Impulse-Control Disorders and Restless Leg Syndrome in Parkinson's Disease: Association or Coexistence

Background

Both Impulse-control disorders and related behaviours (ICD-RB) and restless leg syndrome (RLS) are relatively common in patients with Parkinson's disease, but little is known are they related or independent complications of dopaminergic therapy. The aim of this study was to determine the correlation between ICD-RBs and RLS and also, to determine the associated significant psycho-behavioural profile of RLS patients in presence of ICD-RBs.

Methods

PD who visited neurology OPD were screened for the presence of addictive behaviors, alcohol and substance abuse, ICDs including Impulse control disorders not elsewhere classified with the help of a QUIP questionnaire. RLS was evaluated by diagnostic criteria set by the International RLS study group. To evaluate the association of RLS and ICDs, cohort was divided into groups of patients who had both ICD and RLS, ICD with no RLS, RLS with no ICD and no ICD or RLS.

Results

Among 122 PD patients who visited OPD, 95 eligible were included in the study. Out of these 95 patients, 51 (53.6%) had at least one ICD-RB and 18 (18.9%) had RLS. ICD-RB in decreasing order of frequency were compulsive medication (47.4%), compulsive eating (29.4%), compulsive buying (17.6%), gambling (11.7%), hypersexuality (3.9%), and others (29.8%). Among 18 patients with RLS, 12 (66.7%) were associated with at least one ICD-RB. The compulsive behaviours significantly associated with PD-RLS group were gambling (27.8%), followed by compulsive eating (44.2%). While comparing disease characteristics, PD-ICD/RLS patients had statistically significant disease duration (p 0.007) and higher LEDD (p 0.004). Other demographic and socioeconomic features did not reveal any differences between the groups.

Conclusion

11% of PwPD can have co-occurrence of RLS and ICD-RBs. Circadian fluctuation in levels of dopamine release on the background of hyper-dopaminergic state produces waves of crest and trough, which may be possible for this behavioral profile. Long-term dopaminergic treatment or degenerative process itself may be the cause leading to emergence of both RLS and ICD-RBs in PD patients.

A cluster-randomized trial comparing home-based primary health care and usual clinic care for epilepsy in a resource-limited country

OBJECTIVE

To ascertain whether home-based care with community and primary healthcare workers' support improves adherence to antiseizure medications, seizure control, and quality of life over routine clinic-based care in community samples of people with epilepsy in a resource-poor country.

METHODS

Participants included consenting individuals with active epilepsy identified in a population survey in impoverished communities. The intervention included antiseizure medication provision, adherence reinforcement and epilepsy self- and stigma management guidance provided by a primary health care-equivalent worker. We compared the intervention group to a routine clinic-based care group in a cluster-randomized trial lasting 24 months. The primary outcome was antiseizure medication adherence, appraised from monthly pill counts. Seizure outcomes were assessed by monthly seizure aggregates and time to first seizure and impact by the Personal Impact of Epilepsy scale.

RESULTS

Enrolment began on September 25, 2017 and was complete by July 24, 2018. Twenty-four clusters, each comprising ten people with epilepsy, were randomized to either home- or clinic-care. Home-care recipients were more likely to have used up their monthly-dispensed epilepsy medicine stock (regression coefficient: 0.585; 95% confidence intervals, 0.289-0.881; P = 0.001) and had fewer seizures (regression coefficient: -2.060; 95%CI, -3.335 to -0.785; P = 0.002). More people from clinic-care (n = 44; 37%) than home-care (n = 23; 19%) exited the trial (P = 0.003). The time to first seizure, adverse effects and the personal impact of epilepsy were similar in the two arms.

SIGNIFICANCE

Home care for epilepsy compared to clinic care in resource-limited communities improves medication adherence and seizure outcomes and reduces the secondary epilepsy treatment gap.

SARS-CoV-19-associated Rhino-orbital and cerebral Mucormycosis: Clinical and Radiological Presentations

