25-hydroxyvitamin D3 concentration in serum and cerebrospinal fluid of patients with remitting-relapse multiple sclerosis.

There is epidemiological, geographical and immunological evidence suggesting that low environmental supplies of vitamin D3 may act as a risk factor for developing multiple sclerosis (MS), possibly due to dysfunction in the immunomodulatory properties of 25-hydroxyvitamin D3 (25-OH-D3) in the brain. The objective of this study is to measure the serum and cerebrospinal fluid (CSF) concentrations of 25-OH-D3 in MS patients during their relapsing phase. 52 patients with remitting-relapse and 58 patients with other non-inflammatory diseases of central and peripheral nervous system were entered into the study. Patients in both groups were admitted for the first time to do diagnostic procedures and they were not on any other treatment for neurological disorders. The means and medians for serum levels of 25-OH-D3 in MS patients and control group were 10.64 ± 9.2 ng/ml (median: 9.6 ng/ml) and 13.23 ± 17.56 ng/ml (median: 11.90 ng/ml), respectively (p=0.328). CSF concentrations for the same values were 2.02 ± 1.94 ng/ml (median: 0.23 ng/ml) and 3.28 ± 2.96 (median: 0.29 ng/ml), respectively (p=0.242). The differences between calculated numbers of serum/CSF ratios were not statistically significant too. The serum and CSF concentrations of 25-OH-D3 in MS group were lower than the control counterpart without any statistical difference and the authors did not find any influence of serum 25-OH-D3 concentration on the CSF concentration based on the non-significant statistical difference between the serum/CSF ratios in two study groups of MS patients and control cases.

Ultrasound evaluation of patients with moderate and severe carpal tunnel syndrome.

The objective of this study is to determine cut-off points for the crosssectional areas of the median nerve proximal and distal to carpal tunnel in moderate and severe Carpal Tunnel Syndrome (CTS) and compare the results of our study with those available in the literature. Forty-three patients with upper limb pain other than CTS and 36 patients with idiopathic CTS enrolled into the study. The diagnosis and categorization of CTS were based on electrophysiologic criteria of the American Academy of Neurology. Median nerve cross-sectional areas were measured. Arithmetic mean values and standard deviation of each variable were measured. Student t-test and chi-squared test were applied to compare continuous and dichotomous variables between CTS and non-CTS control groups. Ultimately the diagnostic performances of the test characteristics including sensitivity, specificity, positive and negative predictive values were measured. Mean cross-sectional area of the nerve is higher in moderate than severe CTS proximal and distal to carpal tunnel. We accepted cut-off points of 11.5 mm² and 13.5 mm² for cross-sectional areas of the proximal and distal portions of carpal canal respectively. The sensitivity, specificity, positive and negative predictive values for the proximal inlet are 83%, 90.7%, 65.5% and 55.7%; and for the distal outlet are 36.1%, 93%, 81.2% and 63.4% respectively. We suggest that ultrasound is a good diagnostic modality for patients referred to tertiary care centers which categorized as moderate CTS.

Which parameter is more reliable in a cold hand, NCV or latency.

Temperature affects distal sensory & motor latencies & nerve conduction velocity but not necessarily at the same degree. Purpose of this study is to see which one is affected less and thus could be more reliable in cold conditions. A total of 32 healthy individuals with age range of 18-28 years (mean 22.25 +/- 2.2) participated in this study. Skin Temperature was recorded at wrist. Distal median motor & sensory latencies and transcarpal median NCV were recorded before and after immersion in cold water. Statistical analysis was performed using paired t-test with SPSS. All parameters were affected by cold but the effect was less dramatic in transcarpal NCV. Transcarpal median NCV is least affected parameter by cold, so it may be more reliable than sensory & motor latencies at wrist.

Sympathetic skin response (SSR) in Crohn disease: a pilot study.

Peripheral neuropathy is one of the most frequently reported neurological extra-intestinal manifestations of the Crohn disease. Former studies have showed sympathetic neuropathy as early manifestation of CD by physical tests. The aim of this study is to examine sympathetic neuropathy in CD by using sympathetic skin response (SSR). We performed SSR on 6 Patients (4 male, 2 female) that were diagnosed as CD. Their age was between 26 till 68 years with the mean of (43.3 +/- 17.1) years. The duration of their disease was at least 4 years (mean: 9.0 +/- 8.4) and none of the patients had any symptoms or signs related to autonomic nervous system dysfunction. Hand and foot latencies in CD patients were prolonged relative to controls and the difference of hand latencies was statistically significant. Two patients demonstrated total abnormal results. In conclusion, there is some sub-clinical sympathetic dysfunction in CD patient. This suggests that SSR can be useful in detecting early autonomic changes in these patients.

