Browsing by Author "Sarma, Sankara P."

Now showing 1 - 9 of 9
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    A Prospective Study on the Cost-Effective Utilization of Long-Term Inpatient Video-EEG Monitoring in a Developing Country
    (JOURNAL OF CLINICAL NEUROPHYSIOLOGY, 2009)
    To investigate diagnostic value, therapeutic benefit and cost-effective utilization of video-EEG monitoring (VEM) in a comprehensive epilepsy program in a developing country, The authors prospectively recruited all patients who underwent long-term (>= 3 hours) inpatient VEM during a 10-month period. The cohort was followed to gather information about the proportion of patients in whom long-term management was altered by VEM and resultant impact on direct health care costs. Out of 143 study subjects (median age 22 years), 102 (71.3%) were referred for presurgical evaluation. The median duration of VEM was 61 hours, and median number of events recorded per patient was 3. Video-EEG monitoring helped to clarify the epilepsy syndromic diagnosis in 123 of 132 (93.2%) patients referred with the diagnosis of epileptic seizures. Video-EEG monitoring confirmed coexistent complex partial seizures in 4 of 11 (36.4%) patients with a referral diagnosis of psychogenic nonepileptic events. During mean follow-up period of 2.2 years, 48 patients (33.6%) underwent epilepsy Surgery. A significant decrease in antiepileptic drug polytherapy, and minimization in recurring direct medical and nonmedical costs occurred. In addition to immediate diagnostic usefulness, VEM contributes significantly to long-term therapeutic and economic benefits for patients with difficult to diagnose and treat paroxysmal events.
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    Clinical and functional outcome and factors predicting prognosis in osmotic demyelination syndrome (central pontine and/or extrapontine myelinolysis) in 25 patients
    (JOURNAL OF NEUROLOGY NEUROSURGERY AND PSYCHIATRY, 2011)
    Aims To assess the functional and clinical outcome in a sizeable cohort of patients with osmotic demyelination syndrome (ODS) and to characterise the factors which could predict the final outcome.Methods Twenty five consecutive patients with ODS formed the study cohort. The diagnosis of ODS was based on clinical features with corroborating imaging findings. Two functional scales-Functional Independent Measure (FIM) and Disability Rating Scale (DRS)-were applied to assess the functional status at the time of admission, discharge and last follow-up. Patients who became independent for activities of daily living (ADL) at last follow-up were classified as favourable outcome, and those who died or became dependent for ADL were classified as a poor outcome group respectively. The Fisher exact test and Manne-Whitney U test were used to assess categorical and continuous variables respectively.Results The mean age at diagnosis was 53 +/- 14 years. Five (20%) had central pontine myelinolysis, seven (28%) had extrapontine myelinolysis, and 13 (52%) had both. Hyponatraemia and hypokalaemia were noted in 20 (80%) and 10 (40%) patients respectively. Six (24%) received intravenous methylprednisolone. Eleven (46%) had a favourable outcome at a mean follow- up of 2.262.5 years. Hyponatraemia <= 115 mEq (p=0.04), associated hypokalaemia (p 0.04) and low Glasgow Coma Scale (GCS) (p=0.008) at presentation were predictive of poor outcome. The mean FIM score at admission (p=0.05) and at discharge (p=0.01), and mean DRS at admission (p=0.05) were predictive of poor outcome.Conclusions Higher GCS scores, better scores in functional scales in hospital, less severe hyponatraemia and absence of superadded hypokalaemia predicted favourable outcome.