We describe presenting clinical and imaging manifestations of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated Rhino-oculo-cerebral mucormycosis (ROCM) in a hospital setting during the second wave of SARS-CoV-2 pandemic in India. Data on the presenting manifestations were collected from 1 March to 31 May 2021. Associations between clinical and imaging findings were explored, specifically: (1) the presence or absence of orbital pain and infiltration of a superior orbital fissure on imaging; (2) the presence of unilateral facial nerve palsy and pterygopalatine fossa infiltration and geniculate ganglion signal on contrast magnetic resonance imaging, and (3) vision loss and optic nerve findings on imaging. Orbital pain was reported by 6/36 subjects. A fixed, frozen eye with proptosis and congestion was documented in 26 (72%), complete vision loss in 23 (64%), and a unilateral lower motor neuron facial nerve palsy in 18 (50%). No association was found between the presence of orbital pain and superior orbital fissure infiltration on imaging. The ipsilateral geniculate ganglion was found to enhance more profoundly in 7/11 subjects with facial palsy and available magnetic resonance (MR) imaging, and the ipsilateral pterygopalatine fossa was found infiltrated in 14. Among 23 subjects with complete loss of vision, 9 (39%) demonstrated long-segment bright signal in the posterior optic nerve on diffusion MR images. We conclude that orbital pain might be absent in SARS-CoV-2-associated ROCM. Facial nerve palsy is more common than previously appreciated and ischemic lesions of the posterior portion of the optic nerve underlie complete vision loss.

An Uncommon Case of Celiac Disease and Deep Cerebral Venous Sinus Thrombosis

Celiac disease is an enteropathy characterized by malabsorption related with gluten intolerance and immune-mediated pathogenesis. It may manifest with gastrointestinal features like diarrhea, abdominal pain, weight loss, and anemia. Besides, it can manifest with various extraintestinal features like ataxia, neuropathy, stroke, or sometimes venous sinus thrombosis. Being of autoimmune origin, relation with systemic lupus erythematosus has also been reported. Herein, we present a rare case of a young patient with celiac disease who presented with fever, headache, and altered sensorium and was found to have meningitis with deep cerebral venous sinus thrombosis.

Aggressive Vertebral Hemangioma: The Mystery of Spastic Legs Unveiled by a Purple Shoulder

Vertebral hemangiomas (VHs) are benign vascular tumors that develop from the endoderm of blood vessels, although their exact pathogenesis is poorly understood. Most hemangiomas are small, about a third are multiple in number, and a very small number of these hemangiomas cause symptoms. Even more rare are aggressive VHs, which comprise a small number of all VHs, and are associated with expansion and extraosseous extension into the paraspinal and epidural spaces. Management of aggressive VHs involve pre-op embolization, spinal surgery, and reconstruction. Pain management, physical rehabilitation, and close neurological follow-up are imperative to near-total recovery. Aggressive VHs are most commonly seen in the thoracic region but may rarely involve a large number of vertebrae. Cutaneous hemangiomas, when seen along with VHs, are often metameric. 

We present a rare and challenging case of compressive myelopathy and a large cutaneous hemangioma or a "purple shoulder", found during an exam in a young male. He was found to have an extensive VH extending through 13 vertebral levels (C7 to D12), non-metameric to the cutaneous lesion. A thorough physical examination and evaluation along with prompt surgical treatment were the cornerstone of treatment and prevention of permanent neurological deficits.

Factors Affecting Adherence to Pharmacotherapy in Parkinson's Disease

Background:

The goal of dopaminergic replacement therapy to achieve good clinical outcome in Parkinson's disease (PD) patients largely depends on the pattern of adherence to the pharmacological treatment. This study aims to find the factors affecting medication adherence in patients with PD keeping in mind the cultural, economic, and social diversities so that preventive steps can be taken to fill these gaps.

Methods:

Demographic data, disease parameters, treatment-related factors, family characteristics, educational, and employment status were assessed for relationship with the medication adherence pattern in a cohort of non-demented PD patients. Medication adherence was measured by MMAS-8; depression, and socioeconomic status were assessed by GDS-SF and Kuppuswamy scales respectively.

Results:

From 134 PD subjects, high adherence was observed in 43.2%, 18.2% had moderate, and 38.6% reported low adherence level to their pharmacotherapy. The sub-optimal level of adherence was significantly correlated to compliance of follow up with the physician (p 0.03), presence of adverse events related to drugs (p 0.03), and depressive symptoms (p < 0.0001). Also, there was significant negative co-relationship between poor adherence and depression on Spearman's rank coefficient (0.702). There was no effect of demographic factors, living conditions, family type, educational qualification, associated comorbid conditions, and socioeconomic status on adherence to dopaminergic treatment in patients with PD.

Conclusion:

Poor adherence to prescribed medication is a menace that is more than just oversimplification of forgetfulness which should be evaluated at each visit to improve efficacy of the prescribed regimen to achieve better treatment result and thus quality of life of PD patients.