EMLA cream for carpal tunnel syndrome: how it compares with steroid injection.

BACKGROUND: A standard treatment option for carpal tunnel syndrome (CTS) is local injection of anesthetic-corticosteroid. This clinical trial was designed to compare the safety and efficacy of daily application of the EMLA cream (lidocaine 2.5% plus prilocaine 2.5%) with that of a single injection of methyl prednisolone acetate (Depo-Medrol) 40 mg. METHODS: In this randomized, parallel-group, open-label, single-center, case-controlled, prospective study, 65 participants (70 hands) aged 18-75 years with clinical & electrodiagnostic evidences of CTS were randomized to receive either the EMLA cream (n = 30 patients, 35 hands, group 1) or one injection of methylprednisolone acetate 40 mg at wrist (n = 35 patients, group 2). Outcome assessments included the visual analog scale and clinical assessment. RESULTS: After 4 weeks of treatment, patients in both groups reported significant changes (P < 0.001) in pain intensity. Both treatments were well tolerated, with treatment-related adverse events (AEs) reported in 2 patients in group 1 (5.7%) and 10 patients in group 2 (28.5%) No systemic treatment-related AEs were observed with the EMLA cream. CONCLUSION: EMLA cream was effective in reducing pain associated with CTS and well tolerated and it may offer patients with CTS an effective, noninvasive symptomatic treatment.

Study of sympathetic skin response in visceral leishmaniasis.

BACKGROUND: Neurologic changes in visceral leishmaniasis are rarely reported. Some articles have reported symptoms suggestive of peripheral neuropathy and showed some degree of axonal degeneration and demyelination. The main purpose of the present study was to identify and quantitatively evaluate sympathetic dysfunction in VL. METHOD: Twenty patients with visceral leishmaniasis and 20 healthy controls were studied. All the patients and controls were examined at first and skin sympathetic response was measured in all of the patients and control group by standard protocol. RESULTS: The patients had mean age of 24.2 +/- 17.8 months. The SSR to the electrical stimulus was absent in 10 patients with VL. In four patients all responses were present and, in four patients only one response from hand or foot was present and, in two cases responses were present from both hands. For right median nerve, median latency was 2.4 (min: 1.19, max: 6.92) seconds. CONCLUSION: In conclusion impairment of SSR was demonstrated electrophysiologically in the patients with visceral leishmaniasis.

Evaluation of effectiveness of local insulin injection in non-insulin-dependent diabetic patient with carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common type of peripheral nerve entrapment and is a significant cause of morbidity. Carpal tunnel syndrome (CTS) has more incidences in diabetic patients. It has been suggested that insulin has an effect on nerve regeneration similar to that of nerve growth factor (NGF). Therefore, we aimed to evaluate the effectiveness of local insulin injection on the median nerve in patients with non-insulin-dependent diabetes mellitus (NIDDM) who have mild-to-moderate carpal tunnel syndrome (CTS). MATERIALS AND METHODS: We carried out a prospective, randomized, single-blind, case-controlled study in these patients. We randomly selected 50 patients, 20 of whom had bilateral mild-moderate CTS. Therefore we had 70 hands and categorized them into two groups. At the baseline we injected NPH insulin (10U) directly into the carpal tunnel in group 1, and performed physiotherapy for the other group (group 2). Two weeks later, NPH insulin (10U) was injected into the carpal tunnel again and we continued physiotherapy for group 2. Electrodiagnostic study was performed for these two groups before treatment and 4 weeks after the last injection and physiotherapy. The patients were followed up for 6 weeks. RESULTS: In both groups decrement of distal motor latency (DML) of the median nerves statistically was significant. In both groups, the increment of the sensory nerve conduction velocity was statistically significant. Also the decrement of pain, paresthesia, numbness, weakness/clumsiness and nocturnal awaking was statistically significant in both groups. But there was no significant difference between the two groups. CONCLUSION: Local insulin injection is an effective and safe treatment for carpal tunnel syndrome in NIDDM patients as physiotherapy

The diagnostic value of ultrasonography in patients with electrophysiologicaly confirmed carpal tunnel syndrome.

