Sunday, March 31, 2013

MULTIPLE SCLEROSIS

DIAGNOSIS AND TREATMENT OF MULTIPLE SCLEROSIS

  1. What is multiple sclerosis?
Multiple sclerosis is a demyelinating disease of central nervous system-CNS (brain and spinal cord), which is characterized by involvement of “multiple” parts of CNS.
The disease is also characterized by remissions (improvement of symptoms) and relapses (occurrence of new symptoms) over a period of time, causing “multiple” episodes of symptoms.  
Multiple sclerosis is an autoimmune disease, which means the antibodies produced in the body attacks own healthy tissues.

  1. What is the meaning of demyelination or demyelinating illness?
Nerves in central nervous system are like “electric wires”, that is, they have a central core surrounded by an insulation or covering. This covering of the nerves is called “myelin sheath”.
A disease, where the myelin sheath is affected or damaged is called a demyelinating disease or illness, and the process is called as demyelination. Multiple sclerosis is one of the most common demyelinating diseases of the CNS.

3. Who are the common people affected by multiple sclerosis?

·        Multiple sclerosis is commonly seen between the ages of 10 and 60 years, which means, it is uncommon in children below 10 years and those adults who are above 60 years of age.
·        Multiple sclerosis is typically more common in young women (between the ages of 18-36 years),
·        Multiple sclerosis is seen all over the world, probably more common in the West, as compared to Asian countries.
·        Also, the severity of multiple sclerosis seems to be lesser in Asians, leading to lesser degrees of disability, which has led some people to label Asian multiple sclerosis as relatively “benign form” of multiple sclerosis.

  1. What are the common symptoms of multiple sclerosis?
Common symptoms of multiple sclerosis include:
    • Sudden onset diminished vision in one or both eyes, which may get worse over a few days,
    • Numbness of arm or leg on one or both sides of body,
    • Weakness of arm or leg on one or both sides of body,
    • Imbalance while walking,
    • Bladder symptoms,
Less common symptoms of multiple sclerosis include
·        Memory disturbances,
·        Seizures or fits,
·        Depression
It is important to note that a patient with multiple sclerosis may have only one or more than one symptom described above at one point of time, or different symptoms may occur during multiple episodes of the disease.

  1. How is the diagnosis of multiple sclerosis confirmed?
A person who has one or more symptoms suspicious of multiple sclerosis should consult a neurologist. A neurologist would take history and do a clinical examination to ascertain the number of episodes of illness, and also to identify the affected the parts of central nervous system.
After that he would order for investigations to confirm the diagnosis of multiple sclerosis.

  1. What are the important investigations for confirming a diagnosis of multiple sclerosis?
  • MRI (Magnetic resonance imaging) of brain and spinal cord- this is the most important investigation. MRI shows the involvement of different parts of brain and spinal cord. The white matter of brain and spinal cord are typically affected in multiple sclerosis. The diseased part of brain and spinal cord are also referred to as “lesions” or “plaques”. A new or active lesion shows enhancement on MRI with contrast dye injection. In addition, there may be swelling around the active lesions. MRI is also able to distinguish new versus old lesions, and is useful to monitor the disease progression or improvement and also the effectiveness of treatment.
    • CSF (cerebrospinal fluid) analysis- CSF is removed by lumbar puncture (LP) by inserting a needle in lower back. In multiple sclerosis, the CSF protein is elevated; however, the number of white blood cells (WBCs) is either normal or only slightly elevated. CSF sugar is often normal. CSF is also tested for the presence of oligoclonal bands (OCBs), the presence of which indicates an active disease.
    • Evoked potential studies may be ordered to look for involvement of optic nerve (visual evoked potential or VEP) or spinal cord (somatosensory evoked potential).
    • Blood tests (such as ANA, Anti-dsDNA, ANCA, etc) may be ordered to exclude other diseases that can mimic multiple sclerosis.

