B Vengamma

Economic Burden of Epilepsy in India

Summary:  Purpose: The economic burden due to epilepsy is not adequately examined in developing countries. Cost estimates are very important in health care planning and delivery of services. We have estimated the direct and some of the indirect costs of epilepsy in India.

Thalamic disequilibrium syndrome after thrombolytic therapy for acute myocardial infarction

Thalamic disequilibrium syndrome (TDS) refers to unsteady stance and gait resulting from unilateral thalamic lesion. Posterolateral thalamic involvement may result in disequilibrium with minimal motor or sensory deficit.1 However, this entity has received less attention in comparison with thalamic sensory, movement, and ataxic disorders. The transient nature of TDS underscores its importance for the prevention of falls in neurorehabilitation. The current report highlights development of TDS due to right thalamic hemorrhage after thrombolytic therapy for acute myocardial infarction. A 65-year-old man underwent thrombolytic therapy for acute anterior wall myocardial infarction with streptokinase followed by heparin and oral antiplatelet agents. When he tried to move 3 days later, he could not stand or walk unassisted. On assisted standing, he had truncal instability with axial lateropulsion to the left. He also required assistance for sitting up in bed. Neurologically he had normal visual fields, cranial nerve function (especially ocular movements), muscle power, and …

In vitro differentiation of cultured human CD34+ cells into astrocytes

BACKGROUND Astrocytes are abundantly present as glial cells in the brain and play an important role in the regenerative processes. The possible role of stem cell derived astrocytes in the spinal cord injuries is possible related to their influence at the synaptic junctions. AIM The present study is focused on in vitro differentiation of cultured human CD34+ cells into astrocytes. MATERIALS AND METHODS Granulocyte-colony stimulating factor mobilized human CD34+ cells were isolated from peripheral blood using apheresis method from a donor. These cells were further purified by fluorescence-activated cell sorting and cultured in Dulbeccos modified eagles medium. Thus, cultured cells were induced with astrocyte defined medium (ADM) and in the differentiated astrocytes serine/threonine protein kinases (STPK) and glutamine synthetase (GLUL) activities were estimated. The expression of glial fibrillary acidic protein (GFAP) and GLUL were confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR). RESULTS The cultured human CD34+ cells differentiated into astrocytes after 11 h of incubation in ADM. The RT-PCR experiment showed the expression of GLUL (1.5 kb) and GFAP (2.9 kb) in differentiated astrocytes. The high enzyme activities of GLUL and STPK in differentiated astrocytes compared with cultured human CD34+ cells confirmed astrocyte formation. CONCLUSION In the present study, in vitro differentiation of stem cells with retinoic acid induction may result in the formation of astrocytes.

Epilepsy care in six Indian cities: a multicenter study on management and service

BACKGROUND Epilepsy care in developing countries is lagging behind than in the developed countries. Precise data on delivery of neurological services for epilepsy is essential to optimize the medical services for epilepsy care with limited resources. OBJECTIVE This study was carried out in order to examine the management practices and utilization of various medical services for epilepsy in different parts of India. METHODOLOGY University centers with epilepsy clinics, one each from six states of India, had participated in this study. Demographic data, clinical details, and data on epilepsy care were collected simultaneously on standard proforma. RESULTS Data on 285 patients with epilepsy (generalized epilepsy: 49.1%, localization-related epilepsy: 49.9%, others: 1%) were included. Mean age of onset of epilepsy was 14.8+11.1 years. Mean delay in diagnosis was 1.5+/-4 years. Mean distance from place of residence to the consulting neurologist was 70+/-82 km. Medical consultations before referral to epilepsy center included general practitioners (54.1%) and specialists (43.3%). Very few patients received services from clinical psychologist or social worker. Investigations included, EEG (63.2%), CT Scan (36.2%). MRI brain (8.5%) and video EEG (2.1%) were limited to a few. Nearly 75.5% were on monotherapy. Newer Anti-Epileptic Drugs (AEDs) were used only in less than 5% patients. CONCLUSION The services for epilepsy are urban-based and there is underutilization of services, general practitioners and specialists. Newer AEDs (although expensive) are gradually emerging in Indian market. Facilities for epilepsy surgery, therapeutic drug monitoring and services of clinical psychologist or medical social workers are limited.

