operating room mainly to achieve bloodless surgical field. However, it does carry several risks including fire burn. Abundant fuels and oxidizer in operation theatre in the presence of electrocautery can easily get ignited, imposing serious risk to the patient and health professionals. This report of a case of surgical site burn injury due to unintentional reuse of a spirit soaked gauze piece intends to create awareness among health professionals and staff regarding such serious complication.

Topical anaesthesia of the vocal cords by nebulized lignocaine inhalation to facilitate fi breoptic nasotracheal intubation in a head-size parotid tumour patient

This case report describes a successful fi breoptic naso-tracheal intubation in a patient with difficult airway due to a nearly head-size right parotid swelling. Nasal fi breoptic intubation was performed by maintaining spontaneous breathing under propofol infusion at a dose of 25 mcg/kg/hour and topical anaesthesia of vocal cords by using oxygen (6 l/min) fl ow to nebulize 4 % lignocaine from the side port of the fi breoptic bronchoscope. The topical anaesthesia was achieved by keeping the scope in close proximity of the vocal cords and in the centre of view of the scope. This case emphasizes the possibility of fi breoptic intubation in a sedated yet spontaneously breathing patient by allowing inhalation of nebulized lignocaine during fi breoptic intubation.  Keywords: fibreoptic intubation, naso-tracheal intubation, nebulized lignocaine, spontaneous breathing, topical anaesthesia.

Incidence and risk factor for ventilator-associated pneumonia in Kathmandu University Hospital

BACKGROUND

Ventilator associated pneumonia is a major cause of morbidity in the intensive care unit. Difficulties in identification of the risk factors, in diagnosing and in prevention, have intensified the problem.

OBJECTIVES

To measure the incidence of ventilator associated pneumonia in intensive care unit and to identify the risk factors associated.

METHODS

A prospective observational cohort study was done in which we evaluated 69 patients who were mechanically ventilated for more than 48 hours to find out the development of nosocomial pneumonia and presence or absence of risk factors. Data were subjected to univariate analysis using chi-square and t-test. Level of significance was set at 0.05.

RESULTS

Twenty two (31.88%) out of 69 patients developed ventilator associated pneumonia, majority of them between four days to 14 days. Reintubation, invasive lines, H2 blockers and low PaO2/FiO2 were identified as major risk factors in our study. Enteral feeding via nasogastric tube and use of steroids was not associated with development of ventilator associated pneumonia. The patients with ventilator associated pneumonia had significantly longer duration of mechanical ventilation (18.88+/-7.7 days vs 7.36+/-4.19 days) and stay (29+/-17.8 days vs 9.22+/-5.14 days). The morality was similar for both the groups with or without ventilator associated pneumonia.

CONCLUSION

The incidence of ventilator pneumonia is high. Patients requiring prolonged ventilation, re-intubation, more invasive lines and H2 blockers, are at high risk and need special attention towards prevention.

Topical anaesthesia of the vocal cords by nebulized lignocaine inhalation to facilitate fibreoptic nasotracheal intubation in a head-size parotid tumour patient

This case report describes a successful fibreoptic naso-tracheal intubation in a patient with difficult airway due to a nearly head-size right parotid swelling. Nasal fibreoptic intubation was performed by maintaining spontaneous breathing under propofol infusion at a dose of 25 mcg/kg/hour and topical anaesthesia of vocal cords by using oxygen (6 l/min) flow to nebulize 4% lignocaine from the side port of the fibreoptic bronchoscope. The topical anaesthesia was achieved by keeping the scope in close proximity of the vocal cords and in the centre of view of the scope. This case emphasizes the possibility of fibreoptic intubation in a sedated yet spontaneously breathing patient by allowing inhalation of nebulized lignocaine during fibreoptic intubation.

Ketamine gargling and postoperative sore throat

INTRODUCTION: Tracheal intubation is a foremost cause of trauma to the airway mucosa, resulting in postoperative sorethroat (POST). The aim of the study was to compare the effectiveness of ketamine gargle with placebo in preventing POST after endotracheal intubation. METHODS: Forty patients scheduled for elective surgery under general anaesthesia were enrolled in this randomized, control trial. Patients were randomly allocated into two groups of 20 patients each: Group C, gargling with drinking water 30 ml; Group K, gargling with ketamine 50 mg in drinking water 30 ml for 30 s, 5 min before induction of anaesthesia. POST was graded at 4, 8, and 24 hours respectively after operation on a four- point scale (0-3). RESULTS: POST occurred more frequently in Group C, when compared with Group K at 4, 8, and 24 hours. CONCLUSIONS: Ketamine gargle reduces the incidence of POST after endotracheal intubation.

Curved knife "Khukuri" injury in the back and anaesthesia induction in lateral position for thoracotomy

Penetrating injury in the back with knife (Khukri) demands induction of anaesthesia and intubation in lateral position. In thoracic injury a double lumen tube placement is required to facilitate one lung ventilation during thoracotomy. In emerging situation, we could successfully execute induction of patient in right lateral position using right sided DLT for left thoracotomy. Its correct placement was confirmed by fiberoptic bronchoscopy. In conclusion right-DLT intubation can be performed without difficulty by conventional direct laryngoscopy using Macintosh blade in lateral position. Keywords: khukuri knife, lateral position, one lung ventilation, thoracic injury.