  1. What are the current treatment options for multiple sclerosis?
Treatment of multiple sclerosis can be divided into two categories- treatment of acute episodes and treatment to prevent future relapses of disease.
Treatment for acute episodes:
Steroid injections are the preferred treatment options. The drug of choice is methylprednisolone given as injections in the veins over 3-5 days. Then, steroid tablets are given for 15-20 days.
Treatment to prevent relapses of disease:
The most preferred treatment is interferon injections (such as avonex, relibeta and rebif in India). Avonex and relibeta are given as injections in the muscles, once a week, whereas rebif is given as injections underneath the skin three times a week.
Other FDA-approved treatment options to prevent relapses of disease in multiple sclerosis are:
1. Glatiramer acetate (copaxone)- given as injection underneath the skin, once a day.
2. Fingolimod- oral capsule (0.5 mg) once daily
3. Mitoxantrone- given as infusion in the vein, every three months (maximum 8-12 doses over two-three years),
4. Natalizumab (tysabri)- given as infusion in the vein, once every four weeks.
5. Dimethyl fumerate (tecfidera)- twice a day oral capsules.
6. Teriflunomide (Aubagio)- once daily tablets. 


 8. Is Multiple sclerosis curable?

As of today, there is no cure for multiple sclerosis. However, with current treatments, the disease can be kept under control and new relapses can be prevented.

9. Is multiple sclerosis always disabling?

Multiple sclerosis does cause disability in a significant number of people. However, more than two-thirds of patients suffering from multiple sclerosis are independent for their activities of daily living and are gainfully employed in a job. The good outcome depends on proper treatment as well as physical & occupational therapies.

10. Is multile sclerosis contagious or genetic?

Multiple sclerosis is not contagious and does not get transmitted from one affected person to another.

There may be genetic predisposition to get multiple sclerosis but it is not a genetic disease in a strict sense, as most patients with multiple sclerosis do not give a positive family history.

11. Is multiple sclerosis fatal or lethal?

In more than 95% of patients with multiple sclerosis, it does not lead to death. However, in a minority (less than 3%) it may lead to death either due to the direct effect of the severe disease or another complication such as pneumonia or deep vein thrombosis.

I hope this article is useful for hundreds of patients with multiple sclerosis as well as their caregivers. In addition, if someone is looking for information on multiple sclerosis (MS), it should be useful.

For any additional information, please email me at drsudhirkumar@yahoo.com

DR SUDHIR KUMAR MD (Internal Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad, India
Phone: 0091-40-23607777/60601066

Tuesday, March 12, 2013

PARKINSON'S DISEASE

PARKINSON’S DISEASE (PD)

What is Parkinson’s disease (PD)?
Parkinson’s disease is a disease of the brain, which is caused by selective degeneration of nerves in the basal ganglia, leading to deficiency of dopamine in brain.

What are the symptoms of Parkinson’s disease?
The most typical symptoms of this disease include:
  1. Tremors- shaking of hands and feet,
  2. Slowness of all activities,
  3. Stiffness of arms and legs,
  4. Loss of balance while standing or walking.
A patient may have only one or some or all of these at onset. However, as the disease progresses, all of them would eventually develop all these symptoms.

What are some of the other symptoms of Parkinson’s disease?
Other symptoms that may occur in a patient with Parkinson’s disease are:
  1. Mask-like facies or expressionless face, (even in situations of happiness, they may fail to express it on the face),
  2. Stooped posture, with head & trunk bent forwards,
  3. Slurred and low volume speech (it is often difficult to comprehend what they are saying),
  4. Slow speed of walking,
  5. Reduced swinging of arms while walking,
  6. Very small letters while writing, referred to as Micrographia,
  7. Reduced blink rate (which makes them give a staring look),
  8. Short, shuffling steps while walking,
  9. Loss of balance while turning, leading to falling forwards.
Why this disease is called Parkinson’s disease?
This is because the very first description of this disease was given by a doctor named Dr James Parkinson, a neurologist from UK. In his honour, the disease was given his name.

