Madhuri Behari

Restless legs syndrome in Parkinson's disease: a case-controlled study.

Restless legs syndrome (RLS) is a disorder of motor activity with a circadian pattern, occurring frequently in patients with Parkinsons disease (PD). We sought to estimate the prevalence of RLS in Indian PD patients. One hundred twenty‐six consecutive PD patients and 128 healthy age‐ and sex‐matched controls were evaluated using a predesigned questionnaire. RLS was present in 10 of 126 cases of PD (7.9%) and 1 of 128 controls (0.8%, P = 0.01). PD patients with RLS were older than those without RLS (63.70 ± 7.80 years vs. 57.37 ± 10.04 years; P = 0.05) and had higher prevalence of depression (40% vs. 10.3%; P = 0.023). No demographic factors or factors related to PD correlated with the presence or severity of RLS. RLS is more common among patients with PD than controls. A greater medical recognition of this disorder is needed in view of available effective treatment.

Risk factors of Parkinson's disease in Indian patients

Epidemiological data on risk factors of Parkinsons disease (PD) are not available from India. In a case control study, we investigated environmental and genetic risk factors in the etiology of idiopathic Parkinsons disease. Three hundred seventy-seven patients of Parkinson disease (301 men, 76 women, mean+/-SD age 56.78+/-11.08 years) and equal number of age matched (+/-3 years) neurological controls (271 men, 106 women, mean+/-SD age 56.62+/-11.17 years) were included in the study. Conditional logistic regression model was used to determine the risk factors of PD. We found that male gender, family history of Parkinsons disease, past history of depression of up to 10-year duration and well water drinking of more than 10-year duration were significantly associated with occurrence of Parkinsons disease, whereas tobacco smoking of up to 20-year duration and exposure to pets had protective effect. However, tobacco smoking of more than 20-year duration, well water drinking of up to 10-year duration, vegetarian dietary habit, occupation involving physical exertion, rural living, farming, exposure to insecticides, herbicides, rodenticides, alcohol intake and family history of neurodegenerative diseases had no significant correlation with occurrence of PD in the patient population studied. Results of our study support the hypothesis of multifactorial etiology of PD with environmental factors acting on a genetically susceptible host.

Albendazole in single CT ring lesions in epilepsy

Single, small, enhancing lesions that often resolve spontaneously are frequent findings on CTs of Indian patients with seizures. Based on ELISA and biopsy data, the majority of these lesions are probably cysticercosis. To determine if these patients should be treated with albendazole, we performed a double-blind, randomized, placebo-controlled study involving 75 patients with seizures and the appropriate CT abnormality without neurologic abnormality on examination. Patients were randomized to albendazole (15 mg/kg/d) and placebo for 1 week, and we obtained serial CTs at the end of 1 week, 1 month, and 3 months. All patients completed a 3-month follow-up and none had systemic evidence of tuberculosis or cysticercosis. The lesions varied in size from 3 mm to 2.1 cm, with an average size of 1.18 cm. Serum ELISA for cysticercosis was positive in 30 and CSF ELISA was positive in 20 of 45 patients. Forty patients received albendazole and 35 received placebo. At the end of 3 months, a total of 68 patients showed resolution. Thirty-five of 40 patients who received albendazole showed resolution, as opposed to 33 of 35 patients on placebo. We conclude that albendazole therapy was not beneficial.

Excessive daytime sleepiness in Parkinson's disease as assessed by Epworth Sleepiness Scale (ESS)

OBJECTIVE To assess daytime sleepiness in patients with Parkinsons disease (PD) using the Epworth Sleepiness Scale (ESS). MATERIAL AND METHODS One hundred and forty-nine patients with PD (126 men, 23 women) and 115 age matched controls recruited from relatives of medical staff or spouses and other family members accompanying patients to the Movement Disorder Clinic of the All India Institute of Medical Sciences in New Delhi were included in the study. An ESS score of > or =8 was considered abnormal. Data obtained were analyzed using Chi square test for categorical variables and Students t-test for continuous variables. RESULTS The mean age of patients with PD was 58.37 (S.D.=10.45) years, and that of controls 56.50 (S.D.=11.45) years, with a mean duration of disease of 5.68 (S.D.=3.85) years. The mean ESS score was 4.9 (S.D.=3.63) and 2.17 (S.D.=2.54) in PD patients and controls, respectively (P<0.05). Thirty-two patients with PD (21%) had an ESS score of >8 whereas only 3% of controls scored > or =8 on the ESS (P<0.05). Higher ESS scores were associated with a higher Hoehn and Yahr (H&Y) stage of disease and higher Unified Parkinsons Disease Rating Scale (UPDRS) (part I, III and total) scores (P<0.019, P<0.013 and P<0.011, respectively). CONCLUSION Excessive daytime sleepiness was more common in PD patients as compared to controls. Higher ESS scores correlated significantly with higher H&Y stage and higher UPDRS (part I, III and total) scores.

Motor fluctuations in Parkinson's disease.