Ketamine gargling and postoperative sore throat

INTRODUCTION

Tracheal intubation is a foremost cause of trauma to the airway mucosa, resulting in postoperative sorethroat (POST). The aim of the study was to compare the effectiveness of ketamine gargle with placebo in preventing POST after endotracheal intubation.

METHODS

Forty patients scheduled for elective surgery under general anaesthesia were enrolled in this randomized, control trial. Patients were randomly allocated into two groups of 20 patients each: Group C, gargling with drinking water 30 ml; Group K, gargling with ketamine 50 mg in drinking water 30 ml for 30 s, 5 min before induction of anaesthesia. POST was graded at 4, 8, and 24 hours respectively after operation on a four- point scale (0-3).

RESULTS

POST occurred more frequently in Group C, when compared with Group K at 4, 8, and 24 hours.

CONCLUSIONS

Ketamine gargle reduces the incidence of POST after endotracheal intubation.

Caudal bupivacaine vs bupivacaine plus tramadol in post-operative analgesia in children

BACKGROUND

Caudal analgesia with bupivacaine is used commonly for pain relief in children and extradural administration of tramadol seemed to be a safe method of analgesia. The aim of the study is to compare the analgesic efficacy of caudal bupivacaine and bupivacaine and tramadol mixture for postoperative analgesia and to observe for side effects.

METHODS

Forty children, aged between 1- 6 years undergoing infra umbilical surgeries were selected for this randomized, control trial. They were randomly divided into two groups. Group A (n = 20) received 0.5 ml/kg of 0.25 % bupivacaine and Group B (n = 20) received 0.5 ml/kg of 0.25 % bupivacaine with 1 mg/kg of tramadol as a single shot caudal block. In the postoperative period heart rate, respiratory rate, pain score, recovery to first analgesic time, total number of analgesics required in 24 hours and side effects were noted and analyzed.

RESULTS

It was observed that the mean duration of pain relief was significantly longer in Group B (8.8 hrs Vs 7 hrs). Nausea and vomiting was observed in 25% of the patients in group B and 20 % of the patients in group A. None of the patients in both the groups had complication like motor weakness, urinary retention in the postoperative period.

CONCLUSIONS

The addition of tramadol to bupivacaine in the caudal analgesic technique provides longer analgesia and lesser need for rescue analgesic in the postoperative period compared to bupivacaine.

Curved knife "Khukuri" injury in the back and anaesthesia induction in lateral position for thoracotomy

Penetrating injury in the back with knife (Khukri) demands induction of anaesthesia and intubation in lateral position. In thoracic injury a double lumen tube placement is required to facilitate one lung ventilation during thoracotomy. In emerging situation, we could successfully execute induction of patient in right lateral position using right sided DLT for left thoracotomy. Its correct placement was confirmed by fiberoptic bronchoscopy. In conclusion right-DLT intubation can be performed without difficulty by conventional direct laryngoscopy using Macintosh blade in lateral position.

Anaesthesia and perioperative care in remote health camps: patients' concerns

INTRODUCTION

Identifying patients' concerns and expectations regarding anaesthesia and perioperative care in mobile surgical camps is relevant for the camp workers. This prospective observational study was conducted to assess knowledge, concerns, and expectations about anaesthesia and perioperative care in patients undergoing surgery in mobile surgical camps in remote mountainous districts of Eastern Nepal.

METHODS

A questionnaire with seven items related to anaesthesia and perioperative care was used for interviewing 80 individuals of age > or = 12 years, 20 from each camp at Solukhumbu, Sankhuwasabha, Khotang and Bhojpur districts.

RESULTS

Data of two patients were lost leaving only 78 individuals for analysis. The mean age of the subjects was 30.5 (+/- 14.6) years with the male: female ratio of 43: 35. Fifty-eight (74.4%) patients had some gross idea about the modality of administration of anaesthetics. Twenty-six (33.3%) individuals preferred GA over local anaesthesia, whereas 22 (28.2%) were happy either way if there was no pain. Pain was the main concern for 73.1% of the patients. Of the 25 patients expressing fear of GA, death or not being able to wake up anymore was the main concern for 60.0%. Increasing age was associated with lower fear of GA (p < 0.05). Surgical experience was distressing for 17 (21.8%) patients. The overall experience of the anaesthesia and surgery was worse than expected for 25.6% of the patients.

CONCLUSIONS

Patients presenting to these health camps have limited knowledge regarding anaesthesia and perioperative care but have valid concerns and expectations in respect of their safety, comfort and outcome.

