Profile of Rheumatological Manifestations in Leprosy in a Tertiary Care Hospital from Himachal Pradesh.

The rheumatological manifestations of leprosy occur singly or in varying combinations, particularly during lepra reactions. Despite being third most common, these remain under diagnosed and under reported. This study has been carried out to study the spectrum of rheumatological manifestations in leprosy patients. One hundred consecutive patients of leprosy presenting during January to December 2013 were studied for rheumatological manifestations. Complete hemogram, serum biochemistry, urinalysis, rheumatoid factor, ASO titer, C-reactive protein, ANA, and x-rays for hands, feet, chest and involved joints were performed. These 100 (M:F 66:34) patients aged between 16-80 years had indeterminate (2 patients), TT (4 patients), BT (26 patients), BB (2 patients), and LL leprosy (32 patients). 27 patients had rheumatological manifestations; arthritis involving large or small joints in 23 patients being the commonest. 7 of 24 patients in type-1 lepra reaction had enthesitis in 3 patients and oligoarthritis in 4 patients. Rheumatoid arthritis-like polyarthritis was noted in 19 patients with type-2 reaction. Tenosynovitis, dactylitis, bony changes were also noted. Except for one case, these features were present in patients having lepra reactions. Rheumatoid factor in 14, ANA in 15, C-reactive protein in 45 cases was positive. ASO was positive 34 cases. Symmetrical polyarthritis involving small joints of hands and feet, oligoarthritis, enthesitis and dactylitis are common in leprosy particularly with borderline leprosy, type-2 lepra reaction especially in the presence of positive RAfactor.

Pesticide residue in water--a challenging task in India.

Modern agriculture practices reveal an increase in use of pesticides to meet the food demand of increasing population which results in contamination of the environment. In India, crop production increased to 100 %, but the cropping area has increased marginally by 20 %. Pesticides have played a major role in achieving the maximum crop production but maximum usage and accumulation of pesticide residues is highly detrimental to aquatic and other ecosystem. Pesticide residues in drinking water have become a major challenge over the last few years. It has been monitored in public water supply resources in National capital territory, i.e., Delhi. Organochlorine pesticides (OCPs), mainly isomers of hexachlorohexane (HCH), dichloro-diphenyl-trichloroethane (DDT), endosulphan, endrin, aldrin, dieldrin, and heptachlore, were identified from potable water samples. Results suggested that continuous consumption of contaminated water can pose severe health threats to local residents of this area. Central Pollution Control Board (CPCB), Delhi, had found α and ß isomers of endosulphan residues in the Yamuna river. High concentrations of γ-HCH (0.259 µg/l) and malathion (2.618 µg/l) were detected in the surface water samples collected from the river Ganga in Kanpur, Uttar Pradesh (UP). High concentration of methyl parathion, endosulfan, and DDT were observed in water samples collected from the river at Bhagalpur, Bihar. The Industrial Toxicology Research Centre (ITRC), Lucknow (UP) study also found 0.5671 ppb concentrations of endosulfan in the river at Allahabad, UP. Similar results were found in other water samples in India.

Quality of life in children with epilepsy.

Quality of life was assessed in 108 epileptic children (6-15 years) using a hindi translation of Quality of Life in Children with Epilepsy (QOLCE) questionnaire. The questionnaire consist of 76 items with 16 subscales covering five domains of life: physical function, social function, cognition, emotional and behavioral well being. Overall score was 62.62±21.32. Chronbachs-a for all 13 multi-item subscales was above 0.70, indicating good internal consistency and reliability. Pearson correlation revealed good construct validity. Overall quality of life was affected by age, type of epilepsy, seizure frequency and maternal education (P<0.05). Energy levels, language and attention (P<0.05) were better in older children whereas younger children had better self esteem and lower levels of anxiety. Seizure frequency compromised all fields except stigma, attention, and energy levels (P>0.05).

Acute lung injury prediction score: derivation and validation in a population-based sample.