Which age group is commonly affected with Parkinson’s disease?
This disease typically affects people above 40 years of age, and the incidence increases with advancing age.
Occasionally, this can occur in people younger than 40, when it is called young onset Parkinson’s disease (YOPD).

How is Parkinson’s disease diagnosed?
Like many other neurological problem, Parkinson’s disease too is diagnosed on the basis of typical symptoms (as described above).
It may be difficult to diagnose PD in very early stages, as the affected person may have only minor symptoms such as mild tremors of hands, and perfectly well otherwise. However, careful examination by a Neurologist would help confirm its diagnosis in this stage too.

Is there a very specific test for diagnosing Parkinson’s disease, especially in early stage?
In doubtful cases, or in very early stages, PET scan (positron emission tomography) can help in accurate diagnosis of PD. This facility is available in our hospital, and I do use it in some cases.

Can Parkinson's disease be transmitted genetically to the children of patients suffering from this disease?

In about 10% of cases, PD can be genetic in origin. But about 90% of cases of PD are sporadic (they have no family history of Parkinson's disease).

What are the treatment options available for Parkinson’s disease?
The mainstay of treatment of PD is medications. Various medications are available. These include levodopa/carbidopa combination (which provide direct dopamine to the brain); ropinirole & pramipexole (which increase the action of dopamine); trihexiphenidyl, amantadine, entacapone, etc.
The choice of drug depends on the patient’s symptoms as well as the severity & duration of PD.
Your neurologist is the best person to decide the most appropriate medications and their doses.

What are the common side effects with medications used for treating PD?
Though these medications are generally safe, some side effects may occur:
  1. Giddiness while sitting up or standing- this is because of drop in BP while standing, which is a side effect of levodopa/carbidopa (syndopa/sinemet),
  2. Behavioural disturbances- agitation, hallucinations (seeing something that is not there or hearing something when no one is speaking, etc), sleep disturbances can occur with syndopa, especially if the last dose is taken late (such as after 8 pm). 
  3. Nausea, vomiting, loss of appetite may occur with syndopa.
  4. Abnormal movements of hands or feet, akin to dancing or rhythmic movements, referred to as dyskinesias.
What are the common precautions while taking medications for PD?
1. Medications for PD should be taken on empty stomach, as presence of food may interfere with their absorption,
2. They should be taken on exact time, as advised by the doctor,
3. Any change in the dosage or timing of the medications should be done only after consulting the neurologist.

How long are the medications required in Parkinson’s disease?
Medications are usually required for lifelong. However, the dose would change as per the severity of disease.

Are botulinum toxin injections (Botox) helpful in treating PD?
In selected cases, where there is increased rigidity or dystonia, botox may be useful. The decision can be made by the neurologist after clinical examination.

Are there any surgeries available for treating Parkinson’s disease?
Deep brain stimulation (DBS) surgery is the standard surgery performed in some cases of PD. This surgery can be compared to pacemaker (of heart); wherein an electrode is placed in the brain.
It should be noted that not all cases of PD require surgery, nor would all cases of PD benefit from DBS surgery.
Patients with predominant tremors of hands may be the best candidates for DBS surgery.
Another group of patients who may benefit are those with inadequate response to levodopa, or those with levodopa-induced dyskinesias (see above under side effects).
The decision regarding the need or usefulness of surgery can be made by the neurologist after detailed clinical evaluation.

Is DBS surgery available in India?
Yes, many centers in India (Mumbai, Bangalore, New Delhi, Hyderabad, Trivandrum, etc) have the facilities for doing DBS surgery in India.
We perform DBS surgery in our institute too.

