Manvir Bhatia

Restless legs syndrome in hemodialysis patients in India: a case controlled study

OBJECTIVE To assess the prevalence of restless legs syndrome (RLS) in Indian patients on hemodialysis as compared to controls. METHODS One hundred and twenty-one consecutive hemodialysis patients and 99 controls were evaluated using a standard predesigned questionnaire. The control group comprised completely normal healthy adults who were being evaluated as renal donors. Nerve conduction studies were done in those patients diagnosed with RLS. RESULTS RLS was present in eight hemodialysis patients (6.6%) and none of the controls. Patients (87.5%) with RLS had delayed sleep onset. Nerve conduction showed evidence of sensori-motor neuropathy in five patients and a normal study in one patient. When we compared the patients with RLS to those without RLS, there was no significant difference in their age, duration of hemodialysis, hemoglobin, blood urea, creatinine, serum ferritin or use of erythropoeitin. CONCLUSIONS The prevalence of RLS was 6.6% in patients on hemodialysis; and 0% in controls, which is much lower than that reported from the West.

Expert model for detection of epileptic activity in EEG signature

Seizure detection and classification using signal processing methods has been an important issue of research for the last two decades. In the present study, a novel scheme was presented to detect epileptic seizure activity with very fast and high accuracy from background electro encephalogram (EEG) data recorded from epileptic and normal subjects. The proposed scheme is based on discrete wavelet transform (DWT) and energy estimation at each node of the decomposition tree followed by application of probabilistic neural network (PNN) for classification. Normal as well as epileptic EEG epochs were decomposed into approximation and details coefficients till the sixth-level using DWT. Approximate energy (EDA) values of the wavelet coefficients at all nodes of the down sampled tree were used as a feature vector to characterize the predictability of the epileptic activity within the records of EEG data. In order to demonstrate the classification accuracy of the proposed probabilistic neural network, tenfold cross-validation was implemented in the expert model. Clinical EEG data recorded from normal as well as epileptic subjects were used to test the performance of this new scheme. It was found that with the proposed scheme, the detection is 99.33% accurate with sensitivity and specificity as 99.6% and 99%, respectively. The proposed model can be widely used in developing countries where there is an acute shortage of trained neurologist.

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.

Auditory P300 event-related potentials and number connection test for evaluation of subclinical hepatic encephalopathy in patients with cirrhosis of the liver: A follow-up study

Background and Aims: The P300 event‐related potentials (P3ERP) have been recently advocated for detection of cognitive disturbances in early encephalopathy. However, no systematic follow‐up study has been conducted to understand the clinical significance of subclinical hepatic encephalopathy (SHE) detected by this or other methods. The present study was therefore undertaken to examine the diagnostic usefulness of auditory P3ERP in the detection of SHE, to compare it with that of the number connection test (NCT), and to investigate the clinical outcome of patients with SHE in terms of progression to overt encephalopathy.

Usefulness of short-term video EEG recording with saline induction in pseudoseizures.

Objectives ‐ To study the usefulness of short‐term recording of video electroencephalography (VEEG) as an outpatient procedure with placebo induction (PLIN) and intravenous saline in cases of pseudoseizures (Psz). Material and methods ‐ Fifty cases of suspected Psz were enrolled. They were divided into 2 groups: Group 1 consisted of patients with frank Psz, Group 2 those where diagnosis was uncertain. VEEG recording was done and 10 ml of saline used for placebo‐induction. Results ‐ Of 50 patients, 24 (48%) were in Group 1 and 26 (52%) in Group 2. Fifteen (30%) had a spontaneous event during VEEG and 33% had an event only on PLIN. The diagnosis was confirmed in 60%. In 24% of patients anti‐epileptic drugs were discontinued. Conclusion ‐ Short‐term monitoring with VEEG using PLIN is a useful initial screening procedure and in patients where it is inconclusive, long term recordings may be done.

Autonomic dysfunction in systemic lupus erythematosus.

The objectives were to study the frequency and pattern of autonomic dysfunction in systemic lupus erythematosus (SLE). Fifty-one patients of SLE and 30 age- and sex-matched healthy controls were studied prospectively using a standard battery of noninvasive tests. Autonomic symptoms were seen in 37% patients. On laboratory testing incipient dysfunction was seen in 9 (18%) cases and 1 (3%) control, while atypical involvement was seen in 11 (21%) cases and 6 (20%) controls. Autonomic dysfunction did not correlate with disease duration, lupus activity, disease damage, any particular organ involvement or the presence/absence of peripheral neuropathy. Autonomic neuropathy is not uncommon in lupus and may exist independent of peripheral neuropathy. There are no specific clinical predictors. The clinical significance of autonomic dysfunction detected by laboratory testing warrants longitudinal studies.

