Role of Biomarkers in Differentiating New-onset Seizures from Psychogenic Nonepileptic Seizures

Introduction:

Review of literature revealed very limited studies considering a combination of serum prolactin (PRL) and serum creatine kinase (CK) as markers for differentiating epileptic and psychogenic nonepileptic seizures (PNES). Therefore, in the present study, we analyzed the role of serum PRL and serum CK, individually and in combination.

Methodology:

This prospective study was conducted in a tertiary care medical teaching hospital over a period of 18 months. Patients aged over 15 years suspected to have new-onset seizures presenting within 5 h of ictus were included in this study. CK, serum PRL was measured at 0–1, 1–3, and 3–5 h after seizures.

Results:

Hundred subjects were studied for the role of serum PRL and serum CK in differentiating epileptic and PNES. The mean age was 42.24 years with a male:female ratio of 1.27:1. All patients of generalized tonic–clonic seizures (GTCS), who presented within 1 h, had elevated PRL, whereas 75% of patients with partial seizures had elevated PRL within 1 h of presentation. Nearly 91.66% of patients with GTCS who presented within 1 h had elevated CPK, whereas 70% of patients with partial seizures had elevated CPK. None of the patients diagnosed with PNES showed rise in either of the markers.

Conclusion:

In the present study, none of the patients with PNES showed raise in either serum PRL or CK. However, there was no correlation between the types of seizure and PRL or serum CK levels.

Hypocalcemia and bone mineral density changes following denosumab treatment in end-stage renal disease patients: a meta-analysis of observational studies

The incidence of hypocalcemia and bone mineral density (BMD) changes in end-stage renal disease (ESRD) patients on denosumab remains unclear. We performed this meta-analysis to assess the incidence of denosumab-associated hypocalcemia and effects of denosumab on BMD in ESRD patients. A literature search was conducted using MEDLINE, EMBASE, and Cochrane Database from inception through November 2017 to identify studies evaluating incidence of denosumab-associated hypocalcemia and changes in serum calcium, phosphate, alkaline phosphatase (ALP), parathyroid hormone (PTH), and BMD from baseline to post-treatment course of denosumab in ESRD patients. Study results were pooled and analyzed using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017081074). Six observational studies with a total of 84 ESRD patients were enrolled. The pooled estimated incidence of hypocalcemia during denosumab treatment was 42% (95% CI 29-55%, I² = 0%). Hypocalcemia occurred approximately 7 to 20 days after the first dose and reached nadir of low calcium levels in the first 2 weeks up to 2 months. However, there were no significant changes in serum calcium or phosphate from baseline to post-treatment course (≥ 3 months after treatment) with mean differences [MDs] of 0.20 mg/dL (95% CI, - 0.30 to 0.69 mg/dL) and - 0.10 mg/dL (95% CI, - 0.70 to 0.49 mg/dL). There were significant reductions in ALP and PTH levels with standardized mean differences (SMDs) of - 0.65 (95% CI - 1.13 to - 0.16) and - 1.89 (95% CI - 3.44 to - 0.34), respectively. There were significant increases in T-scores with MDs of 0.39 (95% CI 0.10 to 0.69) and 0.79 (95% CI 0.60 to 0.98) for lumbar spine and femoral neck, respectively. Our study demonstrates the estimated incidence of denosumab-associated hypocalcemia in dialysis patients of 42%. From baseline to post-treatment course, although there are no differences in serum calcium and phosphate, our findings suggest significant reductions in ALP and PTH and a significant increase in BMD. Currently, denosumab should not be considered as the treatment of choice in ESRD patients until more safety and efficacy data are available.