Early recognition of patients at high risk of acute lung injury (ALI) is critical for successful enrollment of patients in prevention strategies for this devastating syndrome. We aimed to develop and prospectively validate an ALI prediction score in a population-based sample of patients at risk. In a retrospective derivation cohort, predisposing conditions for ALI were identified at the time of hospital admission. The score was calculated based on the results of logistic regression analysis. Prospective validation was performed in an independent cohort of patients at risk identified at the time of hospital admission. In a derivation cohort of 409 patients with ALI risk factors, the lung injury prediction score discriminated patients who developed ALI from those who did not with an area under the curve (AUC) of 0.84 (95% CI 0.80-0.89; Hosmer-Lemeshow p = 0.60). The performance was similar in a prospective validation cohort of 463 patients at risk of ALI (AUC 0.84, 95% CI 0.77-0.91; Hosmer-Lemeshow p = 0.88). ALI prediction scores identify patients at high risk for ALI before intensive care unit admission. If externally validated, this model will serve to define the population of patients at high risk for ALI in whom future mechanistic studies and ALI prevention trials will be conducted.

Non contrast-enhanced four-detector multisection CT for the detection of ring lesions in seizures.

AIM: To evaluate the role of non contrast-enhanced multidetector computed tomography (MDCT) in the detection of ring lesions in the brain in patients from the Indian subcontinent, presenting with seizures. MATERIALS AND METHODS: Ninety-four patients presenting with seizures were examined using four-detector MDCT. Contiguous axial non contrast-enhanced CT of the brain was performed with a section width/section collimation of 5mm/5mm. A single axial non-contrast enhanced examinaton of section width 2.5mm was obtained through the region of interest, if necessary. This was followed by contrast-enhanced sequential imaging in all patients, using the same parameters as for unenhanced CT (i.e., 5mm/5mm). Non-contrast and contrast-enhanced CT images were recorded and reviewed separately. RESULTS: In 63 out of 94 cases non-enhanced MDCT (with section width 5mm) was able to identify the ring lesions. In 11 cases, which were doubtful on unenhanced CT (5mm), performing a single examination using a section width of 2.5mm through the area of interest, helped to detect the ring lesion. Hence in 74 out of 94 (79%) cases ring lesions could be detected using unenhanced MDCT. In the remaining 21% cases, the presence of ring lesions in the brain was confirmed only after the intravenous administration of contrast medium. CONCLUSION: Non contrast-enhanced MDCT is recommended for detecting ring lesions in the brain of patients on the Indian subcontinent, presenting with seizures. This can help to decrease the radiation dose to the patient and reduce the duration of examination. The risk of adverse reactions and patient discomfort associated with intravenous contrast medium injection are also reduced as are the costs incurred. Contrast-enhanced MDCT should be performed only in those cases in which the presence of ring lesions is doubtful on unenhanced CT.

Changes in visual evoked potentials on acute induction to high altitude.

BACKGROUND & OBJECTIVES: Induction to high altitude leads to altered central nervous system (CNS) functions induced by hypobaric hypoxia. The sensory systems like visual and auditory systems are reported to be affected by hypoxia. The present study was undertaken to assess the effects of hypobaric hypoxia on visual evoked potentials (VEPs) at 3200 m and 4300 m. METHODS: The VEP of 30 human volunteers were recorded at sea level (SL) and then at high altitude (HA) of 3200 m (HA I) and 4300 m (HA II) in eastern Himalayas and on return to sea level (RSL). The absolute latencies and amplitude of positive and negative waves were recorded. RESULTS: High altitude of 3200 m did not alter the latency of major wave N1, P1 and N2 of the VEPs. At HA II (4300 m), there was a statistically significant increase (P < 0.01) in the latency of NI wave as compared to the SL value and HA I (3200 m) in both left and right eye. There was a slight increase in latenty of P1 wave in both left and right eye at HA II. INTERPRETATION & CONCLUSION: From these results it may be concluded that induction to HA causes increase in latency of N1 wave at 4300 m which is still within physiological limits. This increase in wave latency of N1 wave in both eyes may be due to synaptic delay and/or altered neuronal processing at HA.

Effect of high altitude on human auditory brainstem responses.

The effect of hypobaric hypoxia on Brain Stem Auditory evoked potentials (BAERs) were studied. BAERs were recorded in 30 volunteers at sea level (SL) and then at high altitude (HA) of 3200 m (HA I) and 4300 m (HA II) in Eastern Himalayas and on return to sea level (RSL). The BAERs were recorded using Nicolet Compact - 4 (USA) in response to monaural auditory stimuli consisting of clicks of 100 ps square pulse at a rate of 15/sec. The BAERs were recorded on day 4 of their stay at 3200 m and 4300 m respectively. Findings indicated an increase in absolute peak latencies of wave V at 3200 m, which was statistically significant. On further ascent to 4300 m there was an increase in absolute peak latencies of wave I and III indicating delay in sensory conduction at the medullo-pontine auditory pathways.