What kind of outcome can be expected in patients with PD after treatment?
  1. There is no cure available for PD,
  2. Disease continues to progress despite medical treatment, and the severity of disease would worsen over time,
  3. The disease leads to severe motor disability, hampering the activities of daily living and occupation,
  4. There is generally no increase in the chances of death, if the patients are looked after well.
  5. However, it should be noted that a reasonably good quality of life can be maintained with proper medical treatment and physiotherapy for more than 20 years after the onset of PD symptoms.
Is there a specific diet to be followed by patients suffering from Parkinson’s disease?
Protein content should be reduced by 50%, and protein-rich foods (such as pulses, meat, etc) should be shifted to dinner time (after the last dose of syndopa has been taken). This is to ensure proper absorption of syndopa, as presence of high protein food may interfere with the absorption of levodopa.

Is there any limitation on physical activities?
No, there is none. In fact, it is better for a patient with PD to indulge in regular physical activities, including outdoor games, to maintain good physical fitness & mobility.

If you have any additional queries on Parkinson's disease, please send me an email: drsudhirkumar@yahoo.com

DR SUDHIR KUMAR MD (Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Hyderabad, India
Phone: 0091-40-23607777


Friday, January 11, 2013

MEGA NEURO CAMP (HYDERABAD)

ADVANCED NEURO CAMP


For the benefit of patients, we regularly organize a NEURO CAMP in Hyderabad. Patients suffering from various neurological problems can avail of consultation with a neurologist, investigations and medical treatment during the camp.

Last Neuro camp was held on 14th July 2013.

Patients with following problems can consult during the camp:

1. Headache/migraine/tension headache
2. Vertigo/dizziness/giddiness
3. Neck pain/back pain/sciatica/disc prolapse
4. Stroke/paralysis/blood clot in brain
5. Memory loss/dementia/Alzheimer's disease
6. Parkinson's disease
7. Fits/epilepsy
8. Neuropathy
9. Multiple sclerosis
10. NEURO CHECK UP
11. All other neuro problems.

Facilities available: EMG/EEG/NCS/MRI/CT/Carotid Doppler

VENUE: ELBIT NEURO CLINIC, ROAD NO-12, BANJARA HILLS, HYDERABAD

DATE: To be decided

TIME: 10 AM TO 12.00 PM

For details and appointment, please contact Mr Srinivas (9618204512) or reception (040-23372731, 23372732, 23372733, 23372734)

OR Send an email to: drsudhirkumar@yahoo.com


Thursday, January 3, 2013

MANAGEMENT OF MIGRAINE HEADACHES

Management of Migraine Headaches

There are two steps involved in ensuring the best outcomes for a patient with migraine:

1. Correct diagnosis, and 
2. Correct treatment.

Diagnosis of Migraine Headaches

Migraine is a common condition, affecting about 15% of women and 5% of men. Often, no tests are required for diagnosing migraine. Despite this, there is a significant delay in diagnosis of migraine in many cases. The correct diagnosis depends on the clinical features. Therefore, a good history, as given by the patient, is often sufficient for the diagnosis of migraine. The details can be read on my earlier post in May 2011

http://bestneurodoctor.blogspot.in/2011/05/how-to-diagnose-migraine.html

Treatment of Migraine Headaches

Starting appropriate treatment is equally important.

Many patients come to me telling that there is no treatment available for migraine or it can not be cured or I have to suffer with these headaches whole life and so on. So, they never take any treatment. Obviously, it is totally incorrect. There are excellent treatments available for treating migraine, and more than 95% of patients get better with proper treatment. You can read about these treatments later on in this post.

There is another group of patients who take only pain-killers, as and when they get headaches. This approach is not correct and may be harmful too, on account of three reasons:

1. Taking a pain-killer may help in reducing one episode of headache, however, it does not prevent the recurrence of headaches in future.
2. Pain-killers may cause side effects such as gastric ulcers, acidity, liver damage and kidney damage, if used for long.
3. Taking more than 15 tablets of pain-killers per month may actually worsen the headaches, a condition called as analgesic-abuse or analgesic-overuse headaches.