OBJECTIVE: To evaluate the diagnostic value of ultrasonography in patients with electrophysiologically confirmed carpal tunnel syndrome. DESIGN: A prospective ultrasonographic study of 70 wrists with electrophysiologically confirmed carpal tunnel syndrome and of 80 normal wrists. Receiver-operating-characteristics curves for the ultrasonographic measurements of median nerve were plotted to identify the most optimal cutoff values. RESULTS: The ultrasonographic measurements of median nerves were found to be increased significantly in patients with carpal tunnel syndrome when compared with controls, particularly in terms of cross-sectional area (P <0.001). According to receiver-operating-characteristics curve results, the most optimal cutoff value for the cross-sectional area of the median nerve was obtained at the level of middle carpal tunnel, which was 9.3 mm2, with a sensitivity of 80% and specificity of 77.5%. CONCLUSION: Ultrasonographic examination of the median nerve seems to be a promising method in the diagnosis of carpal tunnel syndrome, evaluating the morphologic changes of the median nerve in patients with clinical signs and symptoms. Further studies with wider series are needed to confirm our preliminary results.

Autologous blood injection in carpal tunnel syndrome (CTS).

INTRODUCTION: Most medical treatments for carpal tunnel syndrome (CTS) have focused on suppressing the inflammatory process. An injection of autologous blood might provide the necessary cellular and humoral mediators to induce a healing cascade. The purpose of this study was to evaluate prospectively autologous blood injection in CTS. METHOD & MATERIALS: Twenty patients with CTS were recruited using strict inclusion and exclusion criterias. All patients were injected with 1 ml of autologous blood and 0.5 ml lidocaeine 1% under the carpal tunnel. Pain intensity (based on VAS) and electrophysiologic parameters of median nerve (transcarpal SNCV, DML and DSL) were recorded before and 3 weeks after autologous blood injection. RESULTS: The average pain scores before and 3 weeks after autologous blood injection was 8.70 +/- 0.92 and 4.30 +/- 0.76 respectively (P < 0.005). Also transcarpal SNCV of median nerve was 33.7 +/- 6.3 m/s and 24.5 +/- 6.8 m/s (P = 0.001); DML of medin nerve was 5.16 +/- 1.04 ms and 4.70 +/- 0.53 ms (P = 0.001) and DSL of median nerve was 4.84 +/- 0.77 ms and 4.2 +/- 0.6 ms (P = 0.001), respectively. CONCLUSIONS: After autologous blood injection, pain intensity and electerophysiologic parameters were significantly improved. This study offers encouraging results for an alternative minimally invasive treatment for CTS. This study cannot prove conclusively whether the blood itself induced an inflammatory cascade or the injury created by the injection was responsible.

Tuberculous myelopathy: current aspects of neurologic sequels in the southeast of Iran.

OBJECTIVE: The spinal cord may be affected in different ways in the course of tuberculous infection. The objective of this study was to determine the epidemiologic features, clinical manifestations, pathophysiologic mechanisms, neurologic sequels, and treatment outcomes of tuberculous myelopathy in the southeast of Iran in which the disease is endemic. METHOD: A retrospective study was scheduled. All cases of tuberculous myelopathy treated in our hospital over the last 7 years were reviewed. Only those with histologic or microbiologic confirmation or those who responded to antituberculous therapy were included. RESULTS: During a 7-year period, 43 cases of tuberculous myelopathy were found. The most frequent clinical manifestations were backache (86%) and fever (67%). Twenty patients were paraparetic or paraplegic and 40% had kyphosis. Imaging studies revealed thoracic and/or lumbar spine involvement in 92% of patients with tuberculous spondylitis. Fifteen, five and two patients had sensorimotor spinal cord syndrome, radiculomyelitis and intramedullary syringomyelic syndrome, respectively. Forty-seven percent required surgical intervention. There was improvement in 81% of the cases. CONCLUSION: Different pathophysiologic mechanisms acted on the clinical manifestations of spinal neurotuberculosis. A good outcome is expected if the diagnosis is made in the early stages before the appearance of spinal deformity and neurologic deficits.

An evaluation of gender, body mass index, wrist circumference and wrist ratio as independent risk factors for carpal tunnel syndrome.