Anxiety in Parkinson's Disease: Correlation with Depression and Quality of Life

Introduction  Anxiety is common in patients with Parkinson's disease (PD). Its prevalence ranges from 20 to 40% but despite that, the high prevalence anxiety in PD is often undiagnosed and untreated. This research was aimed to study the pattern of anxiety with regard to its prevalence and risk factors and to establish the association of anxiety with depression and quality of life (QOL) in patients with PD. Methods  A total of 105 patients with PD were prospectively observed. Demographic and clinical variables were recorded and patients were assessed for anxiety (the Parkinson anxiety scale [PAS]), depression (geriatric depression scale [GDS]), and QOL (Parkinson's Disease Questionnaire-39 [PDQ-39]). Multiple forward logistic regression analysis was done for parameters showing association with anxiety. Pearson's correlation was used to calculate the strength of association of depression and QOL with anxiety. Results  Anxiety was present in 56 PD patients (53.3%). Episodic anxiety was noted in 50%, avoidance behavior in 35%, and persistent anxiety in 15% of these patients. There was significant association of anxiety with duration of disease ( p = 0.001), severity ( p < 0.005), levodopa equivalent dose (LED; p = 0.001), and tremor phenotype of PD ( p = 0.004). Anxiety coexisted with depression in 50 patients (79.4%), which was statistically significant in our cohort ( p = 0.001). There was significant linear relationship between the PAS and PDQ-39. Conclusion  Anxiety exerts a negative impact on the QOL as revealed by proportionately worsening PDQ-39 and PAS scores. Screening for anxiety will allow efficient delivery of support and treatment to patients with PD and their families.

Clinical characteristics of epilepsy in resource-limited communities in Punjab, Northwest India

OBJECTIVES

To describe clinical characteristics of a community-based epilepsy cohort from resource-limited communities in Punjab, Northwest India.

METHODS

The cohort was gathered following a two-stage screening survey. We cross-sectionally examined and followed up the cohort for one year. A panel of neurologists assigned seizure types, syndromes, and putative etiologies and categorized drug responsiveness.

RESULTS

The cohort of 240 included 161 (67.1%) men, 109 (45.4%) illiterates and 149 (62.1%) unemployed. Current age was >18 years in 155 (64.6%) but age at epilepsy onset was <18 years in 173 (72.1%). Epilepsies due to structural and metabolic causes were diagnosed in 99 (41.3%), but syndromic assignments were not possible in 97 (40.4%). After one year, drug-resistant epilepsy was established in 74 (30.8%). Perinatal events (n = 35; 14.6%) followed by CNS infections (n = 32; 13.3%) and traumatic brain injury (n = 12; 5.0%) were common risk factors. Most of those with CNS infections (n = 19; 63.3%), perinatal antecedents (n = 23; 76.7%), and other acquired risk factors (n = 27; 90.0%) presented with epilepsy due to structural and metabolic causes. Perinatal events were the putative etiology for nearly 40.7% of generalized epilepsies due to structural and metabolic causes and 28.2% of all epilepsies with onset <10 years.

SIGNIFICANCE

Existing classifications schemes should be better suited to field conditions in resource-limited communities in low- and middle-income countries. The finding of drug-resistant epilepsy in nearly at least a third in a community-based sample underscores an unmet need for enhancing services for this segment within healthcare systems. Perinatal events, CNS infections, and head injury account for a third of all epilepsies and hence preventative interventions focusing on these epilepsy risk factors should be stepped up.

Unabridged Histoplasmosis Myositis: Unsolved Dissemination with Diagnostic Challenge

Histoplasmosis occurs predominantly in immunocompromised hosts and typically presents with mild constitutional symptoms, weight loss, weakness, fatigability, hepatosplenomegaly, and lymphadenopathy. The diagnosis is generally delayed and is based upon isolating the organism in blood cultures or by identifying intracellular organisms in tissues. Disseminated Histoplasmosis is well described in HIV patients but Histoplasmosis myositis is a rare manifestation and has not been reported in seronegative patients till date. We here address a case of a pharmacologically immunosuppressed patient with extensive Histoplasmosis myositis invading almost all the skeletal muscles of body (including plantar foot muscles) with no evidence of dissemination to other organ-systems. Clinical examination and investigations co-related with infiltrative muscle disease and skeletal muscle biopsy revealed Histoplasma capsulatum. This patient illustrates a distinctive clinical presentation of fungal infection with subtle constitutional symptoms and isolated muscle weakness which added to the diagnostic challenge. Hence, differential diagnosis of fungal infection must always be considered as a cause of myopathy in any pharmacologically immunosuppressed patient.