Effect of chronic hypobaric hypoxia on components of the human event related potential.

BACKGROUND & OBJECTIVES: Induction to high altitude (HA) leads to deterioration in cognitive functions. The event related potentials (ERPs) like P300 are reported to be affected by hypoxia and bring about impairments in cognitive performance. The aim of the study was to investigate the effect of hypobaric hypoxia on event related potentials at two different altitudes i.e., 3200 m (HA I) and 4300 m (HA II) in ascending order to see how ERPs change with increasing altitude. METHODS: The study was carried out on 20 healthy male volunteers at sea level (SL) and thereafter at high altitude (HA) in Eastern Himalayas and on return to sea level (RSL). The P300 was recorded by using standard auditory odd ball paradigm with compact -4 (Nicolet, USA). RESULTS: The N1, N2 and P2 latencies were not significantly affected at HA I and HA II in comparison with SL indicating no effect of hypobaric hypoxia on sensory conduction. However, at HA II, most of the subjects showed an increase in latency of P3 component reflecting sensory discrimination and delay in evaluation process at 4300 m. At HA I, only 10 out of 20 subjects showed an increase in P3 wave latency and 3 did not show any change in N2-P3 components. INTERPRETATION & CONCLUSION: The results of the present study showed an increase in P300 wave latency at 3200 and 4300 m of high altitude. The observations suggest that hypoxia causes slowing of the signal processing at 4300 m, and magnitudes of the effects are altitude dependent with higher level of decline observed with increasing altitude.

Auditory evoked functions in ground crew working in high noise environment of Mumbai airport.

The continuous exposure to the relatively high level of noise in the surroundings of an airport is likely to affect the central pathway of the auditory system as well as the cognitive functions of the people working in that environment. The Brainstem Auditory Evoked Responses (BAER), Mid Latency Response (MLR) and P300 response of the ground crew employees working in Mumbai airport were studied to evaluate the effects of continuous exposure to high level of noise of the surroundings of the airport on these responses. BAER, P300 and MLR were recorded by using a Nicolet Compact-4 (USA) instrument. Audiometry was also monitored with the help of GSI-16 Audiometer. There was a significant increase in the peak III latency of the BAER in the subjects exposed to noise compared to controls with no change in their P300 values. The exposed group showed hearing loss at different frequencies. The exposure to the high level of noise caused a considerable decline in the auditory conduction upto the level of the brainstem with no significant change in conduction in the midbrain, subcortical areas, auditory cortex and associated areas. There was also no significant change in cognitive function as measured by P300 response.

Effect of high altitude (HA) on event related brain potentials.

Event Related brain potentials (ERPs) were recorded in 15 subjects using standard auditory odd ball paradigm, in which subjects were presented a sequence of two distinguishable sound stimuli of that occurred frequently (frequently (frequent stimulus-non target) and the other infrequently (rare stimulus-target). These recordings were made at sea level (SL) and then the subjects were air lifted to 3500 m altitude (HA), where they stayed for 3 weeks. Their ERPs were recorded during the first and third week of stay at HA and on return to sea level (RSL). Data indicated impairment in cognitive function as a result of exposure to HA as depicted by increase in the latency of P3 which was significant during the 1st week of stay at HA compared to sea level. The P3 wave latency during the 3rd week of stay at HA showed an increase compared to SL but was not statistically significant. From the results it may be concluded that high altitude hypoxia induced slow processing of stimulus evaluation, may be responsible for increase in P3 latency. The difference in the latent period of P3 waves during the first and third week of stay at HA may be due to continuous stay at HA which might lead to the time dependent adaptive processes occurring with increasing duration of exposure to HA which may induce learning effects.

Effect of yogic exercises on physical and mental health of young fellowship course trainees.