Computational approaches to identify common subunit vaccine candidates against bacterial meningitis

Bacterial meningitis, an infection of the membranes (meninges) and cerebrospinal fluid (CSF) surrounding the brain and spinal cord, is a major cause of death and disability all over the world. From perinatal period to adult, four common organisms responsible for most of the bacterial meningitis are Streptococcus pneumonia, Neisseria meningitidis, Haemophilus influenza and Staphylococcus aureus. As the disease is caused by more organisms, currently available vaccines for bacterial meningitis are specific and restricted to some of the serogroups or serotypes of each bacterium. In an effort to design common vaccine against bacterial meningitis, proteomes of the four pathogens were compared to extract seven common surface exposed ABC transporter proteins. Pro-Pred server was used to investigate the seven surface exposed proteins for promiscuous T-cell epitopes prediction. Predicted 22 T-cell epitopes were validated through published positive control, SYFPEITHI and immune epitope database to reduce the epitope dataset into seven. T-cell epitope 162-FMILPIFNV-170 of spermidine/putrescine ABC transporter permease (potH) protein was conserved across the four selected pathogens of bacterial meningitis. Hence, structural analysis was extended for epitope 162-FMILPIFNV-170. Crystal structures of HLA-DRB alleles were retrieved and structure of potH was modeled using Prime v3.0 for structural analysis. Computational docking of HLA-DRB alleles and epitope 162-FMILPIFNV-170 of potH was performed using Glide v5.7. RMSD and RMSF of simulation studies were analyzed by Desmond v3.2. The docking and simulation results revealed that the HLA-DRB-epitope complex was stable with interaction repressive function of HLA. Thus, the epitope would be ideal candidate for T-cell driven subunit vaccine design against bacterial meningitis.

Leptospirosis with acute renal failure and paraparesis

Leptospirosis is an important zoonosis with a worldwide distribution that is characterized by a broad spectrum of clinical manifestations ranging from inapparent infection to fulminant disease. The presentation of paraparesis in combination with acute renal failure is rare.

MYASTHENIC CRISIS-LIKE SYNDROME DUE TO CLEISTANTHUS COLLINUS POISONING

Poisoning with Cleistanthus collinus frequently causes cardiac manifestations such as rhythm disturbances and also results in other manifestations such as metabolic acidosis and hypokalemia. We present the case of a patient who presented with a rare myasthenic crisis-like syndrome requiring assisted ventilation due to Cleistanthus collinus poisoning, which responded to treatment with neostigmine.

Stroke in chronic kidney disease

Chronic kidney disease (CKD) is associated with a higher risk for stroke in studies from developed countries. This prospective study was conducted to study the clinical profile, management, and outcome of stroke in patients of chronic kidney disease who had been admitted in our institute during the period from December 2004 to December 2006. A higher incidence of stroke was found in men and in the fifth decade of life. Hypertension and diabetes were found in 88.8 and 48.1% of the patients respectively. CKD was detected for the first time during stroke evaluation in 55.5% of the patients. Stroke was due to cerebral infarction in 48.14% and due to cerebral hemorrhage in 40.7% of the patients. Surgical intervention was needed in 14.8% of all patients while stroke was managed medically in the rest. Over 70% of the patients were discharged after they showed improvement in the symptoms.