Gender Differences in Impulse Control Disorders and Related Behaviors in Patients with Parkinson's Disease and its Impact on Quality of Life

BACKGROUND

Dopaminergic medications administered to remedy motor symptoms in Parkinson's disease are associated with an enhanced risk for impulse control disorders (ICD) and related compulsive behaviors (ICD-RB). Thus, the present study focuses on investigating the gender difference in the prevalence of ICD-RBs in Indian PD patients on dopamine replacement therapy (DRT), its impact on quality of life and to identify ICDs relevant in Indian scenario apart from the criteria set in QUIP-RS.

METHOD

This was a hospital-based observational cross-sectional study in which Parkinson's disease patients attending neurology clinic were included. Complete details of anti-parkinsonian therapy along with demographic and clinical variables were recorded on a predesigned Performa. Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease (QUIP), which is a validated quick screening tool, was used to detect ICD-RBs. The relative frequency and comparative impact of ICD on health-related quality of life (QOL) was studied using validated PDQ-39 Questionnaire.

RESULTS

Out of 102 patients, at least one ICD or ICD-RB was present in 41.19% and ≥2 ICD-RBs were present in 15.59%. At least one ICD was present in 16.67%, any ICD-related compulsive behaviors was present in 34.31% patients. The most common was punding and compulsive medication use (12.75% each), followed by hobbyism (7.84%), compulsive eating (6.86%), pathological gambling (3.92%), and hypersexuality, walkabout, and compulsive shopping (2.94% each). ICDs not classified elsewhere such as trichotillomania were found 3 patients (2.94%). ICD-RBs showed a trend to be more frequent in women (44.82% women vs. 39.39% men). As compared with patients without ICD-RBs, those with ICD-RBs were found to have higher dose of LD and DA and higher Hoehn and Yahr stage. ICD-RBs have a negative impact on the quality of life of Parkinson's disease patients.

CONCLUSION

ICDs and ICD-RBs have been included in the behavioral spectrum of nonmotor symptoms in PD. PD patients are at increased risk of developing ICD-RBs which interfere with important activities and have obligation in ordinary life, leading to legal and psychological consequences with a great impact on QOL.

Chorea as unusual complication of fungicide poisoning

Chorea is a rare manifestation of poisoning. We report an index case of a young woman who developed generalized chorea following propiconazole toxin ingestion. As large series on neurological complications of toxic compounds are difficult to be compiled, it is of interest to report our experience. This report adds one more compound to the increasing list of toxic chorea.

Educational achievement, employment, marriage, and driving in adults with childhood-onset epilepsy

BACKGROUND

People with epilepsy (PWE) beginning in childhood often experience psychological and social hold-ups in addition to seizures. The hold-ups relate to education, employment, driving, and marriage.

OBJECTIVE

The objective of this study was to document the impact of long-standing, childhood-onset epilepsy on sociopersonal accomplishments of adults pertaining to education, employment, marriage, and driving.

METHODS

A prospective, questionnaire-based survey was undertaken in a hospital-based sample of PWE and their unaffected (by epilepsy) older siblings within the immediate/extended family unit.

RESULTS

People with epilepsy were significantly more likely to abandon formal education after primary (6; 2.4% compared to none in controls) or secondary (69; 31.1% compared with controls 58; 26.1%) school, less likely to be currently married (97; 43.7%) when compared with their elder siblings (158; 71.2%) (P = 0.0001), and less likely to be currently employed (103; 46.4%) (P = 0.0001) or driving (111; 50%) (P = 0.0001) compared with the older same-gender siblings (employed: 148; 66.7%; driving: 165; 74.3%). In multivariate models, having epilepsy and age were associated with employment status, whereas age and education and employment status were associated with both marriage and driving.

CONCLUSION

Notwithstanding the influence of a number of socioeconomic and epilepsy-related variables, childhood-onset epilepsy stands apart in exerting a huge negative impact on educational achievement, employability, marital status, and driving in adulthood.

Stroke profile and outcome between urban and rural regions of Northwest India: Data from Ludhiana population-based stroke registry

Introduction

The objective of this study is to compare the clinical profile, risk factors, type and outcome of stroke patients in urban and rural areas of Punjab, India.

Methods

The primary data source was from the Ludhiana urban population-based stroke registry. The data of first-ever stroke patients with age ≥18 years were collected using WHO stepwise approach from all hospitals, general practitioners, physiotherapy and scan centres between 26 March 2011 and 25 March 2013.

