One year outcome of babies with severe neonatal hyperbilirubinemia and reversible abnormality in brainstem auditory evoked responses

Brainstem auditory evoked responses (BAER) were longitudinally recorded prospectively in 18 term infants with neonatal hyperbilirubinemia (NHB) (total serum bilirubin > 15 mg/dl). Seven neonates had abnormal BAER. Wave complex IV-V was absent in eight recordings in NHB group while they were normal in the control group (p < 0.001). Prolongation of latency of waves I and V and interwave conduction time (wave I-V) occurred in jaundiced infants especially when unconjugated serum bilirubin level rose above 22 mg/dl. The abnormalities in BAER reversed to normal in all seven neonates after exchange blood transfusion indicating transient nature of bilirubin toxicity to the brain. All seven neonates in the study and control group had normal hearing, development quotient and were free of neurological sequelae on follow up for one year.

Albendazole in single CT ring lesions in epilepsy

Single, small, enhancing lesions that often resolve spontaneously are frequent findings on CTs of Indian patients with seizures. Based on ELISA and biopsy data, the majority of these lesions are probably cysticercosis. To determine if these patients should be treated with albendazole, we performed a double-blind, randomized, placebo-controlled study involving 75 patients with seizures and the appropriate CT abnormality without neurologic abnormality on examination. Patients were randomized to albendazole (15 mg/kg/d) and placebo for 1 week, and we obtained serial CTs at the end of 1 week, 1 month, and 3 months. All patients completed a 3-month follow-up and none had systemic evidence of tuberculosis or cysticercosis. The lesions varied in size from 3 mm to 2.1 cm, with an average size of 1.18 cm. Serum ELISA for cysticercosis was positive in 30 and CSF ELISA was positive in 20 of 45 patients. Forty patients received albendazole and 35 received placebo. At the end of 3 months, a total of 68 patients showed resolution. Thirty-five of 40 patients who received albendazole showed resolution, as opposed to 33 of 35 patients on placebo. We conclude that albendazole therapy was not beneficial.

Randomized controlled trial of dexamethasone in tuberculous meningitis

SETTING

The patients admitted to the Neurology ward of the All India Institute of Medical Sciences Hospital.

OBJECTIVE

To assess the role of dexamethasone as an adjunct to antimicrobial therapy in the treatment of tuberculous meningitis.

DESIGN

A randomised controlled trial of 47 patients was conducted over a 13-month period. 41 patients completed the trial. Patients were stratified into mild, moderate and severe groups and randomly allocated to steroid and non-steroid groups. All patients received a standardized antituberculosis drug regime. The end point was 3 months, or death if earlier. The evaluation at the end point included survival, resolution of symptoms, sequelae and activities of daily living. Results were analysed using the Wilcoxon rank sum test.

RESULTS

The patients in the dexamethasone group fared better. 75% of this group had mild sequelae as opposed to 62% of the control group. Amongst the survivors, those who received dexamethasone sensorium improved earlier, and there was greater improvement in mental function and daily activities. The difference, however, did not reach statistical significance.

CONCLUSIONS

Dexamethasone appears useful as an adjunct in the treatment of tuberculous meningitis especially in patients who have severe disease. The results need confirmation by a larger trial.

Diagnostic criteria for tuberculous meningitis and their validation

SETTING

Tuberculous meningitis (TBM) has high morbidity and mortality. Demonstration of tubercle bacilli in cerebrospinal fluid (CSF), the only reliable method of diagnosis, is time consuming and has a low yield. Early diagnosis and treatment are of utmost importance for favourable outcome.

OBJECTIVE

The study was conceived to define easy to use criteria.

METHODS

A set of criteria using clinical features, CSF examination and computed tomography (CT) findings were defined. 76 patients suspected of having TBM were divided into definite, highly probable, probable and possible TBM based on the criteria. The validity of criteria was tested using information from bacterial isolation, polymerase chain reaction (PCR) test for tuberculosis, response to treatment and autopsy.

RESULTS

PCR was positive in over 75% of patients in the highly probable and probable groups. 91% of patients with highly probable and 66% with probable TBM improved on antituberculosis therapy.

CONCLUSION

The criteria are reliable in making early diagnosis of TBM.

Botulinum toxin A in blepharospasm and hemifacial spasm

We report the first Indian experience of botulinum toxin A in the treatment of blepharospasm and hemifacial spasm. Sixteen patients, 7 with essential blepharospasm, 5 with Meige syndrome and 4 with hemifacial spasm received botulinum toxin A injection. One patient received 3 courses of injections, 2 received 2 courses and the rest received only one course. The effect was observed after a latent period of less than 48 hours in all patients and lasted for a mean of 16.65 weeks. More than 70% improvement occurred after 17/20 injections (85%). Poor response was more often seen when blepharospasm was associated with oromandibular dystonia (2/5 injections). Though the duration of response and subjective score of improvement was best in patients with hemifacial spasm, the numbers were very small for any statistical evaluation. The side effects were local, transient, mild and well tolerated. The commonest side effect was blepharoptosis.