Chest Trauma Requiring Admission: Differences in Earthquake Victims and other Modes of Injury

Background The April 25, 2015 Nepal earthquake (7.8 Richter scale) followed by May 12, 2015 major aftershock (7.3 Richter scale) killed more than 9,000 people and injured more than 23,000 people. Dhulikhel Hospital situated at Kavre district of Nepal encountered major bulk of Earthquake victims residing at Sindhuplanchowk, Kavre and Dolakha districts during subsequent earthquake events. Objective To distinguish any significant differences in hospital admitted Earthquake and nonEarthquake chest trauma cases. Method Retrospective study was done comparing earthquake with non-earthquake chest trauma cases admitted in Dhulikhel Hospital. Study included parameters like mode of injury, time taken to reach health center, symptoms at presentation, involvement of chest area, presence and site of rib fracture, presence of hemothorax or pneumothorax, spectrum of treatment required, hospital admission days. Result There were total 23 earthquake victims of which 14 (61%) were female and rest of 9(39%) were male whereas out of total 95 non earthquake cases 23(24%) were female and 72 (76%) were male (p< 0.01). Mean age in earthquake victims was 53.73 (SD 18.33, range 19-84) while non earthquake cases was 46.83(SD 16.53, range 11-90), (p >0.05). Major mode of injuries in earthquake victims was hit by objects (82.60%) followed by fall (17.4 %). Incidence of rib fractures was 69.56% in earthquake victims and 85.26 % in non earthquake cases with average of 2-3 ribs in both cases (p>0.05). There was higher rates of pneumothorax in earthquake victims (52.17%) compared to non earthquake cases (30.52%), (p<0.05). There wasn't evidently major differences in incidence of pulmonary contusion, hemothorax and surgical emphysema. The mean duration of hospital admission days in earthquake victims was 7.78 days while non earthquake cases was 5.04 days (p >0.05). The total number of patients requiring chest tube insertion in earthquake victims was 16(69.56%) while that was 29(30.52 %) in non earthquake patients (p <0.01). Conclusion There was preponderance of female gender in earthquake related cases compared to non earthquake cases. Incidence of rib fracture was higher in earthquake victims. In earthquake victims, higher proportion of patient required chest tube drainage compared to non earthquake cases.

Precontoured Clavicular Locking Plate with Broad Lateral End: A Newly Designed Plate for Lateral Third Clavicle Fractures

Introduction: Various treatment modalities are available but no consensus has been reached for optimal treatment of lateral third clavicle fractures. Precontoured locking plates with broad lateral end for multiple screws fixation is a newly designed plate for lateral third clavicle fractures. The objective of our study was to analyse the functional outcomes as well as complications of this technique in a significant number of cases with long follow-up duration.

Materials and Methods: Forty-six patients with distal third clavicle fractures were treated by precontoured clavicular locking plate with broad lateral end. Functional outcomes were assessed on the basis of Constant-Murley Shoulder Outcome Score and University of California, Los Angeles (UCLA) Shoulder Rating Score, active shoulder range of motion, time for fracture union and coraco-clavicular distance.

Results: The mean Constant-Murley score was 92.56±4.47 (range: 79-98) for injured side and 96.22±2.23 (range: 90-100) for normal side with p-Value 0.56. Mean coraco-clavicular distance at final follow-up was 10.52±1.13 mm (range 9.7 to 11.7 mm) in injured side and 10.25±0.98 mm (range 9.6 to 11.2 mm) in normal side. Mean UCLA Shoulder Rating Score was 32.55±2.12 (range: 27-34) for injured side and 33.46±1.88 (range: 31- 35) on normal side with p value 0.58. No major complications that necessitated revision of surgery occurred in our study.

Conclusion: This newly designed plate seemed extremely useful in successful union of lateral third clavicle fractures, with reduced rate of complications like fixation failures, iatrogenic rotator cuff injury, AC joint osteoarthritis and sub-acromial bursitis, with good functional outcomes.

Use of multiplex PCR based molecular diagnostics in diagnosis of suspected CNS infections in tertiary care setting-A retrospective study

OBJECTIVES

CNS infections like meningitis and encephalitis pose enormous healthcare challenges due to mortality, sequelae and socioeconomic burden. In tertiary setting, clinical, microbiological, cytological and radiological investigations are not distinctive enough for diagnosing microbial etiology. Molecular diagnostics is filling this gap. We evaluated the clinical impact of a commercially available multiplex molecular diagnostic system - SES for diagnosing suspected CNS infections.