Results

A total of 4989 patients were included and out of 4989 patients, 3469 (69%) were from urban areas. Haemorrhagic stroke was seen more in rural as compared to urban regions (urban 1104 (32%) versus rural 552 (36%); p = 0.01). There were significant differences seen in stroke risk factors; hypertension (urban 1923 (84%) versus rural 926 (89%); p = 0.001) and hyperlipidaemia (urban 397 (18%) versus rural 234 (23%); p = 0.001) between two groups. In the multivariable analysis the rural patients were more likely to be younger (age < 40 years) (OR: 1.82; 95% CI: 1.24-2.68; p = 0.002), Sikhs (OR: 2.57; 95% CI: 1.26-5.22; p = 0.009), farmers (OR: 9.41; 95% CI: 5.36-16.50; p < 0.001), housewives (OR: 2.71; 95% CI: 1.45-5.06; p = 0.002), and consumed alcohol (OR: 1.57; 95% CI: 1.19-2.06; p = 0.001) as compared to urban patients. In addition, use of imaging was higher in rural patients (OR: 1.99; 95% CI: 1.06-3.74; p = 0.03) as compared to urban patients.

Discussion and Conclusion

In this large cohort of patients, rural and urban differences were seen in risk factors and type of stroke. Stroke prevention strategies need to take into consideration these factors including regional sociocultural practices.

The dilemma of arranged marriages in people with epilepsy. An expert group appraisal

INTRODUCTION

Matrimony remains a challenging psychosocial problem confronting people with epilepsy (PWE). People with epilepsy are less likely to marry; however, their marital prospects are most seriously compromised in arranged marriages.

AIMS

The aim of this study was to document marital prospects and outcomes in PWE going through arranged marriage and to propose optimal practices for counseling PWE contemplating arranged marriage.

METHODS

A MEDLINE search and literature review were conducted, followed by a cross-disciplinary meeting of experts to generate consensus.

RESULTS

People with epilepsy experience high levels of felt and enacted stigma in arranged marriages, but the repercussions are heavily biased against women. Hiding epilepsy is common during marital negotiations but may be associated with poor medication adherence, reduced physician visits, and poor marital outcome. Although divorce rates are generally insubstantial in PWE, divorce rates appear to be higher in PWE undergoing arranged marriages. In these marriages, hiding epilepsy during marital negotiations is a risk factor for divorce.

CONCLUSIONS

In communities in which arranged marriages are common, physicians caring for PWE are best-equipped to counsel them about their marital prospects. Marital plans and aspirations should be discussed with the family of the person with epilepsy in a timely and proactive manner. The benefits of disclosing epilepsy during marital negotiations should be underscored.

Unseen face of varicella-zoster infection in adults

Varicella infection is common in children caused by varicella-zoster virus (VZV). VZV is known to cause cerebral arterial vasculopathy and antibody-mediated hypercoagulable state leading to thrombotic complications in children. Such complications in adults are very rare. We report three cases that represent the unseen face of primary varicella infection in adults. Simultaneous involvement of cortical venous sinus thrombosis and deep vein thrombosis leading to clot in right atrium and pulmonary embolism in first case; cortical venous sinus thrombosis in second case; and deep vein thrombosis in third case. Early diagnosis and management can help prevent associated morbidity and mortality.

Endovascular treatment for acute pulmonary embolism in neurological patient

Among the spectrum of venous thrombo-embolic disease, acute pulmonary embolism accounts for the most life threatening manifestations with mortality exceeding 50%. It can affect many patient populations across various disciplines, hence immediate attention and aggressive treatment is crucial. With the advancement of technologies, various catheter-based devices are available to treat massive or submassive PE. In this paper we report two patients of acute pulmonary embolism with neurological issues where the life threatening emergency was successfully managed by utilizing endovascular directed thrombolytic reperfusion therapy.

Establishment of Population-Based Stroke Registry in Ludhiana City, Northwest India: Feasibility and Methodology

Background/Aims: The Indian Council of Medical Research (ICMR) initiated the Task Force Project to evaluate the feasibility of conducting a population-based stroke registry in Ludhiana city, Punjab, Northwest India. Methods: All first-ever, stroke patients over 18 years from the city of Ludhiana were included in the study from March 26th 2010 to March 25th 2011. Stroke information was collected based on the WHO STEPS approach from the participating hospitals, scan centres and doctors. Modified Rankin Scale (mRS) was administered by telephonic interview at 28 days after stroke. The information on stroke deaths was obtained from the Municipal Corporation (MC) office. Results: A total of 905 first-ever stroke patients were documented. After excluding duplicate cases and patients from outside the city, 493 patients were included. The practical issues identified in data collection from these centres were reluctance to take informed consent, lack of willingness to share the data, difficulty to identify key persons from each centre, retrieving medical records from public hospitals and poor documentation of deaths in MC office. Conclusion: Population-based stroke registry was feasible in an urban population with the above methodology. The issues related to feasibility were identified and necessary changes were made for the main phase of the registry.