Quantitative thermal sensory testing — value of testing for both cold and warm sensation detection in evaluation of small fiber neuropathy

OBJECTIVE Small fiber neuropathy is a common neurological disorder, often missed or ignored by physicians, since examination and routine nerve conduction studies are usually normal in this condition. Many methods including quantitative thermal sensory testing are currently being used for early detection of this condition, so as to enable timely investigation and treatment. This study was conducted to assess the yield of quantitative thermal sensory testing in diagnosis of small fiber neuropathy. MATERIAL AND METHODS We included patients presenting with history suggestive of positive and/or negative sensory symptoms, with normal examination findings, clinically suggestive of small fiber neuropathy, with normal or minimally abnormal routine nerve conduction studies. These patients were subjected to quantitative thermal sensory testing using a Medoc TSA-II Neurosensory analyser at two sites and for two modalities. QST data were compared with those in 120 normal healthy controls. RESULTS Twenty-five patients (16 males, 9 females) with mean age 46.8+/-16.6 years (range: 21-75 years) were included in the study. The mean duration of symptoms was 1.6+/-1.6 years (range: 3 months-6 years). Eighteen patients (72%) had abnormal thresholds in at least one modality. Thermal thresholds were normal in 7 out of the 25 patients. CONCLUSION This study demonstrates that quantitative thermal sensory testing is a fairly sensitive method for detection of small fiber neuropathy especially in patients with normal routine nerve conduction studies.

Reversible peripheral neuropathy in idiopathic hypoparathyroidism

We describe a 40‐year‐old male with idiopathic hypoparathyroidism presenting with tetany, proximal weakness, signs of hypocalcaemia including Chvostek and Trousseaus and diminished tendon reflexes in the upper and lower limbs. Electrophysiological studies revealed a sensory‐motor neuropathy, predominantly axonal as evidenced by decreased CMAP amplitudes, with normal distal latencies‐velocites, except for median nerve where a prolonged distal latency was observed. Serial nerve conduction studies were performed at repeated intervals for 2 years, while he received treatment for hypoparathyroidism (calcium and vitamin D supplementation). A progressive improvement in neuropathy both clinical and on electrophysiological studies was observed. Occurrence of peripheral neuropathy in hypocalcaemic states such as hypoparathyroidism and its reversibility after normalization of calcium homeostasis lend proof to the role of critical Ca2+ ion concentration in the normal functioning of the peripheral axons.

Low prevalence of restless legs syndrome in patients with advanced chronic renal failure in the Indian population: a case controlled study.

Background: Restless legs syndrome (RLS) is reported to occur in 20–70% of uremic patients. There is no study from India regarding the prevalence of RLS in chronic renal failure (CRF) patients. Studies from other Asian countries have shown a much lower prevalence compared to the West. This study investigated the prevalence of RLS in patients with advanced CRF in the Indian population. Patients and Methods: Sixty‐five CRF patients and 99 controls were evaluated using a predesigned standard questionnaire. The control group consisted of prospective renal donors. Results: The mean age of our patients was 42.4 ± 14.9 years as compared to 43.7 ± 11.2 years (p = NS). The distribution of cause of CRF was as follows: diabetes 38.5%, hypertension 13.9%, chronic interstitial nephritis 29.2% and chronic glomerulonephritis 18.4%. RLS was present in 1 patient (1.5%) and none of the controls. Conclusion: The prevalence of RLS in CRF patients in India is very low as compared to the Western population.

Serum prolactin levels for differentiation of nonepileptic versus true seizures: limited utility

Frequently occurring nonepileptic psychogenic seizures (PNES) are a cause of substantial morbidity. Differentiation of these from true seizures may sometimes be very difficult. Serum prolactin level estimation following the event has been described as a useful test for this purpose. We conducted this study to assess the role of this test in diagnosis of PNES. Serum prolactin was estimated from venous blood samples of 19 patients (13 females, 6 males) with PNES and 17 patients (5 females, 12 males) with true complex partial seizures with or without secondary generalization. The age range was 12-39 years in the PNES group and 9-42 years in the true seizure group. Five patients (all females) in the PNES group (26.3%) had raised prolactin levels, all of them having greater than twice normal levels. In the true seizure group, 10 of 17 (58.8%) patients had raised levels; only 3 (17.6%) of these had greater than twice normal levels. The difference in percentage of patients with abnormal prolactin levels between these groups was not found to be significant. We demonstrate that serum prolactin level estimation is not a useful method for differentiation of psychogenic nonepileptic from true epileptic seizures.