A study was undertaken to observe any beneficial effect of yogic practices during training period on the young trainees. 54 trainees of 20-25 years age group were divided randomly in two groups i.e. yoga and control group. Yoga group (23 males and 5 females) was administered yogic practices for the first five months of the course while control group (21 males and 5 females) did not perform yogic exercises during this period. From the 6th to 10th month of training both the groups performed the yogic practices. Physiological parameters like heart rate, blood pressure, oral temperature, skin temperature in resting condition, responses to maximal and submaximal exercise, body flexibility were recorded. Psychological parameters like personality, learning, arithmetic and psychomotor ability, mental well being were also recorded. Various parameters were taken before and during the 5th and 10th month of training period. Initially there was relatively higher sympathetic activity in both the groups due to the new work/training environment but gradually it subsided. Later on at the 5th and 10th month, yoga group had relatively lower sympathetic activity than the control group. There was improvement in performance at submaximal level of exercise and in anaerobic threshold in the yoga group. Shoulder, hip, trunk and neck flexibility improved in the yoga group. There was improvement in various psychological parameters like reduction in anxiety and depression and a better mental function after yogic practices.

Effect of sojourn at altitude of 3,500 m on auditory evoked potential in man.

Auditory evoked potentials were studied on 27 male subjects to evaluate the effect of sojourn at high altitude (HA). They were initially studied at Delhi (260 m) for their auditory evoked potentials and were then flown to an altitude of 3,500 m. During their stay at HA the same parameter was tested twice, once on the second day of arrival at HA and another on 21st day of stay. Then they were flown back to sea level (SL) and were retested on the third day of return. The results showed a significant delay in the peak latency of wave I of both the right and left ears on the second day of arrival at HA with a persistent delay in wave V even after 3 days of return to SL. The results suggest that HA stress caused a delay in sensory conduction at the cochlear level during the first week of induction, which was normalised during further stay.

Effect of Sahaja yoga meditation on auditory evoked potentials (AEP) and visual contrast sensitivity (VCS) in epileptics.

The effect of Sahaja yoga meditation on 32 patients with primary idiopathic epilepsy on regular and maintained antiepileptic medication was studied. The patients were randomly divided into 3 groups: group I practiced Sahaja Yoga meditation twice daily for 6 months under proper guidance; group II practiced postural exercises mimicking the meditation for the same duration; and group III was the control group. Visual Contrast Sensitivity (VCS), Auditory Evoked Potentials (AEP), Brainstem Auditory Evoked Potentials (BAEP), and Mid Latency Responses (MLR) were recorded initially (0 month) and at 3 and 6 months for each group. There was a significant improvement in VCS following meditation practice in group I participants. Na, the first prominent negative peak of MLR and Pa, the positive peak following Na did not register changes in latency. The Na-Pa amplitude of MLR also showed a significant increase. There were no significant changes in the absolute and interpeak latencies of BAEP. The reduced level of stress following meditation practice may make patients more responsive to specific stimuli. Sahaja Yoga meditation appears to bring about changes in some of the electrophysiological responses studied in epileptic patients.

Effect of Sahaja yoga practice on seizure control & EEG changes in patients of epilepsy.

The effect of Sahaja yoga meditation on seizure control and electroencephalographic alterations was assessed in 32 patients of idiopathic epilepsy. The subjects were randomly divided into 3 groups. Group I (n = 10) practised Sahaja yoga for 6 months, Group II (n = 10) practised exercises mimicking Sahaja yoga for 6 months and Group III (n = 12) served as the epileptic control group. Group I subjects reported a 62 per cent decrease in seizure frequency at 3 months and a further decrease of 86 per cent at 6 months of intervention. Power spectral analysis of EEG showed a shift in frequency from 0-8 Hz towards 8-20 Hz. The ratios of EEG powers in delta (D), theta (T), alpha (A) and beta (B) bands i.e., A/D, A/D + T, A/T and A + B/D + T were increased. Per cent D power decreased and per cent A increased. No significant changes in any of the parameters were found in Groups II and III, indicating that Sahaja yoga practice brings about seizure reduction and EEG changes. Sahaja yoga could prove to be beneficial in the management of patients of epilepsy.

Brainstem auditory evoked potentials in epileptics on different anti-epileptic drugs.