Spectrum of neurological complications in HELLP syndrome

BACKGROUND

Hemolysis (H), elevated liver enzymes (EL), and low platelets (LP), HELLP syndrome is the extended spectrum of severe preeclampsia and is associated with high mortality. A large proportion of mortality can be attributed to catastrophic central nervous system events.

AIMS

The purpose of this study was to access the clinical manifestations, radiological abnormalities and outcome in patients of HELLP syndrome with neurological manifestations.

SETTING

Obstetric unit and neurology intensive critical unit (ICU) of an academic medical center.

STUDY DESIGN

Retrospective study.

SUBJECTS AND METHODS

Case records of all obstetrical patients who were admitted between January 2012 and December 2012 were screened and data was collected from those patients who were diagnosed with HELLP syndrome with neurological complications. It was entered into a structured performa and analyzed using percentages .

RESULTS

During the study period; 1,166 deliveries were conducted, 108 patients had pregnancy-induced hypertension (PIH); and of the 12 patients with HELLP, eight (66%) patients had neurological complications. The presenting neurological features were seizures (four), focal neurological deficits (two), and encephalopathy (two). Of the eight patients, in six patients neuroimaging showed features of posterior reversible encephalopathy syndrome (PRES), three of them had associated hemorrhage, and two patients had isolated intracranial hemorrhage. All except two were discharged home.

CONCLUSIONS

Neurological complications are not uncommon in patients with HELLP syndrome and a high index of suspicion is essential. Aggressive multidisciplinary approach is the key to reduce the morbidity and mortality.

Sedation in neurological intensive care unit

Analgesia and sedation has been widely used in intensive care units where iatrogenic discomfort often complicates patient management. In neurological patients maximal comfort without diminishing patient responsiveness is desirable. In these patients successful management of sedation and analgesia incorporates a patient based approach that includes detection and management of predisposing and causative factors, including delirium, monitoring using sedation scales, proper medication selection, emphasis on analgesia based drugs and incorporation of protocols or algorithms. So, to optimize care clinician should be familiar with the pharmacokinetic and pharmacodynamic variables that can affect the safety and efficacy of analgesics and sedatives.

Isaac's syndrome associated with myasthenia gravis and thymoma

A 65-year-old male developed fatigable weakness of ocular and bulbar muscle and positive anti-acetyl cholinesterase antibodies suggesting the diagnosis of myasthenia gravis. His condition responded to anticholinesterase and immunotherapy. However, 18 months later, he developed painful paresthesiae, muscle cramps with hyperhiderosis, and was diagnosed as having Isaac's syndrome (neuromyotonia, continuous muscle fibre activity). Computed tomography of the chest revealed a thymic mass, which was confirmed after surgery and histopathology as thymic cell carcinoma. The co-occurrence of myasthenia gravis and continuous muscle fiber activity should prompt the consideration of the occurrence of these disorders as one of the paraneoplastic manifestations, most often due to a thymic neoplasm. Both these conditions respond to treatment of underlying thymoma. This case is a very rare presentation worth reporting.

Acute renal failure caused by pheniramine maleate induced rhabdomyolysis: an unusual case

Antihistamines are easily available over-the-counter medications, which are frequently involved in overdoses. The usual course is accompanied by the anticholinergic effects of these agents. We report a case of a suicide attempt in a young male, where ingestion of antihistamine pheniramine maleate was complicated by nontraumatic rhabdomyolysis and oliguric acute renal failure. Rhabdomyolysis and acute renal failure is a rarely reported but potentially serious complication among patients who present to the emergency after intentional overdoses making recognition and prompt intervention essential. We also describe the potential mechanism of muscle injury in antihistamine overdose.

