Lucknow, India
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Kalita J.,Sanjay Gandhi PGIMS | Kumar B.,Sanjay Gandhi PGIMS | Misra U.K.,Sanjay Gandhi PGIMS | Pradhan P.K.,Nuclear Medicine
Pain Medicine | Year: 2011

Objective. The objective of this study was to report clinical spectrum of central post stroke pain (CPSP) and correlate these with magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT) findings. Design. The study was designed as a prospective study. Setting. The study was set in a tertiary care teaching hospital. Subject and Method. Twenty-three consecutive CPSP patients were included and their severity of pain, sensory threshold, allodynia, hyperalgesia, and temporal summation were assessed by quantitative sensory testing (QST). Cranial MRI and 99Tc ethylene cystine dimmer SPECT findings correlated with QST. Results. The duration of CPSP was 5 months (0.25-108). Allodynia was present in 12 patients, punctuate hyperalgesia in 11, and temporal summation in 12. SPECT was abnormal on visual analysis in 17 patients; hypoperfusion in corresponding thalamus in nine, and parietal cortex in 11 patients. Semiquantative analysis revealed hyperperfusion of thalamus in four and parietal cortex in five patients. MRI revealed infarction in 14 and hematoma in nine patients. The QST findings were similar in thalamic and extrathalamic CPSP. The MRI and SPECT findings were also not different in CPSP patients with and without allodynia. Conclusion. The QST findings in patients with CPSP were similar in patients with thalami and extrathalamic lesions. SPECT and MRI findings were also not different in CPSP patients with and without allodynia. Wiley Periodicals, Inc.


Misra U.K.,Sanjay Gandhi PGIMS | Kalita J.,Sanjay Gandhi PGIMS | Phadke R.V.,Sanjay Gandhi PGIMS | Wadwekar V.,Sanjay Gandhi PGIMS | And 4 more authors.
Acta Tropica | Year: 2010

There is paucity of studies regarding the utility of various conventional MRI sequences in the diagnosis of viral encephalitis. The present study evaluates the usefulness of various MRI sequences in acute viral encephalitis. 88 consecutive viral encephalitis patients, aged 2-72 years were subjected to clinical evaluation. Consciousness was assessed by Glasgow Coma Scale (GCS). Serum or cerebrospinal fluid (CSF) was analyzed for dengue, Japanese encephalitis (JE), herpes, measles, echo, coxsackie and polio viruses using ELISA or PCR. Cranial MRI was done and T1, T2, FLAIR and DW images were obtained. The MRI changes were correlated with type of encephalitis and duration of illness. All the patients had altered sensorium and 37 had seizures. 22 patients had JE, 9 had dengue, 8 had herpes simplex encephalitis (HSE), 2 had Epstein-Barr virus encephalitis (EBVE) and 47 had non-specific encephalitis. The median duration of MRI study from onset was 10 days. In JE (20/22), HSE (8/8), and EBVE (2/2), MRI abnormalities were more common compared to dengue (2/9) and non-specific (20/47) encephalitis. The MRI abnormalities were more common in FLAIR (57.1%) compared to T2 (52.9%), DWI (38.1%) and T1 (19.3%) sequences. The mean ADC value in JE patients was lower (974.0±110.85×10-6mm2/s) than HSE (1024.33±485.76×10-6mm2/s). Additional MRI lesions were seen in 12.6% cases on FLAIR sequence. FLAIR and T2 sequences were more sensitive in revealing abnormalities in viral encephalitis. © 2010 Elsevier B.V.


Nair P.P.,Sanjay Gandhi PGIMS | Kalita J.,Sanjay Gandhi PGIMS | Misra U.K.,Sanjay Gandhi PGIMS
Journal of Postgraduate Medicine | Year: 2011

Status epilepticus (SE) is an important neurological emergency with high mortality and morbidity. The first official definition of SE was the product of 10 th Marseilles colloquium held in 1962 which was accepted by International League Against Epilepsy in 1964. There are as many types of SE as of seizures. SE is supposed to result from failure of normal mechanisms that terminate an isolated seizure. In half of the cases, there is no history of epilepsy and SE is precipitated by some intercurrent infection. In children, it is often infection, whereas in adults, the major causes are stroke, hypoxia, metabolic derangements, and alcohol intoxication or drug withdrawal. The treatment of SE aims at termination of SE, prevention of seizure recurrence, management of precipitating causes, and the management of complications. The extent of investigations done should be based on the clinical picture and cost benefit analysis. The first line antiepileptic drugs (AED) for SE include benzodiazepines, phenytoin, phosphenytoin, and sodium valproate. Mortality of SE ranges between 7 and 39% and depends on underlying cause and response to AEDs.


