Development of standard therapeutic guidelines for selected common diseases for the primary health care centres of a South Indian district

Method

A questionnaire survey of medical officers was conducted to collect data on the most commonly-presenting diseases and doctors' treatment choices in PHCs in Mysore. Draft guidelines were developed for these conditions based on available literature, together with microbiological sensitivity data from the three district hospitals. User feedback on the draft guidelines and on guidelines in general was obtained from medical officers using a postal questionnaire.

Objective

To develop standard therapeutic guidelines for selected common diseases for the primary health care centres (PHCs) of a South Indian district and to evaluate medical officers' perceptions about the proposed guidelines and about guidelines in general.

Setting

Sample of 17 of the 93 PHCs in Mysore.

Key findings

Upper respiratory tract infection was the most commonly-presenting condition. Procaine penicillin was the most commonly-used drug and there were examples of inappropriate treatment choices. The survey produced evidence that access to medicines on the government's “essential” list was not uniform, with many patients having to purchase prescribed drugs that were not on the list. The response rate to the user feedback questionnaire was 62 per cent (31 doctors). The medical officers had positive opinions about guidelines in general and felt that the guidelines we proposed were useful and would help them to improve their prescribing habits.

Conclusions

Prescribing in primary care in India needs to be improved. The involvement of potential users of the guidelines in their development should increase their acceptability and thus their use in practice.

The effects of ingested aluminium on brain cytochrome oxidase activity

Aluminium has a unique combination of physical and chemical properties which has enabled man to put this metal to very wide and varied use. However prolonged exposure to aluminium ions may lead to adverse health effects. In this study, we evaluated the effects of dietary aluminium on the protein composition and the intrinsic activity of cytochrome oxidase (COX) for brain mitochondria. New Zealand white rabbits were maintained on a diet of commercial rabbit pellets and distilled water for a period of 12 weeks. For the experimental group, AlCl3, 330 mg/kg/L was added to the drinking water. When compared to the control, mitochondria isolated from the brains of the AICl3 fed rabbits showed no change in Km but an approximate 35% decrease in both the low and high affinity Vmax values. Also, whereas the protein composition of the mitochondria from both sources appeared to be normal, isolation of highly purified COX proved to be difficult and for the AlCl3 fed rabbits, a number of the enzyme's low molecular weight subunits were absent. These results appear to confirm a relationship between long term aluminium consumption and low brain COX activity; they further suggest that an altered COX structure may be the cause of the low enzymic activity.

Breakthrough of toluene vapours in granular activated carbon filled packed bed reactor

The objective of this research was to determine the toluene removal efficiency and breakthrough time using commercially available coconut shell-based granular activated carbon in packed bed reactor. To study the effect of toluene removal and break point time of the granular activated carbon (GAC), the parameters studied were bed lengths (2, 3, and 4 cm), concentrations (5, 10, and 15 mg l(-1)) and flow rates (20, 40, and 60 ml/min). The maximum percentage removal of 90% was achieved and the maximum carbon capacity for 5 mg l(-1) of toluene, 60 ml/min flow rate and 3 cm bed length shows 607.14 mg/g. The results of dynamic adsorption in a packed bed were consistent with those of equilibrium adsorption by gravimetric method. The breakthrough time and quantity shows that GAC with appropriate surface area can be utilized for air cleaning filters. The result shows that the physisorption plays main role in toluene removal.

Hypospadias from the perspective of a single-surgeon practice in Malaysia

The last decade has witnessed an alarming increase in the worldwide incidence of hypospadias. For non-hypospadiologists, the surgical correction of hypospadias will be increasingly demanding. This paper aims to evaluate the effectiveness of a treatment strategy devised by a single-surgeon practice in Malaysia to tackle this anticipated surge of caseload. Over a period exceeding eight years, 254 boys underwent corrective hypospadias surgery by a single paediatric surgeon at Alor Star Hospital, Malaysia. Patient demographics, racial distribution and meatal location were among the data collected retrospectively. The various types of corrective procedure employed, their outcome as well as complications were evaluated. Distal type of hypospadias dominated this series. There was an explainable peculiarity in the age distribution of hypospadias. For all types of repair, the complication rate was 33% consisting mainly of urethrocutaneous fistula (18%) and meatal stenosis (9%). Complication rate for tubularised incised plate (TIP) urethroplasty, the commonest technique of repair, was 30%, mainly from meatal stenosis (15%) and urethrocutaneous fistula (13%). Univariate analysis revealed that proximal hypospadias, repairs done during the initial four years of study and utilisation of repair other than TIP to be adverse risk factors. Tubularised incised plate urethroplasty was appropriate for almost all types of hypospadias. For the remainder, the two stage repair is satisfactorily employed. This study from a primary referral centre also dispelled the notion that proximal hypospadias predominate in this region. The versatility and reliability of TIP urethroplasty lends itself readily in tackling primary and repeat hypospadias surgery within a single-surgeon practice.