Organelle-specific injury to melanin-containing cells in human skin by pulsed laser irradiation

Physical models predict that ultraviolet laser radiation of appropriately brief pulses can selectively alter melanin-containing cellular targets in human skin. We exposed skin of normal human volunteers to brief (20 nanosecond) 351-nm wave length pulses from a XeF excimer laser, predicting that those cells containing the greatest quantities of melanized melanosomes (lower half of the epidermis) would be selectively damaged. Transmission electron microscopy revealed the earliest cellular alteration to be immediate disruption of melanosomes, both within melanocytes and basal keratinocytes. This disruption was dose dependent and culminated in striking degenerative changes in these cells. Superficial keratinocytes and Langerhans cells were not affected. We conclude that the XeF excimer laser is capable of organelle-specific injury to melanosomes. These findings may have important clinical implications in the treatment of both benign and malignant pigmented lesions by laser radiations of defined wave lengths and pulse durations.

The effect of temperature and other factors on selective microvascular damage caused by pulsed dye laser

Brief pulses of 577-nm radiation have recently been shown to selectively damage superficial cutaneous blood vessels, resulting clinically in purpura. There was a sharp threshold of exposure dose necessary for causing purpura in any given subject, which correlated with histologic evidence of extravasation and specific vascular injury. As a means of studying mechanisms for such damage, heat, cold, pressure, suction, UV radiation, and intradermal epinephrine were used to alter human cutaneous microvasculature prior to and during 577-nm pulsed dye laser exposures. When compared with control sites, only cooling of the skin significantly affected the exposure dose needed to cause purpura. The magnitude of this effect is quantitatively most consistent with intravascular microvaporization as the cause of vessel rupture and hence purpura.

Effect of repeated oral administration of quinalphos on blood esterases in Bubalus bubalis

The effect of quinalphos on blood esterases was investigated in male buffalo calves after daily oral doses of 0.7, 1.4 and 2.1 mg/kg body weight for 28 consecutive days. Quinalphos markedly inactivated serum carboxylesterase (69-90%) and plasma cholinesterase activity (75-88%). Esterase activities in animals receiving 0.7 mg/kg/day of quinalphos approached normal levels 14 days after the termination of its ingestion. The results suggest that quinalphos is an effective inhibitor of blood esterases in vivo and its repeated exposure to buffaloes may impair detoxification of organophosphorus insecticides that are mainly biodegraded by carboxylesterase enzyme.

Treatment of pityriasis rosea with UV radiation

Twenty patients with symptomatic and extensive pityriasis rosea were treated with unilateral UV-B phototherapy in a bilateral comparison study. Five consecutive daily erythemogenic exposures resulted in substantially decreased pruritus and extent of disease greater than that on the untreated side in approximately 50% of the patients. Therapy seems to be most beneficial to patients receiving treatment within the first week of the eruption.

Effect of chloramphenicol pretreatment on malathion-induced acute toxicity in the rat

Pretreatment of rats with chloramphenicol (CAP) (100 mg/kg, ip) 30 min prior to a single oral LD50 dose of malathion (MTH) at 340 mg/kg completely protected against MTH-induced signs of cholinergic toxicity. Pretreatment with CAP also decreased the extent and duration of MTH-induced inhibition of cholinesterase (ChE). It was previously established that CAP inhibits (1) the cytochrome-P-450-catalyzed oxidative desulfuration of methylparathion to the much more toxic oxygen analog methylparaoxon (MOX) and (2) the carboxyesterase in rat liver. Since carboxyesterases account for 60% or more of the catabolism of MTH in the rat, the present results were surprising. Thus it appears that the inhibition of MTH toxicity by CAP pretreatment is attributable to inhibition by CAP of the metabolic activation of MTH to MOX.

Pharmacokinetics and plasma protein binding (in vitro) of oxytetracycline in buffalo (Bubalus bubalis)

The pharmacokinetics of oxytetracycline given in a single dose (22 mg/kg) either IV or IM was studied in 4 female buffalo calves. The half-life (t1/2) after IV administration varied between 169.02 and 216.56 minutes and that after IM administration, between 630 and 990 minutes. The drug was distributed well in the body after IM administration (Vdarea 1.18 to 2.15 L/kg). The total body clearances varied between 1.02 and 1.45 and between 1.17 and 1.49 ml/kg/min after the IV and the Im dosings, respectively. It has been proposed that oxytetracycline is excreted mainly by glomerular filtration in the buffalo species, but tubular reabsorption also may have a small part. About 42% of the drug was bound to plasma proteins at concentrations of 2 to 20 micrograms of oxytetracycline/ml. The drug dosage schedules to maintain serum levels of 0.5, 1, 2, and 5 micrograms/ml also are determined.

