A case of valproate-induced hyperammonaemic encephalopathy.

We report the case of a 65-year-old woman with hyperammonaemic encephalopathy induced by sodium valproate. This is a rare complication of treatment with sodium valproate. The encephalopathy can be reversible on withdrawal of treatment and does carry a risk of morbidity and mortality. This case demonstrates the importance of recognising this potential complication of a drug in common use.

Status of liver enzymes in babies with perinatal asphyxia.

Because of hypoxemia, different organ systems of the body are affected in perinatal asphyxia. In this study, the functional status of liver of the asphyxiated babies was assessed through estimation of liver enzymes to see any correlation existing between enzyme changes and severity of perinatal asphyxia. A total of 70 full-term asphyxiated newborns (study group) were studied during January'2008 to December'2008 in the department of Paediatrics, Mymensingh Medical College Hospital. After enrollment these babies were grouped according to Sarnat & Sarnat stages of Hypoxic-ischemic encephalopathy (HIE) as stage I, II & III. Babies who are small for gestational age, having severe jaundice, sepsis or congenital anomalies of the hepatobiliary system were excluded from the study. Another 50 healthy newborns were also studied as control group. Venous blood was analyzed between 2nd and 5th day of life to estimate serum AST, ALT & alkaline phosphatase (ALP). Unpaired student's 't' test and Spearman's rank correlation was used for data analysis and P value of <0.05 were considered significant. Mean AST, ALT and ALP of the asphyxiated babies were 76.27±37.44, 82.16±48.08 & 369.59±123.05 U/L and that of normal babies were 23.46±8.45, 26.54±7.76 & 208.20±46.95 U/L respectively and these rise were statistically significant (p<0.001). The levels of transaminases and ALP were positively correlated with the severity of asphyxia and these correlations were also statistically significant (p<0.001). So, this study concludes that AST, ALT & ALP significantly elevated in perinatal asphyxia and this elevation was proportional to the severity of hypoxia.

Introduction of an acute stroke team: an effective approach to hasten assessment and management of stroke in the emergency department.

Recombinant tissue plasminogen activator (rtPA) reduces the combined endpoint of death and disability if given within three hours of onset of ischaemic stroke. However few patients receive rtPA, with delays in in-hospital evaluation and treatment being key barriers to therapy. The Austin Hospital Acute Stroke Team (AST) was introduced with the aim of improving the speed of assessment and management of acute stroke patients presenting to the emergency department. We sought to assess the effect of the AST on number of eligible patients receiving rtPA and assessment times within our already active stroke service. Data were obtained prospectively for all AST calls during the period from 17 January 2005--31 December 2005. Information recorded included: demographics, time of call, clinical features, diagnosis and any treatment with rtPA. Information prospectively acquired from patients receiving stroke thrombolysis the previous year was also analysed. There were 663 stroke unit admissions and 224 AST calls during the study period. 53% of calls occurred within working hours and 68% had a final diagnosis of stroke. Twenty-seven patients received treatment with rtPA (12% of calls), whereas only ten patients received rtPA in 2004. The most common reason for not treating was mild or rapidly resolving deficit. Onset-needle time and door-needle times significantly improved following introduction of the AST. Thus, we conclude that the introduction of the AST emergency call system has increased the number of eligible patients receiving rtPA. Improved onset-needle and door-needle times are achievable by this team approach.

What is "normal" blood pressure in the aged?

Blood pressure was studied in two groups of institutionalized subjects ranging in age from 50 to over 100 years. The first group comprised 199 selected normal subjects; subjects with any disease, including systemic hypertension, were excluded. The second group consisted of 947 unselected subjects; those with acute illness were excluded. In the first group, systolic pressure increased slightly, but diastolic pressure did not change with increasing age. The blood pressures were still within the limits that were considered normal for younger persons. In the second group, both the systolic and the diastolic pressures progressively decreased with age, so that the former fell below normal limits.

Blunted response to systemic nitric oxide synthase inhibition in the cerebral circulation of patients with Type 2 diabetes.

AIMS: Diabetes is a major risk factor for stroke, but the mechanisms that impart the excess risk are unclear. Endothelial dysfunction, which has been demonstrated in the coronary and peripheral vasculature of diabetic patients, is an important early marker of vascular disease. However, the effect of diabetes on cerebrovascular endothelium has not been examined. We sought to investigate the effect of diabetes on basal cerebrovascular endothelial function as assessed by response to the nitric oxide synthase (NOS) inhibitor NG-monomethyl-L-arginine (L-NMMA). METHODS: Fourteen men with Type 2 diabetes and 15 age-matched male control subjects were recruited. The participants had no clinically evident vascular disease and were taking no vasoactive or lipid-lowering medication. Each received a single 15-min intravenous infusion of L-NMMA (0.8 mol/kg/min). Cerebral blood flow was assessed by colour Doppler imaging of the internal carotid artery (ICA) at 10-min intervals for 20 min prior to and following the infusion. Middle cerebral artery velocity (MCAv) was assessed by transtemporal Doppler ultrasound at the same time points. RESULTS: L-NMMA produced a mean reduction in ICA flow area under curve (AUC) in the control group of 12.8 +/- 17.8% compared with a 2.1 +/- 21.7% reduction in the group with diabetes (P < 0.05), indicating blunted basal cerebrovascular response to NOS inhibition in the diabetic group. There was no significant change in MCAv following L-NMMA in either group. Mean +/- sd MAP rose 6.4 +/- 4.2 mmHg in the control group vs. 8.8 +/- 3.5 mmHg in the diabetic group [P = not significant (NS)]. No adverse event or symptom was reported. CONCLUSIONS: Response to NOS inhibition is impaired in the cerebral circulation of patients with diabetes. This observation is consistent with the elevated cerebrovascular risk reported in this population, and may represent a future therapeutic target in stroke prevention.

Clinical features associated with medically unexplained stroke-like symptoms presenting to an acute stroke unit.

In many areas of secondary care, symptoms unexplained by disease account for around one-third of all patients seen. We sought to investigate patients presenting with medically unexplained stroke-like symptoms to identify distinguishing features which may help to identify a non-organic aetiology. Patients given a discharge diagnosis of medically unexplained stroke-like symptoms over the preceding 11 years were identified retrospectively from a prospectively completed stroke unit database. Age- and sex-matched controls with ischaemic or haemorrhagic stroke or transient ischaemic attack were also identified. Clinical features on presentation, ischaemic risk factors, alcohol history, marital status and history of depression or anxiety were examined. Previous or subsequent admissions with medically unexplained syndromes were also examined via record linkage with hospital discharge records. A medically unexplained syndrome was assumed to be present if an International Classification of Diseases 9 discharge code for one or more of the thirteen conditions forming recognized functional syndromes was given. Logistic regression was applied to determine predictors of non-organicity. One hundred and five patients and controls, 1.6% of all stroke unit admissions were identified, 62% (65 patients) were females. Mean age was 50.3 +/- 14.9. Compared with age- and sex-matched controls patients with medically unexplained stroke-like symptoms were significantly more probable to have a headache at presentation (47% vs. 26%, P = 0.0004), have a diagnosis of one or more additional medically unexplained syndromes (24% vs. 11%, P = 0.007) but significantly less probable to present with symptoms of vertebrobasilar dysfunction (32% vs. 61%, P < 0.0001). A history of anxiety or depression, as recorded in the notes, was not found to be associated with a medically unexplained presentation. Medically unexplained stroke-like presentations are common (1.6% of all stroke presentations), they are most strongly predicted by the presence of other functional somatic syndromes, headache and the absence of symptoms of vertebrobasilar dysfunction.