PATIENTS AND METHODS

This study was conducted in our tertiary level Neurology ICU. 110 patients admitted during Nov-2010 to April-2014 were included. CSF samples of patients clinically suspected of having CNS infections were subjected to routine investigation in our laboratory and SES test at XCyton Diagnostics. We studied the impact of SES in diagnosis of CNS infections and its efficacy in helping therapeutic management.

RESULTS

SES showed detection rate of 42.18% and clinical specificity of 100%. It had 10 times higher detection rate than conventional tests. Streptococcus pneumoniae and Mycobacterium tuberculosis were two top bacterial pathogens. VZV was most detected viral pathogen. SES results elicited changes in therapy in both positive and negative cases. We observed superior patient outcomes as measured by GCS scale. 75% and 82.14% of the patients positive and negative on SES respectively, recovered fully.

CONCLUSION

Detecting causative organism and ruling out infectious etiology remain the most critical aspect for management and prognosis of patients with suspected CNS infections. In this study, we observed higher detection rate of pathogens, target specific escalation and evidence based de-escalation of antimicrobials using SES. Institution of appropriate therapy helped reduce unnecessary use of antimicrobials.

A veil in the oral cavity: report of two cases of oral synechiae

An oral synechia is an adhesion between the maxilla and the mandible; these adhesions can be found at various locations in the oral cavity. The presence of oral synechiae associated with cleft palate represents a rare congenital deformity. Oral synechiae with cleft palate can have serious implications for airway management and feeding in babies, and hence requires early intervention to reduce morbidity. Two cases of congenital oral synechiae accompanied by cleft palate, in which the synechiae veiled the oral cavity restricting a detailed intraoral examination, are reported here.

Titanium Elastic Nailing System (TENS) for Tibia Fractures in Children: Functional Outcomes and Complications

INTRODUCTION

Closed reduction and cast application is still regarded as first line treatment for pediatric tibial fractures. Over the past few decades, management of pediatric tibial fractures has shifted more towards operative intervention because of quicker recovery, shorter rehabilitation period, less immobilization, lack of stiffness of adjoining joints, and less psychological impact to the children. Flexible intramedullary nails not only fulfill the above advantage but also maintain alignment and rotation.

METHODS

This was a retrospective study of pediatric tibial fractures fixed with two titanium elastic nails through proximal ends of bones. Alignment of fracture, any infection, delayed union, non union, limb length discrepancy, motion of knee joint, and fracture union time were measured during follow-up examination.

RESULTS

Forty-five patients were enrolled into the study out of which 28 (62.2%) were male and 17 (37.8%) were female. Average age of patient was 9.48±2.17 years and average time taken to heal the fractures (both clinical and radiological) was 11.17±2.81 weeks. There were 2 (4.4%) of malunion, 4 (8.8%) of delayed union, 3 (6.6%) of limb shortening, 2 (4.4%) of limb lengthening, 6 (13.6%) of nail prominence and skin irritation, 2 (4.4%) of superficial infection at nail entry site and one case of re-fracture.

CONCLUSIONS

Titanium elastic nail fixation is a simple, easy, rapid, reliable and effective method for management of pediatric tibial fractures in patients with operative indications. There may be the chances of complication following the TENS in tibia but these are avoidable as well as manageable with careful precautions.

Odorless inhalant toxic encephalopathy in developing countries household: Gas geyser syndrome

Background:

Liquefied petroleum gas geysers are used very frequently for heating water in developing countries such as India. However, these gas geysers emit various toxic gases; one among them is colorless, odorless carbon monoxide (CO). In the past few years, there were reports of unexplained loss of consciousness in the bathroom. However, the exact cause for these episodes has been recognized as toxic encephalopathy due to toxic gases inhalation mainly CO.

Objective:

To analyze the clinical profile and outcome of patients brought with loss of consciousness in the bathroom while bathing using gas geyser.

Materials and Methods:

Case records of patients with the diagnosis of gas geyser syndrome from 2013 to 2015 were retrieved and analyzed. Twenty-four cases were identified and included in the study. This was a retrospective, descriptive study.

