Effects of zolpidem on sleep parameters in patients with cirrhosis and sleep disturbances: A randomized, placebo-controlled trial

Background/Aims

The aim of this study was to study the efficacy and safety of zolpidem for sleep disturbances in patients with cirrhosis.

Methods

Fifty-two Child-Turcotte-Pugh (CTP) class A or B cirrhotics with Pittsburgh Sleep Quality Index >5 were randomized to either zolpidem 5 mg daily (n=26) or placebo (n=26) for 4 weeks.

Results

The therapy of 4 weeks was completed by 23 patients receiving zolpidem (3 stopped treatment due to excessive daytime drowsiness) and 24 receiving placebo (2 refused to continue the study). In the zolpidem group, after 4 weeks of therapy, there was significant increase in total sleep time (TST) and sleep efficiency compared to baseline and improvement in polysomnographic parameters of sleep initiation and maintenance (i.e., decrease in sleep latency time, decrease in wake time, and decreases in number of arousals and periodic limbs movements per hour of sleep), without any significant change in sleep architecture.

Conclusions

Four weeks of 5 mg daily zolpidem in CTP class A or B cirrhosis patients with insomnia led to significant increases in TST and sleep efficiency and improvement in polysomnographic parameters of sleep initiation and maintenance without any significant change in sleep architecture.

Albendazole therapy for neurocysticercosis

Based on clinical evaluation and computed tomography (CT) of the brain, 30 cases of neurocysticercosis were diagnosed. Diagnosis was supported by presence of histopathologically proven subcutaneous cysticerci in 12 cases. Three primary neurological syndromes were established i.e. epilepsy in 22 cases, increased intracranial tension in 6 cases and meningoencephalitis in 2 cases. Albendazole was administered orally in a dose of 15 mg/kg bodyweight/day for 30 days without prophylactic steroids. Follow up CT study at 3 months and 12 months revealed complete regression of all lesions in 2 cases, partial regressions in 14 cases and change in morphology in 4 cases. Transient appearence of fresh subcutaneous cysticerci as a side effect of therapy was noted in 4 cases. Albendazole, though acting slow, is considered a suitable alternative to praziquantel in medical management of parenchymal neurocysticercosis.

Peripartum cerebral venous thrombosis

The clinical and computed tomography (CT) features of 25 patients with peripartum CVT are described. Majority of the patients presented in postpartum period and did not receive proper antenatal care. Headache (92%), altered sensorium (80%, seizures (76%), papilloedema (80%) and hemiplegia (52%) were the common modes of presentation. CT findings included diffuse brain oedema (52%), haemorrhagic or nonhaemorrhagic infarctions on one or both sides of brain (48%), gyral enhancement (40%) and tentorial enhancement (16%). While 15 patients made good recovery, 3 cases (12%) died during acute stage of illness.

Auditory evoked response in patients of diabetes mellitus

Brainstem auditory evoked response (BAER) and the mid latency response (MLR) were recorded in 25 diabetic men and compared with a group of 25 control subjects. The threshold of hearing was higher (P less than 0.001) in the patients. The BAER peak latencies were also significantly prolonged in both the ears; however, the degree of prolongation was more prominent in the right ear. The interpeak latencies of waves I-III were also prolonged (P less than 0.01) in the left ear, with non significant increase noticed in the right ear also. The wave V amplitude was lower (P less than 0.05) in diabetics. The MLR, on the other hand, was not affected in patients. These findings suggest functional impairment in the auditory pathway in patients of diabetes mellitus.