Anthrax meningoencephalitis successfully treated

Dear Editor, A 70-year-old male lawyer was admitted to the emergency room in an unconscious state with a history of high grade fever for the preceding 4 days and headache with vomiting for 2 days. He had hypertension for last 2 years and was taking treatment irregularly. He was a vegetarian; there was no history of contact with pet animals. Twenty years ago he was treated for pulmonary tuberculosis. On examination he was febrile temperature 101 F, pulse was 98 min regular; blood pressure was 210/110 mmHg. There were no cutaneous lesions. Glasgow Coma Scale was 6/15. His pupils were 2–3 mm, equal and reacting to light. Fundus showed congested discs with blurred margins. He had neck rigidity and extensor plantar response. A provisional diagnosis of meningoencephalitis was made and he was started on i.v. cefoperazone/sulbactum 1 g twice a day; metronidazole 500 mg 8th hourly and mannitol 100 ml 8th hourly. His laboratory investigations were normal except for microcytic hypochromic anemia (10 g/dl) and neutrophilic leukocytosis (12 000 cells/mm). C T scan of the head showed diffuse cerebral edema. Chest Xray and the CT scan of the chest revealed fibrotic lesions in both upper zones with left apical pleural thickening and bilateral pleural effusion and basal atelectasis. Ultrasonography of the abdomen was normal. Cerebrospinal fluid (CSF) obtained by lumbar puncture was hemorrhagic and was uniformly blood stained in the four consecutive bottles. CSF examination revealed glucose 20 mg/dl, (simultaneous venous plasma glucose 142 mg/dl), protein 1247 mg/dl, cells 1100/mm; differential count was lymphocytes 8% and neutrophils 92%. CSF did not reveal malignant cells or acid fast bacilli and India ink preparation was negative. Gram staining showed moderate number of pus cells and Gram positive bacilli. CSF culture showed growth of Bacillus anthraces (Fig. 1) sensitive to cefoperazone–sulbactum, ciprofloxacin. Patient showed signs of improvement and was discharged on the 10th day on oral ciprofloxacin 500 twice a day for 60 days. He was asymptomatic on follow-up after 1 month. Anthrax, caused by Bacillus anthracis, is a highly infectious disease of animals especially ruminants. It is transmitted to humans when they come in contact with animals or their products. [1] Anthrax meningitis can occur from bacteremic spread from any of the three forms (cutaneous, inhalation and gastrointestinal) of anthrax. There is an entity known as primary anthrax meningitis, in which no portal of entry has been identified. We suspect that this might be the case in our patient. A repeat CT scan was normal. Hemorrhagic CSF and rod shaped Gram positive shaped bacteria on gram staining are the hallmarks of the disease. The other possible causes for a hemorrhagic CSF could be a traumatic lumbar puncture, subarachnoid hemorrhage (SAH), hemorrhagic meningitis (anthrax, tuberculosis, amoebic meningoencephalitis certain viral infections like Hantavirus, Dengue fever, Ebola virus), intraparenchymal hemorrhage and vasculitis. The incidence of anthrax has decreased over the years. There are reports of endemic outbreaks in India [2–4]. Anthrax can rarely cause a rapidly fatal meningoencephalitis. Survival rate for this condition has been reported to be 6% [5]. An online medline search with the key words anthrax , meningitis and survival revealed seven case reports of survival till date [5]. The initial treatment of suspected anthrax meningitis should anchor on an i.v. fluoroquinolone and should include one or two other agents with activity against Bacillus anthraces and good penetration into the central nervous system such as (penicillin, ampicillin, meropenem and rifampicin [6]. In conclusion, this case highlights the fact that a hemorrhagic CSF in a patient with suspected meningitis should alert the physicians towards the possibility of anthrax meningitis in an endemic area. As anthrax meningoencephalitis may sometimes present in a pure neurological form, a high degree of suspicion and prompt treatment can decrease the mortality of this extremely fatal disease.

N-terminal pro-brain natriuretic peptide levels and short term prognosis in acute ischemic stroke.

Background: Sparse published data are available regarding the prognostic importance of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with acute ischemic stroke. Materials and Methods: We prospectively studied 74 consecutive patients presenting with acute ischemic stroke within 24 hours of onset. All of them underwent laboratory and imaging evaluation and were treated as per guidelines. In all subjects, plasma NT-proBNP levels were measured at initial admission and again on day 7. Results: Their mean age was 54 ± 13.5years; there were 49 males; 18 (24%) patients died during the hospital stay. A statistically significant negative correlation between log NT-proBNP and Glasgow coma scale (GCS) score (P < 0.001); and a significant positive correlation between log NT-proBNP and National Institutes of Health Stroke Scale (NIHSS) score (P < 0.001) were observed. Baseline log NT-proBNP levels were higher among non-survivors compared with survivors (6.7 ± 0.47 vs. 5.37 ± 0.62; P = 0.06); day 7 log NT-proBNP levels were significantly higher in non-survivors compared with survivors (7.3 ± 0.26 vs. 4.5 ± 0.4; P = 0.000). In survivors, there was a statistically significant decline in log NT-proBNP levels from baseline to day 7 (5.3710 ± 0.620 vs. 4.5320 ± 0.451; P < 0.001). In contrast, among non-survivors, log NT-proBNP levels showed a statistically significant increase from baseline to day 7 (4.5322 ± 0.451 vs. 7.2992 ± 0.263; P < 0.001). On receiver operator characteristic curve (ROC) analysis, at a cut-off value of ≥ 6.0661, log NT-proBNP had a sensitivity and specificity of 98.2 and 88.9, respectively, in predicting death. Conclusions: Plasma log NT-pro-BNP level appears to be a useful biological marker for predicting in-hospital mortality inpatients presenting with acute ischemic stroke.