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    Cost-effective utilization of single photon emission computed tomography (SPECT) in decision making for epilepsy surgery
    (SEIZURE-EUROPEAN JOURNAL OF EPILEPSY, 2011)
    Purpose: To investigate the utility of single photon emission computed tomography (SPECT) without subtraction and MRI co-registration in decision making for epilepsy surgeryMethods: Patients with refractory epilepsy and nonlocalizing or discordant non-invasive data (clinical, long-term VEEG, and MRI) were subjected to interictal and ictal SPECT studies before planning invasive or surgical strategy. Final localization was based upon the preoperative information and seizure freedom after surgery. SPECT was considered to be useful for decision-making if it obviated the need for intracranial monitoring or influenced its planning.Results: 61 patients (mean age, 25.1 +/- 8.3 years) underwent SPECT studies between January 2004 and December 2008. Twenty-two patients had mesial temporal lobe epilepsy (MTLE), 13 had neocortical temporal lobe epilepsy (NTLE), and 26 had extratemporal lobe epilepsy (ETLE). As compared to ETLE, SPECT provided more localizing information (77.3% vs 46.2%, p = 0.006) and influenced the final decision-making (45.4% vs 11.53%, p = 0.005) in a significantly higher number of patients with MTLE. SPECT was particularly useful in patients with lesional TLE and nonlocalizing ictal data and in those with dual pathologies. SPECT did not provide any additional information in patients having either TLE or ETLE with normal MRI.Conclusions: SPECT is useful in a selected group of patients and unlikely to provide additional information in others. By restricting its use in patients who are likely to be benefited, a cost-effective utilization strategy can be employed in countries with limited resources. Due to the small number, these findings need to be validated in a larger group of patients. (C) 2010 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
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    Determinants of gestational diabetes mellitus: A case control study in a district tertiary care hospital in south India
    (INTERNATIONAL JOURNAL OF DIABETES IN DEVELOPING COUNTRIES, 2010)
    Objective: To study the determinants of Gestational Diabetes Mellitus (GDM). Design: Case-control study. Setting: Sri Avittom Thirunal Hospital, Thiruvananthapuram district, Kerala, South India. Participants: 300 GDM women as cases and 300 age-matched controls. Study variables: Sociodemographic characteristics, pre-pregnancy Body Mass Index (BMI), menstrual history, obstetric history, infertility history, family history of diabetes in first degree relatives, recurrent urinary tract infection (UTI), and moniliasis. Statistical analysis: T-test, Fishers Exact Test, Chi square test, Adjusted Odds Ratio with 95% CI. Results: Pre-pregnancy BMI >= 25 (P < 0.001, OR = 2.7), irregular menstrual cycle (P = 0.006), treatment for infertility (P = 0.001, OR = 3.3), family history of diabetes (P = 0.001, OR = 4.5), history of diabetes in mother (P = 0.003), previous pregnancy losses (P = 0.04), past GDM (P = 0.035), prematurity (P = 0.01), pre-eclampsia (P = 0.04), polyhydramnios (P < 0.001, OR = 6.0), UTI (P < 0.001, OR = 3.2), and moniliasis (P < 0.001, OR = 7.6) were significantly associated with present GDM. Conclusion: Early identification of women at risk of GDM and prompt treatment is recommended to prevent complications.
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    Feasibility of antiepileptic drug withdrawal following extratemporal resective epilepsy surgery
    (NEUROLOGY, 2012)
    Objective: To identify the rate of successful antiepileptic drug (AED) withdrawal after resective surgery and the predictors of postwithdrawal seizure recurrence in patients with extratemporal epilepsy.Methods: We retrospectively analyzed the postoperative AED profile of 106 consecutive patients who had completed 2 or more years after resections involving frontal, parietal, and occipital lobes for AED-resistant epilepsy. To identify the potential predictors of seizure recurrence, we compared the attributes of recurred and nonrecurred groups by univariate and multivariate analyses.Results: We attempted AED withdrawal in 94 (88.7%) patients. Forty-four (41.5%) patients had seizure recurrence while reducing AED, of which 14 (31.8%) did not become seizure-free subsequently. On multivariate analysis, an abnormal postoperative EEG and longer preoperative duration of epilepsy predicted seizure recurrence, while early postoperative seizures and presence of gliosis or dysplasia were additional predictors on univariate analysis. At mean follow-up duration of 4.6 years, 63 (59.4%) patients were seizure-free. The cumulative probability of achieving complete AED-free status was 20% at fourth year, 34% at sixth year, 40% at eighth year, and 52% at 10th year after surgery.Conclusions: Following resective extratemporal epilepsy surgery, AED can be successfully discontinued in only in a minority of patients. One-third of patients who recur fail to regain seizure control upon AED reintroduction. Longer duration of epilepsy prior to surgery, abnormal postoperative EEG, early postoperative seizures, and focal gliosis or dysplasia as substrate predispose to seizure recurrence. This information will be helpful in making rational decisions on AED withdrawal following extratemporal resective epilepsy surgery. Neurology (R) 2012;79:770-776
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    Fewer women receive tertiary care for epilepsy in Kerala State, India
    (EPILEPTIC DISORDERS, 2006)
    Purpose. The stigma attached to epilepsy often restricts early diagnosis and optimal care, particularly among the underprivileged. We aimed to ascertain any gender bias in the utilization of services for epilepsy in a tertiary and community care facility in Kerala State, India. Methods. The R. Madhavan Nayar Center for Comprehensive Epilepsy Care (RMNC) is a leading tertiary care facility in South India. The District Mental Health Program (DMHP) is a community-based care facility that provides medical consultation and antiepileptic drugs (AED) free of charge. We analyzed the sex ratio (SR) - number of women per one thousand men - of all registrations in these centers according to year of registration, age, religion, income, distance from domicile to the center, and religion. Results. The SR in the RMNC (1976-2004, n = 12354) was 729. At RMNC, age-specific SR increased up to the 3(rd) decade (864), and progressively declined beyond 50 years. The SR was lower for those domiciliated at more than 200 km from the center when compared to others. The SR at the DMHP (1999-2004, n = 221) was high (1125). The age-specific SR at DMHP showed two peaks at 21-30 years (1368) and 51-60 years (2333). Conclusion. Fewer women with epilepsy (particularly in lower socioeconomic groups) receive tertiary care in this state, in spite of a higher SR in the community (907 for epilepsy and 1058 for all population). The tertiary treatment gap is wider for women over 30 years (particularly over 50 years), when their longer life expectancy is also taken into consideration.