Pre-exposure of calli to ozone promotes tolerance of regenerated Lycopersicon esculentum cv. PKM1 plantlets against acute ozone stress

Studies were performed to evaluate the effects of pre-exposure of calli to ozone in promoting tolerance of the regenerated Lycopersicon esculentum cv. PKM1 (tomato) plantlets against acute ozone stress (AOS). Calli induced from tomato leaf explants were subjected to pre-treatment with ozone: T(1)=100 ppb, T(2)=200 ppb and T(3)=300 ppb. For the control (C) calli, charcoal-filtered air was supplied to test differential sensitivity of regenerated plantlets to acute ozone stress. All treated calli were subsequently transferred to shooting, rooting medium and acclimatized. The plantlets regenerated from the respective ozone (T(1), T(2), T(3))-treated calli are referred to here as T(1), T(2), T(3) plantlets and the plantlets regenerated from control calli are referred to as control plantlets. The frequencies of regeneration of tomato plantlets from the calli were T(1)=86%, T(2)=82% and T(3)=67%, and 92% regeneration was obtained from control calli. In order to evaluate the ozone tolerance, all the regenerated plantlets were exposed to the acute ozone exposure (AOE). After AOE, the T(2) plantlets endured remarkably well by experiencing reduced ozone stress, which was evident from the lower level of hydrogen peroxide and oxidative stress-related enzymes such as ascorbate peroxidase (EC 1.11.1.11) and superoxide dismutase (EC 1.15.1.1) activities relative to T(3), T(1) and C plantlets. All T(2) plantlets showed enhanced tolerance against AOE by upholding enhanced soluble phenol content, a higher level of foliar and apoplastic ascorbic acid, elevated dehydroascorbate reductase (EC 1.8.5.1) and glutathione content. The present study reveals that the calli pre-exposed to T(2) ozone treatment resulted in an increase in the level of antioxidants and provided the plants greater protection against acute ozone stress.

A bench-scale, cost effective and simple method to elicit Lycopersicon esculentum cv. PKM1 (tomato) plants against Cucumber mosaic virus attack using ozone-mediated inactivated Cucumber mosaic virus inoculum

Studies were undertaken to evaluate ozone for inactivation of Cucumber mosaic virus present in the inoculum and to stimulate Lycopersicon esculentum cv. PKM1 (tomato) plants against Cucumber mosaic virus infection by using the inactivated Cucumber mosaic virus inoculum. Application of a T(4) (0.4mg/l) concentration of ozone to the inoculum containing Cucumber mosaic virus resulted in complete inactivation of the virus. The inactivated viral inoculum was mixed with a penetrator (delivery agent), referred to as T(4) preparation, and it was evaluated for the development of systemic acquired resistance in the tomato plants. Application of a T(4) preparation 5 days before inoculation with the Cucumber mosaic virus protected tomato plants from the effects of Cucumber mosaic virus. Among the components of the inactivated virus tested, coat protein subunits and aggregates were responsible for the acquired resistance in tomato plants. In field trials, the results of enzyme-linked immunosorbent assay revealed that, Cucumber mosaic virus accumulation was significantly less for all the test plants (16%) sprayed with the T(4) preparation than untreated control plants (89.5%) at 28 days postinoculation (dpi). A remarkable increase in the activities of the total soluble phenolics (10-fold) and salicylic acid (16-fold) was detected 5 days after the treatment in foliar extracts of test plants relative to untreated control plants. The results showed that treatment of tomato plants with inactivated viral inoculum led to a significant enhancement of protection against Cucumber mosaic virus attack in a manner that mimics a real pathogen and induces systemic acquired resistance.