OBJECTIVES To assess patterns, prevalence, and risk factors of motor fluctuations in an unselected population of Parkinsons disease patients attending Movement Disorders Clinic of a tertiary hospital. MATERIAL AND METHODS Eighty patients with Parkinsons disease were interviewed and data about their clinical characteristics, motor fluctuations, i.e. dyskinesia, dystonia, motor blocks and details of drug therapy, were collected. RESULTS Forty patients had at least one type of motor fluctuation. Twenty three patients had motor blocks, 20 had dyskinesia and 11 had dystonia. Interval between onset of symptom and start of levodopa therapy and duration of levodopa therapy correlated with presence of motor fluctuations in general and to dyskinesia in particular. Patients with dyskinesia had younger age of onset of disease. Motor blocks showed a positive relationship to duration of disease. CONCLUSIONS Fifty percent of unselected patients of Parkinsons disease had motor fluctuations after a mean duration of 5 years of illness. Early initiation and longer duration of levodopa therapy were identified as risk factors for motor fluctuations. Younger patients had more risk of developing dyskinesias. Motor blocks were more common in patients with a longer duration of illness.

Absence/rarity of commonly reported LRRK2 mutations in Indian Parkinson's disease patients

Recent discovery of pathogenic mutations in the leucine-rich repeat kinase 2 (LRRK2) gene in Parkinsons disease (PD) patients in different ethnic groups have raised a hope of diagnostic screening and genetic counseling. We investigated the six most commonly reported mutations in LRRK2 gene among Indian PD patients, using PCR-RFLP method. Mutations G2019S, R1441C, R1441G, and R1441H were screened in 1012 individuals (PD, 800; controls, 212) while mutations I2012T and I2020T were screened in 748 PD patients. We did not observe any of these six mutations in this study sample except in a single female young onset PD patient who showed a heterozygous G2019S mutation. The absence of mutations was reconfirmed by sequencing of probands from several autosomal dominant PD families. Our observations suggest that these mutations may be a rare cause of PD among Indians and therefore of little help for diagnostic screening and genetic counseling for Indian PD patients.

Low-dose topiramate versus lamotrigine in migraine prophylaxis (the Lotolamp study).

Objective.—To assess the efficacy and safety of topiramate and lamotrigine for prophylaxis in patients with frequent migraine as compared to each other and to placebo.

Phenytoin levels in catamenial epilepsy.

Summary: We studied the fluctuations in phenytoin (PHT) levels during ovulatory and menstrual phases of the cycle, in eight patients with catamenial epilepsy and in eight age‐matched controls. Pharmacokinetic studies of PHT were done in five patients with catamenial epilepsy. The difference in PHT levels during menstrual and ovulatory phase in catamenial group was 3.44 ± 3.25 (μg/ml as compared with 0.91 ± 2.03 u.g/ml in controls. The mean fall during menstrual phase was significant (p < 0.05) in the catamenial group. There was also rapid though statistically nonsignificant clearance of PHT during menses as compared with the ovulatory period. It is presumed that the fall in plasma PHT levels during menses, though still within therapeutic range, may be responsible for catamenial exacerbation of epilepsy.

Hyperacute thrombolysis with IV rtPA of acute ischemic stroke: Efficacy and safety profile of 54 patients at a tertiary referral center in a developing country

BACKGROUND Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries. Prothrombin time (PT), platelet count and activated partial thromboplastin time (aPTT) may not be feasible within the time window. AIM To evaluate the safety and efficacy of thrombolysis in selected patients without the coagulation profile. DESIGN Open, nonrandomized, observational study. MATERIALS AND METHODS Fifty-four stroke patients were classified using TOAST criteria (large artery atherosclerotic = 13; cardioembolic = 12; small vessel occlusion = 22; other determined etiology =three; undetermined etiology = four). The mean time to reach emergency was 2.4h (1.15-3.4), the mean door to CT, 24 min (10-47) and the door to recombinant tissue plasminogen activator (r-tPA) injection, 26.8 min (25-67). The NIHSS scores ranged from 11 to 22 (mean = 15.5 +/- 2.7). Patients with history of liver or renal disease or those on anticoagulants were excluded. The PT, aPTT and platelet count were not done. Recombinant tissue plasminogen activator was administered at a dosage of 0.9 mg/Kg. RESULTS Thirty-five patients (65%) significantly improved on NIHSS at 48 h (> or =4 points) (mean change = 10; range= 4-17). At one month, 43 (79%) improved on Barthel Index (mean change = 45%). One each developed small frontal lobe hemorrhage and recurrent stroke; one died of aspiration; and eight showed no improvement. CONCLUSIONS Hyperacute thrombolysis was found useful and safe in selected patients with AIS even without the coagulation studies.

Validity of the Berlin Questionnaire in identifying obstructive sleep apnea syndrome when administered to the informants of stroke patients

Given the high prevalence of sleep-disordered breathing (SDB) in stroke and its importance as a vascular risk factor, a clinical instrument to assess its incidence would be useful. Acute stroke patients (n=121) were stratified into high- and low-risk groups for SDB using a modified Berlin Questionnaire (BQ) administered to the informants who were living with the patient. After a minimum of 4 weeks from stroke onset, patients who were fit underwent overnight polysomnography (PSG). On stratifying risk of obstructive sleep apnea (OSA) in these patients based on the BQ, 53% belonged to the high-risk group and 47% belonged to the low-risk group. There was poor correlation between the clinical questionnaire results and PSG findings, with sensitivity of 66.7%, specificity of 55.6%, a positive predictive value of 63.4%, and a negative predictive value of 58.8%.