Therapeutic Drug Monitoring of Levetiracetam in Different Trimesters of Pregnant Women with Epilepsy in a Tertiary Care Center: A Prospective Study.

BACKGROUND: Levetiracetam is the most commonly used antiepileptic drug in pregnant women due to its low teratogenic risk profile, favorable pharmacokinetic characteristics, and safety profile. Serum levels of levetiracetam vary in epilepsy during pregnancy. Therefore, the aim of the study was to evaluate the serum levels of levetiracetam during different trimesters of pregnancy by using therapeutic drug monitoring (TDM). MATERIALS AND METHODS: This was a single-center, prospective study. Pregnant women with epilepsy on levetiracetam were enrolled after getting written informed consent from them. Serum trough levels of levetiracetam were estimated at all trimesters by high-performance liquid chromatography (HPLC). RESULTS: The study included 16 participants with mean ± standard deviation (SD) age of 27.75 ± 4 years. There were nine (56.2%) participants with generalized seizure disorder and seven (43.8%) participants of focal seizure disorder. Among 16 patients, 10 (62.5%) participants were on levetiracetam alone and six (37.5%) participants were on levetiracetam combined with other antiepileptic drugs. In a total of 48 trough samples, 45 sample concentrations were below the therapeutic range of 12-46 mg/l and three sample concentrations were within the therapeutic range. There was a statistically significant difference in the concentration-dose ratio (CDR) of levetiracetam between the third and first trimesters (P-value 0.018). CONCLUSION: There was a statistically significant difference in serum levetiracetam concentration between the third and first trimesters. A well-conducted, intensive pharmacokinetic sampling study in PWWE with a control group is needed in future to evaluate the whole pharmacokinetic profile of levetiracetam and to correlate the clinical outcome.

Isolated pulmonary hydatid cyst.

Echinococcosis is primarily a disease of developing nations with poor medical infrastructure, where cohabitation with domesticated animals is common. These conditions, in conjunction with the inherent chronicity of the disease, lead to low rates of diagnosis and high morbidity. Robust surveillance is not readily available in communities with the highest disease burden.WHO classifications assist in diagnostic and treatment endeavours especially in countries where this disease is not commonly encountered. However, the understanding of the pathophysiology of echinococcosis and optimal treatment are still lacking in certain patient populations.We present the case of a female from Central Asia with an isolated pulmonary hydatid cyst. She was diagnosed several months after she had an uncomplicated pregnancy and gave birth to a healthy baby girl. Due to a delay in surgical intervention, our patient received a prolonged course of treatment which resulted in a significant reduction in the size of the cyst. Given her improvement, we questioned the current guidelines set by the WHO regarding surgical resection of pulmonary hydatid cysts, compared with an extended course with albendazole in patients with an unusual and protracted course of the disease. Furthermore, we discuss the possible role of pregnancy in exacerbating symptoms of underlying pulmonary hydatid disease.

Correlation of fine needle aspiration cytology with histopathology in patients undergoing thyroid surgery.

<b>Introduction:</b> Thyroid swellings are one of the most common swellings in the neck. They pose a major problem in developing countries like India, considering the high endemicity for iodine deficiency disorders. Thyroid gland is affected in many conditions. Out of these, majority are benign while less than 5% are malignant. Multiple noninvasive and invasive diagnostic tests are available for the diagnosis of thyroid swelling. However, at present, FNAC is considered the gold standard investigation. Despite the high sensitivity and specificity, FNAC has its limitations. Histopathological examination of surgically excised thyroid swelling is the confirmatory gold standard to determine the pathology of the thyroid gland. <br><b>Material and method:</b> This prospective and observational study was conducted in the Department of Otorhinolaryngology (ENT) in collaboration with the Department of Pathology in a tertiary care hospital and medical school. A total of seventy patients were included. <br><b>Results:</b> The diagnosis on FNAC was correlated with histopathology. Statistical analysis showed FNAC had a sensitivity of 83.3%, specificity of 100%, positive predictive value of 100%, negative predictive value of 96.7%. However, the overall accuracy in this study was determined to be 95.71%. Results were found to be statistically significant (P < 0.05). <br><b>Conclusions:</b> The diagnostic role of FNAC in thyroid lesions is of utmost importance in making preoperative diagnosis. FNAC was found to be highly sensitive and specific for diagnosing thyroid lesions but the final HPE is considered as a gold standard.

Failure of Flow Diverter Therapy: Predictors and Management Strategies.