Electrochemical oxidation of textile wastewater and its reuse

It is attempted in the present investigation to treat organic pollutant present in the textile effluent using an electrochemical treatment technique. Experiments are carried out in a batch electrochemical cell covering wide range in operating conditions. Due to the strong oxidizing potential of the chemicals produced, the effluent COD is reduced substantially in this treatment technique. The influence of effluent initial concentration, pH, supporting electrolyte concentration and the anode material on pollutant degradation has been critically examined. It is further attempted in the present investigation to reuse the treated wastewater for dyeing purpose. Several cycles of dyeing operations have been performed with the treated textile wastewater and the dye uptake and water quality have been critically examined at each cycle of dyeing process. The results indicate that the electrochemical method is a feasible technique for treatment of textile wastewater and electrochemically treated wastewater can be effectively reused for dyeing application.

First Report of Cucumber mosaic virus Subgroup II Infecting Lycopersicon esculentum in India

During a survey in January 2006 near Salem in Tamil Nadu (south India), Cucumber mosaic virus was observed infecting tomatoes with an incidence of more than 70%. Plants exhibiting severe mosaic, leaf puckering, and stunted growth were collected, and the virus was identified using diagnostic hosts, evaluation of physical properties of the virus, compound enzyme-linked immunosorbent assay (ELISA) (ELISA Lab, Washington State University, Prosser), reverse-transcription polymerase chain reaction (RT-PCR), and restriction fragment length polymorphism analysis (DSMZ, S. Winter, Germany). To determine the specific CMV subgroup, total RNA was extracted from 50 infected leaf samples using the RNeasy plant RNA isolation kit (Qiagen, Hilden, Germany) and tested for the presence of the complete CMV coat protein gene using specific primers as described by Rizos et al. (1). A fragment of the coat protein was amplified and subsequently digested with MspI to reveal a pattern of two fragments (336 and 538 bp), indicating CMV subgroup II. No evidence of mixed infection with CMV subgroup I was obtained when CMV isolates representing subgroups I (PV-0419) and II (PV-0420), available at the DSMZ Plant Virus Collection, were used as controls. Only CMV subgroup I has been found to predominantly infect tomato in the Indian subcontinent, although Verma et al. (2) identified CMV subgroup II infecting Pelargonium spp., an ornamental plant. To our knowledge, this is the first report of CMV subgroup II infecting tomato crops in India. References: (1) H. Rizos et al. J. Gen. Virol. 73:2099, 1992. (2) N. Verma et al. J. Biol. Sci. 31:47, 2006.

Induction of systemic resistance in Lycopersicon esculentum cv. PKM1 (tomato) against Cucumber mosaic virus by using ozone

Studies were undertaken to evaluate ozone (O(3)) for induction of resistance against Cucumber mosaic virus in Lycopersicon esculentum cv. PKM1 (tomato) plants. Callus induced from tomato leaf explants on Murashige & Skoog's (MS) medium supplemented with benzyladenine (8.82 microM) were treated with different concentrations of ozone T(1), T(2), T(3) and for control (C), filtered air was supplied. Regeneration of shoots was obtained by culturing ozone treated calli on MS medium containing 17.3 microM benzyladenine. The frequency of regeneration of tomato plants from the callus were T(1)=79%, T(2)=61%, T(3)=42%, but for control 90% regeneration was obtained. Regenerated plants were rooted in half strength MS medium supplemented with 10 microM indole-butyric acid and successfully acclimatized. The plants regenerated from ozone treated callus are referred to as T(1), T(2) and T(3) plants, which hold remarkably increased soluble phenolic content compared to the control plants. All the plants were challenged by mechanical inoculation with Cucumber mosaic virus, shows disease incidence ranged from T(1)=32%, T(2)=56%, T(3)=78% and C=94%. Remarkable increase in activities of salicylic acid (SA), phenylalanine ammonia-lyase (PAL) and peroxidase (POX) were detected after Cucumber mosaic virus inoculation, in foliar extracts of T(1) plants than T(2) and T(3), compared to the control plants.

In situ electrocatalytic oxidation of acid violet 12 dye effluent

Electrochemical treatment of organic pollutants is a promising treatment technique for substances which are recalcitrant to biodegradation. Experiments were carried out to treat acid violet 12 dye house effluent using electrochemical technique for removal color and COD reduction covering wide range in operating conditions. Ruthenium/lead/tin oxide coated titanium and stainless steel were used as anode and cathode, respectively. The influence of effluent initial concentration, pH, supporting electrolyte and the electrode material on rate of degradation has been critically examined. The results indicate that the electrochemical method can be used to treat dye house effluents.