OBJECTIVES: The aim of this study was to evaluate the role of gender, body mass index (BMI), wrist ratio (WR) and wrist circumference as independent risk factors for carpal tunnel syndrome (CTS) and to analyze the strength of association of these factors. METHODS: We have undertaken a case-control study in 128 CTS patients and 109 controls. Based on clinical and electrophysiologic criteria, 109 female and 19 male CTS patients as well as 62 female and 47 male control subjects were selected from patients and their relatives referred to our hospital. In total, 179 hands with CTS in three groups of severity (mild, moderate and severe) were examined. Height, weight, BMI, wrist width, depth, circumference and ratio were measured in all patients and control group. Mean values of different risk factors for CTS group and controls were measured. A logistic regression analysis was conducted to evaluate odds ratio of different risk factors. RESULTS: The mean values for BMI and WR were greater in CTS patients than in the subject group. Thirty-four, 89 and 57 patients had mild, moderate and severe CTS, respectively. Mean age, BMI, wrist circumference and ratio were not statistically significant in the three groups. Female gender, increased BMI and increased WR had odds ratio of 9.95, 1.75 and 1.12, respectively. CONCLUSION: Our study confirms that female gender, obesity and square wrists are independent risk factors for CTS.

Klippel-Feil anomaly associated with thoracic hemivertebrae/butterfly vertebrae and patella hypoplasia.

A case with multiple congenital anomalies of the spine and bilateral patella hypoplasia is reported. To our knowledge, no report of concomitant Klippel-Feil syndrome, thoracic hemi vertebrae/butterfly vertebrae bilateral patella hypoplasia, reducible atlantoaxial instability, and occipitoatlantal fusion simultaneously has been reported in the literature.

Aspergillous sinusitis.

Chronic invasive aspergillous sinusitis is an uncommon disease that usually occurs in healthy individuals. Chronic invasive aspergillus sinusitis is inadequately characterized entity. Despite its rarity, it is going to be recognized increasingly. We report a neglected patient who received several courses of antibiotics before definite diagnosis. Clinical manifestations, differential diagnosis and treatment are discussed. A high degree of awareness for an early diagnosis may participate to improve the poor prognosis.

Tuberculous radiculomyelitis: review and presentation of five patients.

BACKGROUND: The southeast region of Iran is an endemic area for tuberculosis. Tuberculous radiculomyelitis (TBRM) was considered a rare form of parenchymal neurotuberculosis. OBJECTIVE: To analyze the clinical, laboratory and electrophysiological data of patients with TBRM. We report five patients and review the literature. METHOD: We searched Medline since 1966 and reviewed all cases of TBRM, excluding those with Pott's disease. We then evaluated the clinical and electrophysiological data of our patients. RESULTS: Five patients (two men), with a mean age of 25 years, were assessed. The mean duration of symptoms before diagnosis was 4.5 weeks. Three patients had clinical manifestation of tuberculous meningitis (TBM). Diagnosis was based on sputum smear and culture, cerebrospinal fluid (CSF) culture and polymerase chain reaction (PCR) gene amplification of Mycobacterium tuberculosis. Paraparesis or paraplegia, sphincter incontinence and Babinski sign were the main clinical features. CSF analysis was compatible with chronic meningitis. Electromyography showed radiculopathy in all patients and peripheral nerve disease secondary to axonal damage in only three, while myelography showed adhesive arachnoiditis in three. CONCLUSION: Despite the rarity of TBRM, clinical features were well described. To prevent neurological sequelae, early diagnosis and treatment is mandatory. Electrophysiological study may predict the prognosis.

Cerebral arteriovenous malformations: influence of angioarchitecture on bleeding risk.

BACKGROUND: To evaluate the angioarchitecture of cerebral arteriovenous malformations (cAVMs) with special regard to its influence on the risk of intracranial haemorrhage. METHODS: Clinical and neuroradiological data of 171 patients with cAVMs, who were treated at our department, were analysed retrospectively. The angioarchitectonic data were obtained from angiographic series, cranial CT scans and MR images. A chi(2) test was conducted to correlate the parameters and determine the P values. FINDINGS: The following parameters correlate to an increased risk of haemorrhage: diameter of the nidus < or =2 cm (P<0.001), number of arterial feeders < or =2 (P<0.001), diameter of the main feeder < or =1 mm (P<0.0001), number of veins draining the nidus < or =2 (P<0.001), exclusive deep drainage (P<0.05), and low or middle flow-velocity (P<0.01). Specific angioarchitectonic features such as venous stenoses, varicose dilatation of the draining vein, arterial aneurysms of the feeding artery, arteriovenous fistula within the nidus, contralateral drainage and sinushypo/-aplasia did not alter the bleeding rate. INTERPRETATION: Various angiographic features were correlated with the occurrence of intracranial haemorrhage in patients with cerebral AVMs. In addition to the well-known factors influencing the bleeding risk of cAVMs like size, pattern of venous drainage and location within the brain our data demonstrate the importance to look at the diameter of the main feeder and the number of draining veins showing a better correlation.