Comparison of Bolus Phenylephrine, Ephedrine and Mephentermine for Maintenance of Arterial Pressure during Spinal Anesth

INTRODUCTION: Hypotension is common following spinal anesthesia. Various vasopressors have been indicated to prevent it. The study compares three such agents namely phenylephrine, ephedrine and mephentermine. METHODS: The study included 90 patients undergoing elective and emergency cesarean section who developed hypotension following subarachnoid blockade. Parturient were randomly divided into three groups each group had 30 patients. Group P received bolus of Phenylephrine 25 microgram, where as group E received Ephedrine 5mg and Group M received Mephentermine 6mg. RESULTS: It was found that rise of blood pressure was significantly higher in case of phenylephrine group in first six minutes, after the bolus, there was significant reduction in the heart rate in phenylephrine group, but there was tachycardia following administration of bolus ephedrine and mephenteramine. Neonatal APGAR score were similar in all three groups. CONCLUSIONS: All three drugs maintained hemodynamics within 20 percent of the baseline values on intravenous administration. Keywords: APGAR, ephedrine, hypotension, mephentermine, phenylephrine, spinal anesthesia.

Comparison of bolus phenylephrine, ephedrine and mephentermine for maintenance of arterial pressure during spinal anesthesia in cesarean section

INTRODUCTION

Hypotension is common following spinal anesthesia. Various vasopressors have been indicated to prevent it. The study compares three such agents namely phenylephrine, ephedrine and mephentermine.

METHODS

The study included 90 patients undergoing elective and emergency cesarean section who developed hypotension following subarachnoid blockade. Parturient were randomly divided into three groups each group had 30 patients. Group P received bolus of Phenylephrine 25 microgram, where as group E received Ephedrine 5mg and Group M received Mephentermine 6mg.

RESULTS

It was found that rise of blood pressure was significantly higher in case of phenylephrine group in first six minutes, after the bolus, there was significant reduction in the heart rate in phenylephrine group, but there was tachycardia following administration of bolus ephedrine and mephenteramine. Neonatal APGAR score were similar in all three groups.

CONCLUSIONS

All three drugs maintained hemodynamics within 20 percent of the baseline values on intravenous administration.

Anesthetic management of a child with Down's syndrome having atlanto axial instability

Down's syndrome is the most commonly encountered congenital anomaly in medical practice. These patients are of special concern to medical practice because of their associated problems with regard to respiratory, cardiovascular and other systemic problems. As these patients present for repeated surgeries like dental extraction, facial reconstruction and fixation of cervical spine, these patients pose challenges to the anesthesiologist because of their unique set of problems, namely atlantoaxial instability, small trachea, congenital heart disease and repeated chest infections due to lowered immunity. Their reactivity to inhalational anesthetics and atropine is variable. Here we present an interesting case report of a child with Down's syndrome who presented with atlantoaxial instability for MRI of cervical spine under general anesthesia.

Complex regional pain syndrome (CRPS) type-1 following snake bite: a case report

The pathophysiological mechanism and clinical course of complex regional pain syndrome (CRPS) type-I still remain ill defined. Both the treatment and the prediction of the outcome of the treatment are difficult. Abnormal neurohumoral and inflammatory mechanisms have been implicated in its causation usually following trivial noxious event in an extremity. However, to the best of our knowledge CRPS type-1 following snakebite has not been reported yet in the literature. We here report a case of an aggressive CRPS type-1 following a mountain pit viper bite, locally known as Gurube (Ovophis monticola monticola) in a 55-year-old lady. The clinical condition responded well to the therapy with serial sympathetic blockade of the limb with local anaesthetics, non-steroidal antiinflammatory analgesic, antiepileptic, antidepressant and physiotherapy. Our experience in managing this patient and associated pathophysiology in development of CRPS type-1 are discussed.

Erythema nodosum leprosum in Nepal: a retrospective study of clinical features and response to treatment with prednisolone or thalidomide

INTRODUCTION

Erythema nodosum leprosum (ENL) is an inflammatory reaction, which may occur in the course of leprosy and may result in nerve function impairment and subsequent disability.

METHODS

This retrospective study explores demographic and disease specific parameters. Severity of ENL was assessed using the Reaction Severity Scale (RSS). Records of 94 patients were reviewed. The study reports also on the treatment of 76 of these patients who were treated with prednisolone alone or thalidomide in addition to prednisolone. RESULTS Thirty percent of patients presented with ENL at time of diagnosis; 41% developed ENL-reaction in the first year of MDT. Forty-eight percent of patients were treated for ENL-reaction for less than 12 months; 13% for more than 5 years. High RSS-scores correlated with a longer duration of treatment. In group A (prednisolone) 51.7% and in group B (prednisolone and thalidomide) 76.6% of patients were male. Age, leprosy classification, delay of multidrug treatment (MDT) and interval between MDT and first ENL-symptoms did not differ significantly in both groups. Median duration of ENL-treatment was 15 months in group A versus 38 months in group B (P < 0.001). At the start of treatment, ENL-reaction was less severe in group A (RSS = 12) than in group B (RSS = 18; P = 0.003).

DISCUSSION

ENL-symptoms may be of help in the early diagnosis and adequate treatment of ENL. Characterisation of (sub) groups of patients with ENL based on presence and severity of symptoms is important for future prospective studies to better evaluate the efficacy of interventions.