Sahoo D.,Sanjay Gandhi PGIMS | Kumar S.,Sanjay Gandhi PGIMS | Kapoor A.,Sanjay Gandhi PGIMS
Journal of Cardiology Cases | Year: 2016

Rheumatic heart disease (RHD) and congenital heart disease (CHD) rarely co-exist in the same patient. However, such associations are not unknown in areas where RHD is endemic. We report a rare combination of severe rheumatic mitral stenosis, severe pulmonary artery hypertension (PAH), and an incidental clinically silent patent ductus arteriosus (PDA). The patient was initially subjected to a balloon mitral valvotomy to assess if the resultant fall in PA pressure would alter the flow dynamics of the PDA. Since the ductal flow remained small and clinically inaudible, no further intervention was advised. The case highlights the importance of detailed echocardiographic examination in patients with RHD to detect co-existent CHD and logical decision making in their management.<. Learning objective: A detailed echocardiographic examination is needed in all cases even when a diagnosis is apparent. Despite obvious rheumatic mitral stenosis, meticulous echocardiography revealed a small PDA, which was clinically silent. Since severe PAH can alter findings of PDA, we first performed balloon mitral valvotomy to see if resultant fall in PA pressure would alter the flow dynamics of PDA. Despite fall in PA pressures, the PDA flow remained trivial and it was clinically inaudible. Hence, no further intervention was advised.>. © 2016 Japanese College of Cardiology.


Yadav R.K.,Sanjay Gandhi PGIMS | Kalita J.,Sanjay Gandhi PGIMS | Misra U.K.,Sanjay Gandhi PGIMS
Pain Medicine | Year: 2010

Objective: To evaluate the migraine triggers in consecutive patients and correlate these with demographic and clinical variables. Design: A prospective study. Setting: Tertiary care teaching hospital. Subject and Methods: A total of 182 patients with migraine were included whose age ranged between 14 to 58 years and 131 were females. Duration of migraine ranged between 6 and 260 months. Endogenous and exogenous migraine triggers were inquired using a questionnaire. Severity of migraine, associated symptoms, and functional disability were recorded. Presence of trigger was correlated with various demographic and clinical variables. Results: Migraine triggers were present in 160 (87.9%) patients and included emotional stress in 70%, fasting in 46.3%, physical exhaustion or traveling in 52.5%, sleep deprivation in 44.4%, menstruation in 12.8%, and weather changes in 10.1% patients. Multiple triggers (>2) were present in 34.4% patients. Conclusion: The triggers in the Indian migraine patients are similar to other populations but for dietary factors. © American Academy of Pain Medicine.


Misra U.K.,Sanjay Gandhi PGIMS | Kalita J.,Sanjay Gandhi PGIMS | Nair P.P.,Sanjay Gandhi PGIMS
Journal of the Neurological Sciences | Year: 2010