Results:

Twenty-four patients were brought to our Emergency Department with loss of consciousness in the bathroom while bathing. Twenty-one cases had loss of consciousness during bathing and recovered spontaneously. Two cases were found dead in the bathroom and were brought to the Department of Forensic Medicine for postmortem. One case was brought in deep altered state of consciousness and succumbed to illness within 1 week.

Conclusion:

Awareness regarding CO intoxication due to usage of ill-fitted, ill-ventilated gas geyser is necessary as they are entirely preventable conditions.

A study of clinical profile, radiological and electroencephalographic characteristics of suspected Creutzfeldt-Jakob disease in a tertiary care centre in South India

Introduction:

Creutzfeldt-Jakob disease (CJD) is a progressive, fatal, neurodegenerative disease classified under transmissible spongiform encephalopathies (TSE) or prion diseases. It is characterized by long asymptomatic period followed by rapid clinical deterioration leading to the death within months. The disease is still under-reported in India.

Objective:

The aim of this study was to describe the clinical, radiological and electroencephalographic characteristics of eight cases of CJD encountered in MS Ramaiah Medical college and Hospital, Bangalore over the past 3 years (2010-2013). This was retrospective, observational, hospital-based study.

Results:

The mean age of patients was 66.6 years (range: 54-82) and there was female predominance (five patients). The main clinical manifestations were cognitive disturbance (8/8) and myoclonus (8/8), followed by behavioral disturbance (5/8), ataxia (5/8) and extra-pyramidal symptoms/signs (4/8). Time interval (mean) between onset of disease to death was 6.6 months (range: 3-14). Brain MRI abnormalities were noted in 6 patients: Fluid-attenuated inversion recovery hyperintensities with restriction on diffusion-weighted image/apparent diffusion coefficient (DWI/ADC) in caudate and putamen, and diffusion hyperintensities without restriction on ADC in parieto-occipital, frontal and temporal regions. Classical electroencephalogram (EEG) changes of periodic triphasic waves were seen in 87% of patients. The CSF 14-3-3 protein assay was positive in two patients (out of four). Seven cases were probable CJD and one was possible CJD.

Conclusion:

A strong clinical suspicion aided by characteristic brain MRI and EEG abnormalities is essential for timely diagnosis of this fatal disease.

Close Versus Limited Open Method of Ender's Nail Fixation in Paediatric Femoral Shaft Fractures

INTRODUCTION

There are various surgical options for treating fracture of femoral shaft in children. Here we compare the results of close with limited open method of Ender's nails fixation of femoral shaft fractures in children.

METHODS

We studied 60 children with femoral shaft fractures in age group 5-15 years. Ender's nail fixation was done by close technique in 40 cases and in 20 cases by limited open technique.

RESULTS

The mean operative time was significantly high in limited open group being 64 minutes in comparison to 50 minutes in close group. There was no significant difference between close and limited open groups with respect to time for partial weight bearing and time for full weight bearing. Fracture united sooner in close group as compared to open group. Union was achieved in all patients within a mean of 11 weeks in close group in comparison to 12.4 weeks in open group. According to the Flynn criteria in close group 34 patients had excellent results, 6 had satisfactory and none poor. In limited open group outcome was excellent in 14 patients, satisfactory in 4 patients and 2 had poor result. There was no significant difference in outcome based on Flynn criteria between two groups.

CONCLUSIONS

Though operative time is more and healing is delayed in Ender's nail fixation by limited open technique, there is no statistical difference in final outcome as per Flynn criteria between close and limited open technique of Ender's nail fixation of femoral shaft fractures in children.

Clinicomicrobiological profile of infective endocarditis in a tertiary care center of Nepal