The effects of anti-epileptic drugs (AEDs) on brainstem auditory evoked potentials (BAEPs) were studied on 32 female patients of epilepsy and 10 age-matched normal healthy females (NS). The patients were divided into 6 groups, those not receiving medication (drug free, DF) and those receiving AEDs: Phenytoin (PHT), Carbamazepine (CBZ), Phenobarbital (PB), a combination of PHT and PB and a combination of CBZ and PB. DF epileptics had shortened were V absolute latency (AL) and I-V interpeak latency (IPL) as compared to NS. Phenytoin and CBZ monotherapy produced a prolongation of wave III AL (by PHT only), wave V AL, wave I-III IPL and I-V IPL, as compared to DF epileptics. Phenytoin monotherapy also prolonged wave III AL and I-III IPL, as compared to NS. When PB in the dosage of 30-60 mg/d was used in combination with PHT the above mentioned changes were not observed. These findings indicate altered neuronal conduction and/or synaptic transmission in epileptics. Anti-epileptic drugs in the dosages studied, with exception of PHT appear to lead towards "normalization" of BAEPs.

Acclimatization at high altitude in gradual and acute induction.

The study assessed physiological responses to induction to high altitude first to 3,500 m and then to 4,200 m and compared the time course of altitude acclimatization in two groups of male volunteers. The acutely inducted group was transported by aircraft (AI) to 3,500 m in 1 h, whereas the gradually inducted group was transported by road (RI) in 4 days. Baseline recordings of basal cardiovascular, respiratory, and blood gas variables were monitored at sea level as well as at 3,500 m on days 1, 3, 5, and 7. Blood gases were measured on day 10 also. After 15 days at 3,500 m, the subjects were inducted to 4,200 m by road, and measurements were repeated on days 1, 3, and 5, except blood gas variables, which were done on day 10 only. Acute mountain sickness symptoms were recorded throughout. The responses of RI were stable by day 3 of induction at 3,500 m, whereas it took 5 days for AI. Four days in transit for RI appear equivalent to 2 days at 3,500 m for AI. Acclimatization schedules of 3 and 5 days, respectively, for RI and AI are essential to avoid malacclimatization and/or high-altitude illness. Both groups took 3 days at 4,200 m to attain stability for achieving acclimatization.

Brain echinococcal disease in Pondicherry.

A 29-year-old man, a vegetarian, agriculturist and resident of a village near Pondicherry, presented with focal seizures with secondary generalization. EEG showed a right frontoparietal focus, the blood eosinophil count was 25%, the indirect haemagglutination titre was more than 1:2048 for Echinococcus protein and Casoni's skin test was strongly positive, the CT scan showed an isolated rounded lesion in the right frontoparietal area partially enhanced with contrast media. He was subjected to surgery with complete removal of the cyst which confirmed the diagnosis of echinococcal disease of the brain. Post operatively he took only anticonvulsant drugs and was free of seizures during the two-year post-operative follow-up period. The CT scan is a superior neurodiagnostic tool to blood serological tests in the diagnosis of brain echinococcal disease.

Auditory evoked response in patients of diabetes mellitus.

Brainstem auditory evoked response (BAER) and the mid latency response (MLR) were recorded in 25 diabetic men and compared with a group of 25 control subjects. The threshold of hearing was higher (P less than 0.001) in the patients. The BAER peak latencies were also significantly prolonged in both the ears; however, the degree of prolongation was more prominent in the right ear. The interpeak latencies of waves I-III were also prolonged (P less than 0.01) in the left ear, with non significant increase noticed in the right ear also. The wave V amplitude was lower (P less than 0.05) in diabetics. The MLR, on the other hand, was not affected in patients. These findings suggest functional impairment in the auditory pathway in patients of diabetes mellitus.

Neuropsychiatric and psychological aspects related to human immuno deficincy virus (hiv) infection.

The prevalence of HIV infection in India is likely to increase dramatically in coming years. Neuropsychiatric and psychosocial problems are common among HIV infected individuals. Therapeutic measures employing biological, psychological and social approaches are necessary for managing these problems. Strategies for reducing high-risk behavioural patterns need to be developed for preventing the spread of infection. To cope with these tasks, neurology and psychiatric personnel should possess an adequate knowledge of the various aspects of HIV infection. Reports indicate a high prevalence of misconceptions among hospital staff. The paper provides a brief review of the biological, europsychiatric, psychosocial and management aspects of HIV infection relevant to neurology and psychiatry.