Objective: To evaluate the efficacy and safety of aspirin in preventing stroke and mortality in tuberculous meningitis (TBM). Methods: Patients with TBM diagnosed on the basis of clinical, MRI and cerebrospinal fluid (CSF) criteria were randomized into aspirin 150 mg daily or placebo. All the patients received four drug antitubercular treatment- RHZE (rifampicin, isoniazide, pyrazinamide and ethambutol) with or without corticosteroid. The primary endpoint was MRI proven stroke at 3 months and secondary end points were mortality and functional outcome assessed by Barthel Index score at 3 months. The adverse drug reactions were also analyzed. Results: 118 TBM patients were randomized into aspirin and placebo groups. The baseline demographic, clinical (severity of meningitis, MRI and CSF changes) were not significantly different between the two groups. 19 (16.1%) patients lost from follow up. 21 (33.3%) patients developed stroke after randomization which was insignificantly lesser in aspirin (24.2%) compared to the placebo group (43.3%; OR 0.42, 95%CI 0.12-1.39). Aspirin resulted in absolute risk reduction of stroke in 19.1% and significant reduction in mortality compared to placebo (21.7% Vs 43.4%, P = 0.02). On binary logistic regression analysis, the age (OR 1.09, CI 1.03-1.14, P = 0.001) was the only independent risk factor of stroke and aspirin was significantly related to survival (OR 3.17, 95% CI 1.21-8.31). Aspirin was well tolerated and was not withdrawn in any patient because of side effects. Interpretation: Aspirin resulted in insignificantly lesser strokes and significantly reduced 3 month mortality in patients with TBM. © 2010 Elsevier B.V. All rights reserved.


Misra U.,Sanjay Gandhi PGIMS | Kalita J.,Sanjay Gandhi PGIMS
Annals of Indian Academy of Neurology | Year: 2011

A provoked seizure may be due to structural damage (resulting from traumatic brain injury, brain tumor, stroke, tuberculosis, or neurocysticercosis) or due to metabolic abnormalities (such as alcohol withdrawal and renal or hepatic failure). This article is a part of the Guidelines for Epilepsy in India. This article reviews the problem of provoked seizure and its management and also provides recommendations based on currently available information. Seizure provoked by metabolic disturbances requires correction of the triggering factors. Benzodiazepines are recommended for treatment of seizure due to alcohol withdrawal; gabapentin for seizure seen in porphyria; and antiepileptic drugs (AED), that are not inducer of hepatic enzymes, in the seizures seen in hepatic dysfunction. In severe traumatic brain injury, with or without seizure, phenytoin (PHT) may be given for 7 days. In ischemic or hemorrhagic stroke one may individualize the AED therapy. In cerebral venous sinus thrombosis (CVST), AED may be prescribed if there is seizure or computed tomographic (CT) abnormalities or focal weakness; the treatment, in these cases, has to be continued for 1 year. Prophylactic AED is not recommended in cases of brain tumor and neurosurgical procedures and if patient is on an AED it can be stopped after 1 week.


Syal S.K.,Sanjay Gandhi Post Graduate Institute of Medical Sciences | Kapoor A.,Sanjay Gandhi Post Graduate Institute of Medical Sciences | Bhatia E.,Sanjay Gandhi PGIMS | Sinha A.,Sanjay Gandhi Post Graduate Institute of Medical Sciences | And 4 more authors.
Journal of Invasive Cardiology | Year: 2012

Background and Methods: Vitamin D deficiency has been linked to an increased risk of coronary artery disease (CAD) and cardiovascular (CV) death. Endothelial dysfunction plays an important role in pathogenesis of CAD and vitamin D deficiency is postulated to promote endothelial dysfunction. Despite rising trends of CAD in Asians, only limited data are available on the relationship between vitamin D, CAD, and endothelial dysfunction. Results: In a study of 100 patients undergoing coronary angiography, mean 25(OH)D level was 14.8 ± 9.1 ng/mL; vitamin D deficiency was present in 80% and only 7% had optimal 25(OH)D levels. Nearly one-third (36%) were severely deficient, with 25(OH)D levels <10 ng/mL. Those with vitamin D deficiency had significantly higher prevalence of double-or triple-vessel CAD (53% vs 38%), diffuse CAD (56% vs 34%), and higher number of coronary vessels involved as compared to those with higher 25(OH)D levels. Those with lower 25(OH)D levels had significantly lower brachial artery flow-mediated dilation (FMD; 4.57% vs 10.68%: P<.001) and significantly higher prevalence of impaired FMD (values <4.5%; 50.6% vs 7%; P<.002). A graded relationship between 25(OH)D levels and FMD was observed; impaired FMD was noted in 62.2%, 38.6%, and 13.3% in those with 25(OH)D levels <10 ng/mL, 10-20 ng/mL, and >20 ng/mL, respectively. Conclusion: Indian patients with angiographically documented CAD frequently have vitamin D deficiency. Patients with lower 25(OH)D levels had higher prevalence of double-or triple-vessel CAD and diffuse CAD. Endothelial dysfunction as assessed by brachial artery FMD was also more frequently observed in those with low 25(OH)D levels.