Electrochemical removal of chromium from wastewater by using carbon aerogel electrodes

A study has been carried out to determine the feasibility of electrochemical removal of chromium ions from industrial wastewater using carbon aerogel electrodes. In this work the effect of key variables including pH (2-7), concentration 2-8 (mg/l), and charge 0.3-1.3 (A h) was determined. The metal ion removal was significantly increased at reduced pH and high charge conditions. The metal concentration in the wastewater can be reduced by 98.5% under high charge (0.8A h) and acidic conditions (pH 2). The effect of the independent parameters--pH, effluent concentration and charge on the percentage removal was depicted by a quadratic equation obtained using Box-Behnken model. The regression analysis gave a R2 value of 0.9469 shows a close fit between the experimental results and the model predictions. The model was further used to optimise the parameters to maximise the percentage Cr-removal to more than 98%.

Influence of Adyar river in the coastal waters of Chennai (Madras), Bay of Bengal

The impact of the river Adyar which is influenced by industrial wastes and domestic sewage from the city of Chennai (Madras), on the hydrobiology of coastal water in the Bay of Bengal was evaluated. Reduction in pH, dissolved oxygen (DO), nitrite, nitrate, primary productivity and increase of ammonia, phosphate, silicate, heavy metals, biological oxygen demand (BOD), chlorophyll pigments, particulate organic carbon (POC), respiration, suspended solids, ATP, and bacteria in the mixing site during low tide indicated that the Adyar water was heavily polluted and ultimately affect the quality of coastal water near the vicinity of mixing zone. The effects are diluted or nullified as the distance increased from the mixing site due to heavy mixing and littoral current. During high tide, the flow was completely stopped and little or no effect was recorded. The light, water current and wave action are the important factors which minimize the pollution impacts in the receiving coastal water.

Degradation of (+)-catechin by Acinetobacter calcoaceticus MTC 127

Acinetobacter calcoaceticus MTC 127 was able to grow on catechin and protocatechuic acid (PCA) as sole carbon source. Cells induced with catechin oxidized catechin and PCA at rates higher than cells of uninduced cultures. Two aromatic compounds, PCA and phloroglucinol carboxylic acid (PGCA) were isolated from culture filtrate of cells grown in catechin and characterized by infrared spectrometry and high performance thin-layer chromatography. Moreover, A. calcoaceticus MTC 127 produced high levels of PCA compared to PGCA in the degradation of catechin. Based upon these results, a pathway for the degradation of (+)-catechin in A. calcoaceticus MTC 127 is proposed. Enzymes extracted from catechin-induced culture showed catechin oxygenase (cox) and protocatechuate 3,4-dioxygenase (pcd) activities. Catechin oxygenase was purified by column chromatography and SDS-PAGE analysis showed a single band with an apparent molecular weight of 47 kDa.

Cloning of Acinetobacter calcoaceticus chromosomal region involved in catechin degradation

Acinetobacter calcoaceticus utilizes catechin as sole carbon source. The chromosomal region involved in catechin catabolism was cloned in Escherichia coli DH5alpha from the genomic DNA of A. calcoaceticus. A recombinant E. coli containing 9.2 kb DNA fragment of A. calcoaceticus inserted in pUC19 showed a halo zone around the colony in plate assays, indicating the catechin utilizing ability of the clone. Enzyme assays revealed the expression of the cloned DNA fragment of A. calcoaceticus. High performance thin layer chromatography confirmed protocatechuic acid and phloroglucinol carboxylic acid as cleavage products of catechin in A. calcoaceticus and the catechin degrading ability of the clones. A. calcoaceticus followed the beta-ketoadipate pathway for catechin degradation. The sub-clone (pASCI) of this insert was sequenced and analyzed. The sequence showed three major ORFs but only ORF 2 showed similarities to other aromatic oxygenases and the sequence of ORF 2 was submitted to GenBank (AF369935).

Progress in treatment and outcome for children with neonatal haemochromatosis

AIM

To evaluate the role of antioxidant treatment and liver transplantation in the management of neonatal haemochromatosis.

METHODS

A retrospective review was performed of eight infants with acute liver failure and raised ferritin levels between 1990 and 1998. From 1994, treatment with an antioxidant cocktail (vitamin E, N-acetylcysteine, selenium, prostaglandin E1, and desferrioxamine) was begun once the diagnosis was suspected. Pathological and other findings were reviewed, and outcome before and after antioxidant treatment was evaluated.