Randomized, double-blind, placebo-controlled, clinical trial of D-alpha-tocopherol (vitamin E) as add-on therapy in uncontrolled epilepsy

In a double-blind, cross-over trial, vitamin E, and placebo were compared as add-on therapy in 43 patients with uncontrolled epilepsy. The study consisted of a 3-month baseline period followed by two treatment phases of vitamin E or placebo with cross-over to the second phase after 3 months. No significant side effects were noted during the study. Mean seizure frequency in the baseline period was 15.9 +/- 10.5 as compared with 11.8 +/- 10.9 during the placebo phase and 13.7 +/- 11.1 during the vitamin E phase. No significant change in seizure frequency was observed with vitamin E as compared with placebo (p > 0.1). Similar observation was noted in subgroups with generalized seizures (n = 25), partial with secondarily generalized seizures (n = 11), or complex partial seizures (CPS) (n = 7). This study did not corroborate the earlier claims of therapeutic efficacy of vitamin E as add-on therapy in refractory epilepsy in adults.

Ocular myasthenia--factors predictive for generalisation

A retrospective analysis was done from case records of 186 patients with myasthenia. Ninety patients had purely ocular symptoms at the onset. Thirty six of these patients continued to have ocular myasthenia while 54 patients developed features of generalised disease. There were no significant difference between the two groups as regards age at onset, sex distribution, response to repetitive stimulation, radiologic evidence of thymic enlargementor associated thyroid disease. The median time for generalisation was 3 months. A later age of onset seemed to prognosticate for early generalisation.

Haemorheological factors in the pathophysiology of acute stroke

Blood viscosity studies were carried out in fourteen patients with acute stroke, eight with cerebral infarction, six with cerebral haemorrhage and in thirteen controls. We observed a statistically significant higher values of plasma, red cell and whole viscosity in patients with acute stroke than in normal controls. Plasma fibrinogen levels were statistically higher (p less than 0.01) in patients than in normal controls. The platelet aggregation was increased in two young adults with acute stroke. The results suggest that the haemorheological factors play an important role in the pathophysiology of stroke patients.

Combination therapy of parkinsonism with deprenyl

In view of the encouraging results in various trials with deprenyl as an added drug therapy for Parkinson's disease, a pilot study to study deprenyl's efficacy in the Indian population was undertaken. Eleven patients were recruited in this open trial and were objectively assessed by Unified Rating Scale for Parkinsonism of Columbia University, Modified Hoehn and Yahr Staging and Schwab and England activities of daily living. Side effects, mood changes, changes in dyskinesia percentage, early morning dystonia and off period percentage were also noted. This study suggests improvement in the above parameters with minimal side effects.

Behavioural symptoms in dementia: nature and treatment

Cognitive deficits are the recognised symptoms of the dementias of later life. However, behavioural symptoms also contribute significantly to the problem and are often the main reason for a clinical consultation. The present study describes non - cognitive behavioural symptoms in 30 patients during various stages of dementia. Anxiety, depressive features, agitation, wandering and paranoid symptoms are the main features. The paper also discusses the usefulness and limitation of pharmacological treatment of these symptoms.

Effect of vesical feedback on rate of urine formation demonstrated by infusing hypotonic and hypertonic saline into the urinary bladder of dogs

The present study was undertaken to investigate the effect of the presence of solutions of different osmolality (hypertonic 3%, 4% and 5% hypotonic 0.1%, 0.2% and 0.3% in the urinary bladder on renal urine formation. The study was conducted on 36 dogs of either sex. 100 ml normal saline was used for distending the bladder. Various hypertonic and hypotonic solutions were infused inside the bladder and rate of urine formation was recorded. Presence of hypertonic fluid increased the rate of urine formation and hypotonic fluid decreased it.

POEMS syndrome

A patient with peripheral polyneuropathy, hepatosplenomegaly, osteosclerotic myeloma in the ilium, hyperpigmentation and hypertrichosis is described. A diagnosis of POEMS syndrome was made. This is the first report of this syndrome from India.

Flunarizine in migraine prophylaxis: an Indian trial

Flunarizine, a calcium channel blocker is considered useful in migraine prophylaxis. We report the first Indian trial with this drug. Fifteen patients with migraine were studied in a 6 months double-blind, placebo-controlled crossover trial. Flunarizine was superior to placebo in reducing the severity and duration of the individual attacks though there was no statistically significant effect on frequency of migraine attacks. The side effects most frequently caused by flunarizine were weight gain and daytime sleepiness.

Rapid diagnosis of tuberculous meningitis by polymerase chain reaction

The polymerase chain reaction (PCR) in cerebrospinal fluid was compared with conventional bacteriology and an enzyme-linked immunosorbent assay (ELISA) for cerebrospinal fluid antibodies in the diagnosis of tuberculous meningitis (TBM). PCR was the most sensitive technique; it detected 15 (75%) of 20 cases of highly probable TBM (based on clinical features), 4 (57%) of 7 probable cases, and 3 (43%) of 7 possible cases. ELISA detected 11 (55%) of the highly probable cases and 2 each of the probable and possible cases. Culture was positive in only 4 of the highly probable cases. Among the controls (14 pyogenic meningitis, 3 aseptic meningitis, 34 other neurological disorders), 6 subjects tested early in the study (2 pyogenic meningitis, 4 other disorders) were PCR positive. Second DNA preparations from their stored cerebrospinal fluid samples were all PCR negative, suggesting that the false-positive results were due to cross-contamination. 18 PCR-positive TBM samples retested were all still PCR positive. The antibody ELISA was positive in 3 controls despite the use of a high cutoff value.