PubMed | Sanjay Gandhi PGIMS
Type: Journal Article | Journal: Asian cardiovascular & thoracic annals | Year: 2016

Differential release kinetics of the cardiac biomarkers (B-type natriuretic peptide, troponin I, and creatine kinase-MB) following off-pump coronary artery bypass are not well characterized.Biomarker levels were assessed at 6, 24, 48h, and 1 month preoperatively, in 80 patients who underwent off-pump coronary artery bypass.All biomarkers increased within 6h of surgery. Peak B-type natriuretic peptide levels occurred at 24-48h in 96% of patients, but only two-thirds had peak troponin I and creatine kinase-MB levels at this time, reflecting different release patterns. Levels of all biomarkers declined within 48h, but 42% of patients still had B-type natriuretic peptide >100pgmL(-1) at 1 month. Those with baseline B-type natriuretic peptide>100pgmL(-1) had a lower left ventricular ejection fraction (43.6% vs. 55.6%, p<0.01) and longer inotropic (43.8 vs. 31.4h, p=0.03) and ventilator support (34 vs. 25.5h, p=0.04) than those with lower levels. B-type natriuretic peptide levels correlated positively with angiographic Syntax score (p=0.02) and negatively with left ventricular ejection fraction (p<0.001). Only baseline B-type natriuretic peptide predicted the durations of inotropic support (p=0.01) and ventilation (p=0.02). Postoperative B-type natriuretic peptide at 6, 24, and 48h and delta B-type natriuretic peptide were significant predictors of mean ventilation time.Even in patients undergoing off-pump surgery, there is significant natriuretic peptide and myocardial enzyme release. Only B-type natriuretic peptide levels had an association with postoperative variables.


PubMed | Sanjay Gandhi PGIMS
Type: Journal Article | Journal: Cardiovascular therapeutics | Year: 2016

Chronic mitral regurgitation (MR) is characterized by adverse ventricular remodeling and progressive LV dysfunction leading to heart failure (HF). Beta-blockers (BB) improve LV remodeling and prognosis in patients with HF. As chronic severe MR results in neuroendocrine activation similar to HF, it is likely that BB may also exert favorable effects in these patients. No study has assessed the role of oral BB therapy in chronic rheumatic MR.A total of 100 patients of chronic rheumatic MR (mean age 3013.48years, NYHA 2.20.5) were randomized to BB (Metoprolol, 3713.5mg, n=48) vs no BB (n=52) in addition to standard therapy.Baseline BNP and echocardiographic parameters were comparable in the two groups. At 3months, BB therapy resulted in significantly lower NYHA class (1.97 vs 2.35), BNP (141 vs 207pg/mL), LV end-systolic (35.89 vs 51.30) and LV end-diastolic volumes (101 vs 128mL/m(2) ), LV end-systolic stress (81.1 vs 93.3dyn/cm(2) ), LV mass (122 vs 154gm/m(2) ), and LV work (737.02 vs 952.82mmHgL/min, all P significant). Therapy with BB resulted in a -15.6%, -10.4%,-12.1%, and -7.3% reduction in LV end-systolic and end-diastolic dimensions and LVESVi and LVEDVi, respectively. Following BB therapy, BNP levels, end-systolic stress, indexed LV mass, and LV work also reduced significantly by 27.3%, 15.6%, 8.7%, and 28%, respectively. The control group had no significant change. The MR grade reduced from severe to moderate in 11% of those on BB (controls: no change). At 6months, the BB group had further improvement in all echocardiographic parameters ranging from +9.1 to -18.2%.In this first study of BB in rheumatic MR, targeting the sympatho-adrenergic axis exerted favorable effects on NYHA class, LV volumes, LV end-systolic stress, and LV work. Further studies are required to elucidate the role of BB in rheumatic MR.

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