RESULTS

Median age at presentation was 4 days with median ferritin levels of 4180 micro g/l (range 1650-40 000 micro g/l; normal range 110-503 micro g/l). Three infants presented before 1994. One infant died before liver transplantation from acute liver failure and one from neurological damage after transplantation. The third patient underwent successful transplantation at day 13 and remains well on follow up 8 years later. From 1994, five patients received antioxidant treatment, of whom two responded: both responders started antioxidants earlier (by day 5) than non-responders and had lower peak ferritin levels (< 4200 micro g/l) and a milder phenotype. Treatment was continued until ferritin levels were < 500 micro g/l. Both children remain well with mean follow up of 42 months, with no recurrence of iron overload. One child showed a partial response to treatment and survived long enough for a liver transplant, but died from graft failure after the transplant. Two children did not respond to antioxidant treatment; both had multiorgan failure and were not listed for transplantation. Only three of the eight patients survived (37.5%) over this time period.

CONCLUSION

Neonatal haemochromatosis can be a fatal disease with > 60% mortality. Early treatment with antioxidant cocktail is beneficial and may be curative in those who present with milder phenotype. Liver transplantation should always be considered at an early stage in non-responders and in children with more severe acute liver failure.

Effect of phenol on ultra structure and plasmid DNA of Xanthomonas oryzae pv. oryzae

Most phenolic substances of plant origin are toxic to microorganisms and they confer some degree of protection to plants against phytopathogens. Xanthomonas oryzae pv. oryzae, bacterial blight pathogen of rice (Oryza sativa) was treated with phenol (monohydroxy benzene) and its effects on the morphology and cytological changes of the bacterium were studied. Total lysis of cells occurred with 5 mM conc of phenol while at 2 mM conc, the cell walls became rough and cell contents started shrinking. Plasmids isolated from both treated (2 mM) and control cells did not show any marked difference under electron microscope except that they differed in their quantity and might influence pathogenicity.

Knowledge, attitude and practices towards HIV among nurses in a tertiary care teaching hospital: two decades after the discovery

Accidental transmission of HIV infection to health care workers during occupational exposure is a real threat today. The first such case in India has been documented by NACO recently. Adequate knowledge about the disease and practice of safety measures are our best bet to reduce such transmission. A survey was carried out amongst over 500 nurses in a tertiary care referral hospital in Delhi to assess their knowledge, attitude and practices towards HIV/AIDS. While overall knowledge was satisfactory, there were gaping holes in vital areas. The conversion of their theoretical knowledge into safe practices was shockingly poor. It was due to attitude problems as much as inadequate supplies. High incidence of accidental exposures in the near past and complete ignorance of post-exposure prophylaxis guidelines was another highlight of this study. Despite tremendous efforts put in by the Government as well as various Non-Governmental Organizations, we are completely ill equipped to fight the menace of occupational HIV transmission. In order to fight this menace, "safe practices" have to be made a "way of life" for HCWs. Our health care planners need to take note of it and our teaching and training programmes need complete re-orientation to achieve this goal.

Is routine splintage following primary total knee replacement necessary? A prospective randomised trial

It was hypothesised that routine splintage following primary total knee replacement has no affect on flexion deformity and offers no benefit over simple wool and crepe. Fifty-five patients undergoing primary total knee replacement were entered into a prospective study. The patients were randomly assigned to two groups: The first group was rehabilitated without a splint and the second received an adjustable semi-rigid extension splint (Richards splint) for the first 48 h after surgery. Range of motion measurements were recorded pre-operatively and at 2 days, 1 week and 3 months post-operation by a research nurse blinded to the allocation. No statistically significant difference in flexion deformity was found at any stage (P>0.5). No difference was found in general or wound complications, or requirement for blood transfusion, and the post-operative stay was equal in the two groups. We conclude that routine use of a semi-rigid splint following primary total knee replacement has no advantage over simple wound dressings.