Flow diversion is a safe and effective treatment for many types of brain aneurysms. Even so, there remain some aneurysms that persist despite initial treatment. In studies with the longest follow-up (5 yr), at least 5% of aneurysms persist with this treatment modality. As the cumulative experience and clinical indications for flow diversion continue to expand, the anatomic and functional characteristics that are associated with aneurysm persistence are increasingly described. Identification of these factors preoperatively can help to guide initial treatment decisions, enhance monitoring protocols in the follow-up period, and establish best practices for re-treatment when necessary. Herein, we review published clinical series and provide examples to highlight variables implicated in aneurysm persistence after treatment with flow diversion.

Acute Left M1 Stroke With Critical Left Internal Carotid Artery Stenosis: Video Case.

We present the case of a 68-yr-old woman who presented with an acute left middle cerebral artery syndrome. Noninvasive angiography obtained 13 h after last known well time demonstrated both left M1-segment middle cerebral artery (MCA) occlusion and near-complete occlusion of the left internal carotid artery (ICA) just distal to the carotid bifurcation. Intervention was offered given the sizeable mismatch demonstrated by computed tomography (CT) perfusion imaging. After administering loading doses of aspirin and clopidogrel, we initially performed carotid angioplasty and stenting to open the internal carotid artery, which was otherwise impassible. Subsequently, thrombectomy of the M1 occlusion was performed with direct aspiration. Postprocedural imaging demonstrated preservation of the at-risk brain parenchyma. The patient demonstrated significant improvement in strength and speech after the procedure, and she was discharged to an inpatient rehabilitation center for further treatment. The patient and her family gave consent for this report.

The Continued Role and Value of Imaging for Acute Ischemic Stroke.

Advances in neuroimaging in the last 2 decades have revolutionized the management of acute ischemic stroke (AIS). Here we review the development of computed tomography (CT) and magnetic resonance imaging (MRI) modalities used to guide treatment of patients with AIS characterized by large vessel occlusion. In particular, we highlight recent randomized trials and their patient selection methodologies to detail the progression of these selection paradigms. With advanced imaging, distinction between at-risk penumbra and ischemic core in AIS may be performed using either CT or MRI. While limitations exist for methodologies to quantify core and penumbra, commercially available fully automated software packages provide useful information to guide treatment decisions. Randomized controlled trials implementing perfusion imaging to patient selection algorithms have demonstrated marked success in improving functional outcomes in patients with large vessel occlusions. As such, imaging has become a vital aspect of AIS treatment in selecting patients who may benefit from mechanical thrombectomy.

Quantum Transfiguration of Kruskal Black Holes.

We present a new effective description of macroscopic Kruskal black holes that incorporates corrections due to quantum geometry effects of loop quantum gravity. It encompasses both the "interior" region that contains classical singularities and the "exterior" asymptotic region. Singularities are naturally resolved by the quantum geometry effects of loop quantum gravity, and the resulting quantum extension of the full Kruskal space-time is free of all the known limitations of previous investigations of the Schwarzschild interior. We compare and contrast our results with these investigations and also with the expectations based on the AdS/CFT duality.

Levetiracetam versus phenytoin in management of status epilepticus.

The purpose of this study was to compare safety and efficacy of intravenous (IV) levetiracetam (LEV) with IV phenytoin (PHT) in management of status epilepticus (SE). The second-line treatment of SE is limited to a few drugs available in an IV formulation such as PHT, fosphenytoin and valproate. The relative lack of serious side effects and favourable pharmacokinetics of LEV made it a promising option in management of SE. Randomized trials comparing relative efficacy of second-line agents are remarkably lacking. In this study, consecutive patients of SE (n=44) were randomized to receive either IV PHT (20mg/kg) or IV LEV (20mg/kg). The primary end point was successful clinical termination of seizure activity within 30min after the beginning of the drug infusion. Secondary end points included recurrence of seizures within 24 hours, drug related adverse effects, neurological outcome at discharge, need for ventilatory assistance, and mortality during hospitalization. Both LEV and PHT were equally effective with regard to primary and secondary outcome measures. PHT achieved control of SE in 15 (68.2%) patients compared to LEV in 13 (59.1%; p=0.53). Both the groups showed comparable results with respect to recurrence of seizures within 24 hours (p=0.34), outcome at discharge as assessed by functional independence measure (p=0.68), need of ventilatory assistance (p=0.47) and death (p=1). From this study it can be concluded that LEV may be an attractive and effective alternative to PHT in management of SE.

Spinocerebellar ataxia-10 with paranoid schizophrenia.