Background Infective endocarditis is a common problem and data regarding its clinical and microbiological pattern from developing countries are sparse. We studied clinical features and the microbiological pathogens in patients with Infective Endocarditis in our Hospital. Objective To study the clinical profile and microbiological pathogens involved in patients with Infective Endocarditis, admitted under Department of Internal Medicine of B.P Koirala Institute of Health Sciences. Materials and methods A total of 54 patients with history of fever and underlying heart disease were studied. It was a hospital based cross sectional descriptive study done in patients with infective endocarditis presented to us from March 2007 to February 2008 in B.P Koirala Institute of Health Sciences. Results Out of 54 patients, 11 (20.4%) had Dukes definite IE. The male: female ratio was 1.2:1. The mean age of the study group was 27.3 years (range=16-55). In IE group, fever was present in 100% cases (n=11) as it was the inclusion criteria of the study, followed by SOB 81.8% (n=9). History of antibiotic therapy prior to the presentation was present in 36.7 % (n=4) patients. Pallor was the most common sign 63.6% (n=7). Splenomegaly was seen in 18.2% (n=2). Anaemia (Hb<10gm %) in 36.4% (n=4) and microscopic haematuria in 72.3% (n=8) cases. Blood culture positivity was seen in 36.4 %. The most common pathogens were Staphylococcus aureus in 27.3% (n=3) and Acinetobacter species in 9.1% (n=1). Conclusion In our study we found that the clinical spectrum of IE was different from the west in that the majority of patients being young in our study. However, RHD still is the commonest underlying heart disease and Staphylococcus aureus being the commonest isolate. Journal of College of Medical Sciences-Nepal, 2012, Vol-8, No-4, 34-41 DOI: http://dx.doi.org/10.3126/jcmsn.v8i4.8698  

Surgical Management of Cervical Spondylotic Myelopathy

Introduction: The surgical procedure by the anterior, posterior and combined antero-posterior approaches had applied for the treatment of cervical spondylotic myelopathy.  Methods: During the treatment process, all patients were pre-operatively as well post-operatively graded according to Japanese Orthopaedics Association. Several surgical methods such as anterior approach, posterior approach, and combined antero-posterior approach have been addressed for CSM patients, with the choice based on the pathogenesis of the myelopathy. The main indications for surgery were evidence of myelopathy on physical examinations, a JOA score below 13 points help with spinal cord compression observed on plain X-ray, CT scan, MRI studies.  Results: The pre-operative JOA scores were 7.60±1.23 in laminoplasty, 8.30±1.03 in diskectomy and corpectomy and 7.10±1.20 in combined antero-posterior approach patients. At the follow-up after three months the JOA scores were laminoplasty 13.30±1.30, diskectomy and corpectomy 13.55±1.15 and combined antero-posterior 13.50±1.08. The JOA recovery rate averaged, 61.08±11.25% in laminoplasty, 60.67±10.60% in diskectomy and corpectomy and 64.67±10.72% in combined anteroposterior approach. The high- signal intensity changed to normal in 18 out of 28 and no any kyphotic change and instability were found in cervical spine at the follow up.  Conclusions: Patients with OPLL (continuous, segmental and mixed type), stenosis of cervical spinal canal, multilevel cervical spondylosis, large and high ossification of IVDP with stenosis were improved with laminoplasty. Patients with PIVD, CSM with kyphosis, post laminectomy , OPLL herniated type, unstable vertebral alignment, stenosis by osteophytes, were improved with anterior approach . Ossified or deformed OPLL, unstable vertebral with stenosis ,OPLL or OYL with cervical meandearing (swan-neck) were improved with Combined anterior and posterior approach. Keywords: cervical spondylotic mylopathy, anterior cervical diskectomy and fusion, corpectomy.

Surgical management of cervical spondylotic myelopathy

INTRODUCTION

The surgical procedure by the anterior, posterior and combined antero-posterior approaches had applied for the treatment of cervical spondylotic myelopathy.

METHODS

During the treatment process, all patients were pre-operatively as well post-operatively graded according to Japanese Orthopaedics Association. Several surgical methods such as anterior approach, posterior approach, and combined antero-posterior approach have been addressed for CSM patients, with the choice based on the pathogenesis of the myelopathy. The main indications for surgery were evidence of myelopathy on physical examinations, a JOA score below 13 points help with spinal cord compression observed on plain X-ray, CT scan, MRI studies.

