A study on the clinical and electrographic profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG).

Background: Coma is one of the frequently encountered clinical conditions in any intensive care unit (ICU), which is responsible for considerable morbidity and mortality. Therefore, this study was designed to look at the clinical and EEG profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG). Methods: In all 102 patients of unresponsive coma (GCS ≤ 8), who remained in poor sensorium despite 48 h of optimum treatment in ICU, were included in the study. All patients underwent 1 h of electroencephalography (EEG) monitoring with a portable EEG machine. All EEGs were screened according to Salzburg Consensus Criteria (SCC) for Nonconvulsive Status Epilepticus (NCSE). Patients with evidence of NCSE were administered parenteral Antiepileptic Drugs (AED). A repeat EEG was done after 24 h of baseline to ascertain the effect of AED. The primary outcome was the recognition of patients with NCSE on the basis of established EEG criteria. The secondary outcome measure was the Glasgow outcome scale (GOS) at the time of discharge. Results: Out of 102 cases enrolled, 12 (11.8%) cases were detected to have NCSE on portable EEG. The mean age of patients with NCSE was 52.2 years. In terms of gender distribution, 2/12 (17%) were female, and 10/12 (83%) were male (M: F = 5:1). Median GCS was 6 (range 3-8). Looking at CNS infections, 4/12 (33.3%) had evidence of some form of CNS infection in the NCSE group, compared to 16/90 (18%) in the group without NCSE. This difference was statistically significant (P-value < 0.05). The EEG recordings of patients with NCSE showed dynamicity with fluctuating rhythms and ictal-EEG patterns associated with spatiotemporal evolution. All twelve cases showed reversal of EEG changes with AED administration. In 5 out of 12, transient improvement in GCS (>2 points) after administration of AED' was noted with good clinical outcomes (GOS 5). In five of these 12 cases, death was the final outcome (GOS 1). Conclusions: NSCE should be considered in the differential diagnosis of all unresponsive comatose ICU patients. In resource-limited settings, where continuous EEG monitoring may not be feasible, bedside portable EEG testing can be used to diagnose patients with NCSE. Treating NCSE reverses epileptiform EEG changes and improves clinical outcomes in a subset of comatose ICU patients.

Butorphanol-bupivacaine versus Fentanyl-bupivacaine for Extradural Analgesia during Labour.

BACKGROUND: Epidural injection of a combination of local anaesthetic drugs and opioids, is known to provide good analgesia for the first and second stages of labour, with minimal risk to the mother and the foetus. METHOD: 64 pregnant women were allocated to one of two groups in a double blind, randomised, prospective study design. The first group (n=32) received 15ml of 0.1% bupivacaine with 0.1 nignil (-1) butorphanol (1.5mg) and the second group (n=32) received 15ml of 0.1% bupivacaine with 2µgml(-1) of fentanyl. RESULTS: The times of onset and offset of analgesia were comparable. More patients of the butorphanol group were sedated but arousable. The patient satisfaction levels were good in both groups and APGAR scores were comparable. CONCLUSION: Butorphanol and fentanyl when used in combination with 0.1% bupivacaine are effective, offer good patient satisfaction and are comparable in labour analgesia. Though more patients were sedated in the butorphanol group there was no maternal, foetal or neonatal adverse outcome and the drug appears to be a safe alternative to fentanyl in labour epidural analgesia.

Presentations of cranial nerve involvement in two patients with Herpes zoster ophthalmicus.

Two cases of Herpes zoster ophthalmicus complicated by motor nerve palsies are being reported. The investigations ruled out other diseases which can affect ocular motor nerves, e.g., diabetes, hypertension, syphilis and malignancy. The cases are being reported because of the rare presentations of Herpes zoster ophthalmicus like isolated internal ophthalmoplegia and VI nerve palsy in Case-1 and absence of iritis with third nerve involvement in Case-2. The probable etiology for occurrence of these uncommon phenomena has been postulated.

Stevens-Johnson syndrome and respiratory failure in a 9-year-old boy.

The etiology of respiratory failure associated with Stevens-Johnson syndrome may be multifactorial, including upper airway involvement, pneumothorax/pneumomediastinum, and direct involvement of the respiratory mucosa. Respiratory failure from direct involvement of the respiratory mucosa is relatively uncommon. We describe a 9-year-old boy who had respiratory failure associated with Mycoplasma pneumoniae-induced Stevens-Johnson syndrome. Bronchoscopic examination of the airways revealed sloughed mucosa, ulcerative lesions, and inspissated secretions indicative of lower airway involvement with Stevens-Johnson syndrome. Although the mainstay of therapy is supportive care with controlled ventilation, rigid bronchoscopy with bronchoalveolar lavage to clear the airways of the debris was an invaluable adjunct to this patient's care.

Location of the site of bacterial bile-salt deconjugation by combining abdominal scintigraphy with expired C-14.

A combined 14CO2 bile-salt breath and scintigraphic test has proved useful in determining the site of bile-salt deconjugation by bacteria. Data suggest that the procedure can be shortened to less than 8 hr with Tc-99m sulfur colloid abdominal scintigrams added to locate the labeled meal. Moreover the cumulative 14CO2 excretion, which is an indes of the rate of bile-salt deconjugation, gives clearer separation than peak specific activity between normals and either high or low deviations from normal, The test should be helpful in a number of difficult diagnostic problems involving chronic diarrhea, and offers as well both as well both a guide to appropriate therapy and a monitor for relapse in enfected blind-loop syndromes,