Jaundice clearance and cholangitis in the first year following portoenterostomy for biliary atresia

Sixty-one patients with biliary atresia, who underwent portoenterostomy (PE) between 1992 to 1998 in the Institute of Pediatrics, Kuala Lumpur and were followed for a period of one year, were studied to analyze the factors associated with jaundice clearance and cholangitis following PE. Sex distribution was equal. Majority of patients were Malays. Mean age in days at admission to the surgical ward was 66.90 +/- 23.36 and mean age at PE was 75.85 +/- 24.05. At the end of one-year follow-up, six patients (10%) had died, 35 (57%) developed one or more attacks of cholangitis, 35 (57%) had portal hypertension, eight (13%) liver failure and six patients had esophageal variceal bleeding. Thirty-three patients (54%) had jaundice clearance with a mean clearance time of 85 days after PE. The study shows that when the ductules in the porta hepatis were < 150 mu in size, persistence of jaundice after PE and the incidence of cholangitis in the first post-operative year were higher; patients with cholangitis in the first year had lower rate of jaundice clearance. Jaundice clearance was achieved in more patients when their postnatal age at the time of PE was lower but the relationship was not linear. Age at PE also did not have a linear temporal relationship to the incidence of cholangitis and the size of portal ductules. Prospective, multi-center based local studies on a bigger patient population are needed to identify other indicators of successful outcome following PE. This would help to define the indications for primary liver transplantation in the local population.

Demyelination occurring during anti-tumor necrosis factor alpha therapy for inflammatory arthritides

OBJECTIVE

To review the occurrence of neurologic events suggestive of demyelination during anti-tumor necrosis factor alpha (anti-TNFalpha) therapy for inflammatory arthritides.

METHODS

The Adverse Events Reporting System of the Food and Drug Administration (FDA) was queried following a report of a patient with refractory rheumatoid arthritis who developed confusion and difficulty with walking after receiving etanercept for 4 months.

RESULTS

Nineteen patients with similar neurologic events were identified from the FDA database, 17 following etanercept administration and 2 following infliximab administration for inflammatory arthritis. All neurologic events were temporally related to anti-TNFalpha therapy, with partial or complete resolution on discontinuation. One patient exhibited a positive rechallenge phenomenon.

CONCLUSION

Further surveillance and studies are required to better define risk factors for and frequency of adverse events and their relationship to anti-TNFalpha therapies. Until more long-term safety data are available, consideration should be given to avoiding anti-TNFalpha therapy in patients with preexisting multiple sclerosis and to discontinuing anti-TNFalpha therapy immediately when new neurologic signs and symptoms occur, pending an appropriate evaluation.

Demyelination occurring during anti-tumor necrosis factor alpha therapy for inflammatory arthritides

OBJECTIVE

To review the occurrence of neurologic events suggestive of demyelination during anti-tumor necrosis factor alpha (anti-TNFalpha) therapy for inflammatory arthritides.

METHODS

The Adverse Events Reporting System of the Food and Drug Administration (FDA) was queried following a report of a patient with refractory rheumatoid arthritis who developed confusion and difficulty with walking after receiving etanercept for 4 months.

RESULTS

Nineteen patients with similar neurologic events were identified from the FDA database, 17 following etanercept administration and 2 following infliximab administration for inflammatory arthritis. All neurologic events were temporally related to anti-TNFalpha therapy, with partial or complete resolution on discontinuation. One patient exhibited a positive rechallenge phenomenon.

CONCLUSION

Further surveillance and studies are required to better define risk factors for and frequency of adverse events and their relationship to anti-TNFalpha therapies. Until more long-term safety data are available, consideration should be given to avoiding anti-TNFalpha therapy in patients with preexisting multiple sclerosis and to discontinuing anti-TNFalpha therapy immediately when new neurologic signs and symptoms occur, pending an appropriate evaluation.

Demyelination occurring during anti-tumor necrosis factor alpha therapy for inflammatory arthritides

OBJECTIVE

To review the occurrence of neurologic events suggestive of demyelination during anti-tumor necrosis factor alpha (anti-TNFalpha) therapy for inflammatory arthritides.

METHODS

The Adverse Events Reporting System of the Food and Drug Administration (FDA) was queried following a report of a patient with refractory rheumatoid arthritis who developed confusion and difficulty with walking after receiving etanercept for 4 months.

RESULTS

Nineteen patients with similar neurologic events were identified from the FDA database, 17 following etanercept administration and 2 following infliximab administration for inflammatory arthritis. All neurologic events were temporally related to anti-TNFalpha therapy, with partial or complete resolution on discontinuation. One patient exhibited a positive rechallenge phenomenon.

CONCLUSION

Further surveillance and studies are required to better define risk factors for and frequency of adverse events and their relationship to anti-TNFalpha therapies. Until more long-term safety data are available, consideration should be given to avoiding anti-TNFalpha therapy in patients with preexisting multiple sclerosis and to discontinuing anti-TNFalpha therapy immediately when new neurologic signs and symptoms occur, pending an appropriate evaluation.