Spino-cerebellar ataxia type 10 (SCA10) is an autosomal dominant disorder that is characterized by cerebellar ataxia, seizures and nystagmus with a fragmented pursuit. Schizophrenia has been reported with SCAs 1 and 2 yet in SCA 10, psychiatric manifestations are uncommon. We report a Hispanic family involving a father and his four children with SCA10 genetic mutation. Two of his children, a 20-year-old female and a 23-year-old male, presented with gradually progressive spino-cerebellar ataxia and paranoid schizophrenia. Neurological examination revealed ocular dysmetria, dysdiadokinesia, impaired finger-to-nose exam, gait ataxia and hyperreflexia in both the cases. Additionally, they had a history of psychosis with destructive behavior, depression and paranoid delusions with auditory hallucinations. Serology and CSF studies were unremarkable and MRI brain revealed cerebellar volume loss. Ultimately, a test for ATAXIN-10 mutation was positive thus confirming the diagnosis of SCA10 in father and his four children. We now endeavor to investigate the association between schizophrenia and SCA10.

Recurrent severe anaemia: a rare presentation of parvovirus b19 infection.

Secondary pure red cell aplasia is usually seen in immunocompromised hosts or patients who have chronic haemolytic anaemia, which is caused by blood transfusion related transmission. The present patient, a 30-year-old immunocompetent female, presented several times with recurrent severe anaemia, over a period of one and half years. Her history, clinical examination and investigations did not reveal any indigenous drug intake, previous blood transfusions, haemolytic disorders, myeloproliferative disorders, pregnancies, autoimmune diseases or thymoma. She was found to have a thalassaemia minor trait, on the basis of which severity and recurrence of anaemia could not be explained, and on further evaluation, she was diagnosed to have acute aplastic crisis caused by Parvovirus B19 induced, acquired pure red cell aplasia. The co- existence of these two haematological disorders in an immunocompetent, non-transfusion dependent individual is rare, which makes our case report unique.

Historical perspective of Indian neurology.

OBJECTIVE: To chronicle the history of medicine and neurology in India with a focus on its establishment and evolution. BACKGROUND: THE HISTORY OF NEUROLOGY IN INDIA IS DIVIDED INTO TWO PERIODS: ancient and modern. The ancient period dates back to the mid-second millennium Before Christ (B.C.) during the creation of the Ayurvedic Indian system of Medicine, which detailed descriptions of neurological disorders called Vata Vyadhi. The early 20(th) century witnessed the birth of modern Indian medicine with the onset of formal physician training at the nation's first allopathic medical colleges located in Madras (1835), Calcutta (1835) and Mumbai (1848). Prior to India's independence from Britain in 1947, only 25 medical schools existed in the entire country. Today, there are over 355. In 1951, physicians across the field of neurology and neurosurgery united to create the Neurological Society of India (NSI). Four decades later in 1991, neurologists branched out to establish a separate organization called the Indian Academy of Neurology (IAN). DESIGN/METHODS: Information was gathered through literature review using PubMed, MD Consult, OVID, primary texts and research at various academic institutions in India. RESULTS: Neurological disorders were first described in ancient India under Ayurveda. The transition to modern medicine occurred more recently through formal training at medical schools beginning in the 1930's. Early pioneers and founders of the NSI (1951) include Dr. Jacob Chandy, Dr. B Ramamurthi, Dr. S. T. Narasimhan and Dr. Baldev Singh. Later, Dr. J. S. Chopra, a prominent neurologist and visionary, recognized the need for primary centers of collaboration and subsequently established the IAN (1991). The future of Neurology in India is growing rapidly. Currently, there are 1100 practicing neurologists and more than 150 post-graduate trainees who join the ranks every year. As the number of neurologists rises across India, there is an increase in the amount of basic, clinical and epidemiological research being conducted across the country every day. CONCLUSIONS: The history of neurology in India roots back to its rich culture and tradition. Over time, there has been great structural and organizational evolution and the future of neurology in India appears to be bright. However, the number of neurologists and research in neurology needs to experience a significant growth in the future to ensure the best patient care.

Peripheral arterial disease and digital gangrene: a rare presentation of diabetic hand syndrome.