Optic nerve cysticercosis: a case report

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Epilepsy as a manifestation of neurocysticercosis

Epilepsy is the commonest manifestation of neurocysticercosis. Epilepsy was observed in 127 of 150 cases (84.7%) of neurocysticercosis seen over a period of 17 years. The basis of diagnosis was clinical presentation and concomitant evidence of extraneural cysticercosis in the pre-computed tomography (CT) scan era, and typical CT findings in later years. Eighty one cases (54%) who primarily presented as epilepsy without any neurological deficit have been analysed in detail. In the pre-CT period the occurrence of epilepsy as a presenting feature in neurocysticercosis was 43.5% whereas in later years it was 61.4%. Primary generalised seizure (49 cases) was more common than partial seizure (29) and partial complex seizure (3). Status epilepticus was seen in 6 cases. Magnetic resonance imaging, done in 8 cases, proved to be more sensitive in demonstrating various stages in the development of noncalcified cysticercosis. The new larvicidal drugs offer a potential cure and cysticercosis should be entertained as a cause of epilepsy especially in endemic areas.

Clinical spectrum of myasthenia gravis and problems of management

Seventeen cases of myasthenia gravis, aged 20-79 years, including one case of ocular myasthenia gravis, seen over a 3 year period, were analysed. Dysphagia was the presenting symptom in two cases. One patient had ectopic thymus gland in relation to the cardiac border, which posed difficulty in diagnosis. A majority of the patients were on medical treatment, including neostigmine, prednisolone and azathioprim. Plasmapheresis was done in 4 cases during crisis, with significant benefit. One patient was put on intermittent ventilatory support for 14-16 hours a day for over 2 years; she died during a power failure. Seven patients were subjected to thymectomy.

Acute paralysis due to barium carbonate

Poisoning due to barium carbonate (rat poison) resulting in areflexic quadriplegia and respiratory muscle paresis in a young patient is described. The various effects of barium salts on the human body and their treatment are highlighted.

Cysticercal meningoencephalitis

Meningoencephalitic syndrome can be caused by many infective agents. Over a period of 13 years, 15 of 170 cases of neurocysticercosis (NCC) presented as meningoencephalitis. The basis of diagnosis of NCC was positive subcutaneous nodule histopathology (4), CT scan (9) and autopsy (3) findings. The age of the patients ranged from 7-68 years (mean 32). Fever was encountered in 12, altered sensorium in 7, seizures in 10 and abnormal behaviour in 3 cases. All cases had papilloedema. Focal neurological signs included optic atrophy, lateral rectus palsy, hemiplegia, internuclear ophthalmoplegia and cerebellar ataxia. Cerebrospinal fluid was abnormal in 8 of 13 cases, leading to a suspicion of tuberculous meningitis. Twelve patients improved with therapy. Three cases ended fatally and autopsy confirmed the diagnosis.

Computed tomographic spectrum of neurocysticercosis

Computed tomography (CT) is a very sensitive modality for the diagnosis of neurocysticercosis. Fifty eight patients were evaluated by plain radiography and CT scans. The initial presentation was as seizure disorder (33), raised intracranial tension (19), meningoencephalitis (5) and psychiatric manifestation (1). Histologically confirmed subcutaneous nodules were seen in 20 cases and ocular cyst in 2 cases. CT scan showed multiple calcification in 8 cases, disc lesions in 30,ring lesions in 3, and a combination of disc and ring lesions in another 13 cases. Low attenuation lesions were seen in 4 cases in combination with disc/disc and ring lesions. All 58 cases had supratentorial lesions while 19 cases had infratentorial lesions in addition. Perifocal or generalised oedema was seen in 33 and 11 cases respectively. The ventricles were compressed in one case, large in 2 cases and normal in the rest. CT scan is valuable in the diagnosis of neurocysticercosis. Its significance is different in the various clinical and radiological groups.

Lumbosacral plexopathy following regional paracervical block anaesthesia

We report a 35 year old lady who developed lumbosacral plexopathy immediately following regional paracervical block anaesthesia for medical termination of pregnancy. There was only partial recovery at one year. The neurological deficit and its mechanisms are discussed.

Pure motor hemiparesis due to hypertensive putaminal haemorrhage

A hypertensive woman presenting as pure motor hemiparesis with rapid and complete recovery from the neurological deficit is described. The probable aetiology was primary hypertensive putaminal haemorrhage, as revealed by CT scan. This rare presentation has been described only once earlier and emphasizes the value of CT scanning as a tool for diagnosis of such cases.