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    Medically refractory epilepsy associated with temporal lobe ganglioglioma: Characteristics and postoperative outcome
    (CLINICAL NEUROLOGY AND NEUROSURGERY, 2006)
    Objectives: To define the postoperative seizure outcome and its predictors in patients with ganglioglioma-related temporal lobe epilepsy (TLE).Patients and methods: We reviewed the pre- and post-surgical evaluation data of 23 patients with temporal lobe ganglioglioma, who had completed >= 1 year of postoperative follow-up. They comprised 4.9% of the patients with TLE and 67.6% of the tumoral TLE operated in a developing country epilepsy center during an 8-year period.Results: Median age at surgery was 20 years; median duration of epilepsy prior to surgery was 9 years. Magnetic resonance imaging (MRI) revealed tumor in mesial temporal location in 18 patients (78.3%) and in the lateral localtion in 2; in the remaining 3, involved both mesial and lateral regions. EEG abnormalities were localized to the side of lesion in the majority. Mesial temporal lobe structures were included in the resection, if they were involved by the tumor; otherwise, lesionectomy alone was performed. During a median follow-up of 4 years, 19 (82.6%) patients were completely seizure-free. Epileptiform abnormalities persisting in the 1-year postoperative EEG predicted unfavorable seizure outcome.Conclusion: We emphasize that, in patients with temporal lobe ganglioglioma, when the seizures are medically refractory, surgery offers potential for cure of epilepsy in the majority. (c) 2005 Elsevier B.V. All rights reserved.
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    Mini mental state examination and the Addenbrooke's cognitive examination: Effect of education and norms for a multicultural population
    (NEUROLOGY INDIA, 2007)
    Objective: To derive population norms on the Malayalam adaptation of Addenbrooke's Cognitive Examination (M ACE) and the inclusive Malayalam mini mental state examination (M-MMSE).Materials and Methods: Education-stratified norms were obtained on randomly selected cognitively unimpaired community elders (n = 519).Results: Valid data on norms was available on 4813 subjects (age 68.5 +/- 7.1 and education 7.9 +/- 5.4). Education and age, but not gender had a significant effect on both MACE and M-MMSE. When compared to the effect of age, the effect of education was sevenfold more on the M-ACE and ninefold more on the M-MMSE. The mean composite score on the M-ACE (and the M-MMSE) was 42.8 +/- 9.8 (14.9 +/- 3.1) for those with 0 (n = 72), 55.9 +/- 12.5 (19.7 +/- 4.1) with 1- 4 (n = 96), 62.6 +/- 11.4 (21.9 +/- 3.7) with 5-8 (n = 81), 77 +/- 10.2 (25.7 +/- 2.4) with 9-12 (n = 136) and 83.4 +/- 7.2 (26.7 +/- 1.6) with > 12 (n = 103) years of formal education.Conclusions: Education has the most potent effect on performance on both M-ACE and M-MMSE in the Indian cohort. Education-stratified scores on the M-ACE and the M-MMSE, will provide a more appropriate means of establishing the cognitive status of patients. It is also our feeling that these cut-off scores will be useful across India.
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    Prognostic importance of serial postoperative EEGs after anterior temporal lobectomy
    (NEUROLOGY, 2011)
    Objective: To assess the value of postoperative EEG in predicting seizure outcome and seizure recurrence following antiepileptic drug (AED) withdrawal in patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS).Methods: We studied 262 consecutive patients with MTLE-HS with serial EEGs at 3 months, and at 1, 2, and 3 years after anterior temporal lobectomy (ATL), and considered the presence of interictal epileptiform discharges (IED) as abnormal. We attempted AED withdrawal in all seizure-free patients. We defined favorable outcome as freedom from seizures/auras during the entire follow-up period (outcome 1) and during terminal 1-year follow-up (outcome 2).Results: During mean follow-up period of 7.6 (range 5-12) years, 129 (49.2%) patients had favorable outcome 1 and 218 (83.2%) had favorable outcome 2. Of 225 (85.9%) patients in whom AED withdrawal was attempted, 61 (27.1%) had seizure recurrence. Compared to patients with normal EEG, those with IED on 1-year post-ATL EEG had a 3-fold increased risk for unfavorable outcome 1 and 7-fold increased risk for unfavorable outcome 2. The patients in whom all the 4 EEGs were abnormal had 9-fold odds for unfavorable outcome 1 and 26-fold odds for unfavorable outcome 2. An abnormal EEG at 1 year increased the risk of seizure recurrence following AED withdrawal by 2.6-fold.Conclusions: Post-ATL EEG predicts seizure outcome and seizure recurrence following AED withdrawal. Serial EEGs predict outcome better than single EEG. This information will be helpful in counseling of patients after ATL, and in making rational decisions on AED withdrawal. Neurology (R) 2011; 76: 1925-1931