Low-intensity selective UV phototherapy. A clinical trial in outpatient therapy for psoriasis

A UV source of low-intensity output with peak effective emission in the 300 to 320-nm range, termed low-intensity selective UV phototherapy (LISUP), is being advocated for home phototherapy for psoriasis. Twenty patients with plaque-type psoriasis were treated three times a week as outpatients with this unit; the results were compared with those found in a similar group of 20 outpatients treated previously three times a week with a proved and effective protocol using erythemogenic exposures to a conventional UV-B source. Emollients were the only topical agents used during therapy. Eight patients had clearing and five others showed improvement with LISUP. Eighteen patients had clearing and one showed improvement with the UV-B protocol. We found LISUP less frequently effective when used three times a week in clearing plaque-type psoriasis. Therefore, we recommend a trial of this unit before purchase by the patient.

Combined methotrexate--ultraviolet B therapy in the treatment of psoriasis

Twenty-six patients with extensive psoriasis were treated with a 3-week course of methotrexate followed by a combination of ultraviolet B (UVB) therapy and methotrexate. A plaque of psoriasis was shielded during UV therapy to serve as a control. When lesions cleared to less than 5% of body involvement, the methotrexate was stopped and UVB therapy alone was used as maintenance therapy. This protocol achieved clearance of disease in all twenty-six patients in a mean of 7 (+/- 1.5) weeks, with twelve (+/- 4.0) exposures to UVB therapy and a final UVB radiation dose at clearance of 320 (+/- 157) mjoules/cm2. The mean total dose of methotrexate was 112 mg (range, 75 mg-165 mg). At the time of clearing, the shielded area had a decrease in sealing and thickness in twenty-two patients but was free of psoriasis in only four patients. In a preliminary study we were unable to reproduce a methotrexate recall of UV-induced erythema. The combination therapy of methotrexate and UVB allows for clearing of psoriasis at relatively low doses of UVB and methotrexate, and thus may reduce the long-term cumulative toxicity of both agents.

The interaction of UVA and UVB in the production of threshold erythema

A study was done to demonstrate quantitatively and graphically the way in which suberythemogenic doses of broadband UVA and UVB interact in producing a visible erythema. On the backs of fair-skinned human volunteers the minimal erythema dose (MED) was determined for polychromatic UVA and UVB. Increasing fractions of the UVA MED were given to sites already exposed to various fractions of the UVB MED resulting in sites exposed to various doses of both UVA and UVB. The same experiment was repeated with the order of wavebands reversed. It was demonstrated that when UVA was followed by UVB an erythema was produced in those sites where the sum of the fractions was equal to one, an interaction termed photoaddition. When the UVA exposure followed the UVB, erythema was again predominantly noted in those sites demonstrating photoaddition. However, in the latter case, numerous sites of threshold erythema were noted where the sum of the fractions was greater than one. This is suggestive of photorecovery. No evidence of photoaugmentation was observed with either order of exposure.

A study on renal function in the Indian buffalo (Bubalus bubalis)

Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) in buffalo species (Bubalus bubalis) were estimated using a single injection technique. The total body clearances of inulin and para-aminohippuric acid (PAH) served as estimates of GFR and ERPF, respectively. Inulin and PAH were administered to animals as a single i.v. bolus. The time-concentration curves were determined for each compound. Three mathematical models were applied to the data. The two compartment model gave the best fit to the data. The single compartment model gave slightly higher values, but could be used in clinical and certain research situations to estimate renal functions when it is not practical to take large number of samples.

Biological fate of 32P malathion in Gallus domesticus (desi poultry birds)

During this study, a minor surgical technique was developed for the separation of urine and faeces in birds and fate of 32P malathion was studied, following a single oral dose of 394 mg/kg. The birds showed characteristic signs and symptoms of organophosphorus poisoning and the results suggested that the compound is rapidly absorbed from the gastro-intestinal tract, significant quantities being detected in plasma after 0.5 h of ingestion. Highest concentration of 32P was present during 6 to 8 h of administration. At 6 h, 32P was highest in liver followed by other organs. With the lapse of time the concentration of 32P in various organs decreased at 48 h, it was not detected except in liver, kidney, lung and spleen when only traces were observed. The cumulative urinary and faecal excretion study revealed that within 24 h 90% is rapidly excreted mainly via the urine and only small amounts in the faeces. Metabolism studies showed that the compound is quickly metabolised. Because of the rapid turnover of the compound, this study indicated that the accumulation of this compound is unlikely in the body system.