RESULTS

The pre-operative JOA scores were 7.60±1.23 in laminoplasty, 8.30±1.03 in diskectomy and corpectomy and 7.10±1.20 in combined antero-posterior approach patients. At the follow-up after three months the JOA scores were laminoplasty 13.30±1.30, diskectomy and corpectomy 13.55±1.15 and combined antero-posterior 13.50±1.08. The JOA recovery rate averaged, 61.08±11.25% in laminoplasty, 60.67±10.60% in diskectomy and corpectomy and 64.67±10.72% in combined antero-posterior approach. The high-signal intensity changed to normal in 18 out of 28 and no any kyphotic change and instability were found in cervical spine at the follow up.

CONCLUSIONS

Patients with OPLL (continuous, segmental and mixed type), stenosis of cervical spinal canal, multilevel cervical spondylosis, large and high ossification of IVDP with stenosis were improved with laminoplasty. Patients with PIVD, CSM with kyphosis, post laminectomy, OPLL herniated type, unstable vertebral alignment, stenosis by osteophytes, were improved with anterior approach. Ossified or deformed OPLL, unstable vertebral with stenosis, OPLL or OYL with cervical meandearing (swan-neck) were improved with Combined anterior and posterior approach.

Effect of haemodynamic and metabolic predictors on echocardiographic left ventricular mass in non-diabetic hypertensive patients

BACKGROUND

Left ventricular hypertrophy is a forerunner of coronary heart disease, congestive cardiac failure, stroke and may also lead to sudden death. Estimation of left ventricular mass by echocardiography offers prognostic information better than the evaluation of traditional cardiovascular risk factors.

OBJECTIVE

The aim of this study was to determine the relative contributions of haemodynamic and metabolic factors affecting left ventricular mass in non-diabetic patients with essential hypertension.

MATERIAL AND METHODS

100 non-diabetic hypertensive patients were taken. The association between age, gender, smoking, alcohol, height, weight, heart rate, clinic blood pressure, fasting blood glucose, lipid profile, haemoglobin, body mass index and stroke volume with LV mass was studied. Left ventricular mass was measured by using standard M-mode echocardiography measurement obtained by way of standard recommended by the American Society of Echocardiography.

RESULTS

Left ventricular mass was analyzed as a continuous variable. In males body mass index (r = .35, p < .004) and stroke volume(r = -.26, p<.039) were significantly correlated with LV mass. In females body weight was significantly related to left ventricular mass(r = .36, p < .02). The independent association between significant factors and left ventricular mass was assessed by stepwise multivariate logistic regression. Body mass index and systolic blood pressure came as independent determinants of left ventricular mass in all patients. A maximum of 13% of left ventricular mass variability could be explained by these two factors.

CONCLUSION

In untreated patients with hypertension patient's body mass index and systolic blood pressure are independent predictors of left ventricular mass after adjustment for other haemodynamic and metabolic factors. They explain a maximum of 13% of left ventricular mass variability. More knowledge is needed about factors that may alter cardiac morphology in the evolution of hypertensive patients.

Prevalence of the metabolic syndrome in acute myocardial infarction and its impact on hospital outcomes

AIMS

To ascertain the prevalence of the metabolic syndrome in patients with acute myocardial infarction; to study the impact of the metabolic syndrome on hospital outcomes; and to find out the association of each component of the metabolic syndrome with acute myocardial infarction (AMI).

SETTING

Coronary care unit, Department of Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal.

DESIGN

Hospital-based cross-sectional study.

MATERIALS AND METHODS

A total of 84 unselected consecutive patients hospitalized with AMI (diagnosed on the basis of WHO criteria) were categorized according to NCEP ATP III criteria.

STATISTICAL ANALYSIS

Data was analyzed by using the Student's t test and Chi-square test.

RESULTS

Among the 84 AMI patients, 22 (26.19%) fulfilled the criteria for metabolic syndrome. Patients with the metabolic syndrome were older (86% were >50 years of age) and females (27%) were more affected than males (25%). In-hospital case fatality was higher in patients having the metabolic syndrome (5/22) than in those without the syndrome (3/62). Among the five components of the metabolic syndrome, the triglyceride levels had the highest positive predictive value (62%) in AMI; this was followed by fasting blood glucose levels (55%).

CONCLUSION

The prevalence of the metabolic syndrome is 26.19%; it is associated with high mortality; among its components, the triglyceride level has the highest positive predictive value in AMI patients.