Digital gangrene in upper limbs may be due to systemic sclerosis, trauma, connective tissue disorders, vasculitic disorders and various myeloproliferative disorders or as a part of tropical diabetes hand syndrome which follows trauma. Peripheral arterial disease in diabetics commonly involves lower limbs. The present case, 45-year-old diabetic, presented with dry gangrene in fingertips of both hands for last two weeks without any history of trauma or lower limb gangrene. On examination and workup of the patient was found to have bilateral upper limb arterio-occlusive disease involving ulnar vessels as a macrovascular complication of diabetes mellitus. This presentation of diabetic hand syndrome is very, very rare, hence being reported.

Atrial Myxoma-Related to Chronic Immunosuppression: A case report.

Although rare, atrial myxoma is the most common primary tumour of the heart. Its relation to immunosuppression in solid organ transplant is presently debateable. We report the case of a 71-year-old male patient who underwent renal transplant 17 years prior. Since that time he continued high dose immunosuppression without physician consultation and presented to us with atrial myxoma and its complications raising the question of any association between immunosuppression and the development of atrial myxoma.

The therapeutic value of yoga in neurological disorders.

BACKGROUND: The ancient mind and body healing methods of yoga recently sparked fervor in the scientific community as an alternative and complementary means of therapy. Since the World Health Organization officially began promoting yoga in developing countries in 1978, yoga has been cited for its therapeutic potential and has been widely recognized in Western culture. However, as an increasing number of people practice yoga for remedial purposes, researchers raise two important questions: 1) Is yoga a valid complementary management and rehabilitation treatment modality? 2) What conditions show promise of treatment with this intervention?. OBJECTIVE: This review article uses comprehensive scientific, evidence-based studies to analyze the efficacy of various basic and applied aspects of yoga in disease prevention and health promotion. It specifically intends to expose the effects of yoga in neurological disorders, particularly epilepsy, stroke, multiple sclerosis, Alzheimer's disease, peripheral nervous system disease, and fibromyalgia. MATERIALS AND METHODS: Information was gathered from various resources including PubMed, Ovid, MD-Consult, USC, and U.C.L.A. libraries. Studies were selected and reviewed on the basis of sample size, control, randomization, double-blinding, and statistical analysis of results. RESULTS: The pratice of yoga and meditation demonstrates statistically encouraging physiological and psychological improvements in the aforementioned neurological disorders. However, there were certain flaws and inadequacies in the study designs employed to evaluate the same. A critical analysis of these studies is presented. CONCLUSIONS: With the aim to focus attention on this widespread yet largely unexamined treatment modality, this paper seeks to provide direction and support for further research necessary to validate yoga as an integrative, alternative, and complementary therapy.

Negative symptoms presenting as neuropsychiatric manifestation of vitamin B12 deficiency.

Long lists of psychiatric illness or symptoms have been documented to be caused by vitamin B12 deficiency. We describe an atypical case of a young adult who presented with predominant negative symptoms followed by neurological symptoms consistent with vitamin B12 deficiency. The symptoms showed complete remission after vitamin B12 supplementation. The uniqueness of this case is that vitamin B12 deficiency presented with predominant negative symptoms without other psychotic and manic symptoms, which has not been reported previously.

History of neuroimaging: the legacy of William Oldendorf.

The field of neuroimaging witnessed remarkable progress in the post-World War II era, resulting in tremendous benefits for healthcare today. One such important milestone was the development of the computerized axial tomography (CAT) scan. This state of the art technique has paved the way for modern diagnostic imaging like magnetic resonance imaging (MRI). Dr William Oldendorf, the first designer of axial tomography, is regarded by some as the true father of neuroimaging. However, because of various reasons, he was unable to succeed with his concept and was also unfortunately denied his due entitlement of the Nobel Prize for Medicine and Physiology in 1979. This article discusses his contributions to the fields of neuroimaging and neurosciences, along with the politics that surrounded the awarding of the Nobel Prize of 1979. Another associated topic that is touched on in this article is the ever-growing dispute over the interpretations of neuroimaging between neurologists and neuroradiologists.

Quantum bounce and cosmic recall.

Loop quantum cosmology predicts that, in simple models, the big bang is replaced by a quantum bounce. A natural question is whether the universe retains, after the bounce, its memory about the previous epoch. More precisely, does the Universe retain various properties of the state after evolving unitarily through the bounce, or does it suffer from recently suggested cosmic amnesia? We show that this issue can be answered unambiguously at least within an exactly solvable model. A semiclassical state at late times on one side of the bounce, peaked on a pair of canonically conjugate variables, strongly bounds the fluctuations on the other side, implying semiclassicality. For a model universe growing to 1 megaparsec, the change in relative fluctuation across the bounce is less than 10(-56) (becoming smaller for larger universes). The universe maintains (an almost) total recall.