On account of the above, it is advised to restrict the use of pain-killers to as low as as possible.

Medical treatment of Migraine

1. If a person has only one or two episodes of headaches per month, then, there is no need of any preventive medications. Use of analgesics may be justified in these cases, as and when they get headaches. Common drugs in this category include-
  • Paracetamol,
  • Disprin,
  • Zandu balm or tiger balm (very popular in India)
  • Ibuprofen,
  • Diclofenac,
  • Vasograin,
  • Rizatriptan,
  • Sumatriptan
Any of the above can be used at the time of severe headaches. Some people also have vomiting, then ondansetron or domperidone tablets may be used.

2. Preventive therapy of migraine-

If a patient gets more than two episodes of headaches per month, then, it is important to start preventive medications (on daily basis) so that the headache frequency and severity can be minimised (or stopped).
Common drugs in this category include:
  • Flunarizine
  • Beta blockers such as propranolol,
  • Topiramate,
  • Divalproex sodium
In some cases, a combination of two medicines may be required.

Patients, who do not show adequate improvement with above, can be treated with botox injections. More details on this can be read in my previous post (October 2012)

http://bestneurodoctor.blogspot.in/2012/10/botox-treatment-for-migraine.html

I hope this article provides a little help to those with migraine. If you have any further queries, please mail me.

Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
email: drsudhirkumar@yahoo.com

Friday, October 19, 2012

BOTOX TREATMENT FOR MIGRAINE

Botox Therapy for Chronic Migraine

What is migraine?
  • Migraine is a condition, characterized by repeated episodes of headache.
  • Headache can be on one side or both sides of head.
  • Headache typically lasts for more than four hours, but usually resolves in less than 72 hours.
  • Nausea (a sensation to vomit) or vomiting may be present during headache episodes.
  • There may be photophobia (headache becomes more in bright light or sunlight) or phonophobia (headache becomes more in noise).
 What is chronic migraine?
A person, who has been suffering from migraine, for a period of more than six months, is said to be suffering from chronic migraine.

What is the impact of chronic migraine on the sufferer?
Chronic migraine leads to a number of problems in the sufferer:
  • Recurrent headache interferes with job or studies, leading to poor performance at work or in studies.
  • It leads to frequent absenteeism at workplace or in college.
  • People suffering from chronic migraine can not enjoy social functions, as slight triggers such as music can trigger the headaches.
  • They need to avoid road travel, as it can trigger headaches.
  • Patients are frequently forced to take multiple analgesics (pain-killers) every month, leading to significant adverse effects.
What are the treatment options for patients with chronic migraine?
Patients with chronic migraine, who get three or more than three episodes of headache in a month, require preventive therapy (medications to prevent repeated episodes of headache).

What are the commonly used medications to prevent headaches in a migraine patient?
Following medicines (with their brand names) are available for use in chronic migraine:
Tablets
·        Amitryptiline (Tryptomer)
·        Flunarizine (Sibelium)
·        Propranolol (Betacap TR, Ciplar LA)
·        Divalproex (Divaa OD, Dicorate ER)
·        Topiramate (Topamac)
Injections
·        Botulinum toxin (Botox) injections

What are the disadvantages of oral medications?
1.      Lack of efficacy- many people do not adequately respond to these medications. They continue to get recurrent headaches despite taking them for long periods.
2.      Adverse effects- Significant adverse effects are noted with oral medications.
·        Amitryptiline- drowsiness
·        Flunarizine- drowsiness, weight gain
·        Propranolol- aggravation of asthma, depression
·        Divalproex- weight gain, tremors of hands, hair loss, pregnancy-related complications,
·        Topiramate- tingling of feet, weight loss, glaucoma in rare cases, renal stones in rare cases.
 3.      Need to take them on a daily basis

What are the advantages of Botox injections over oral medications in migraine treatment?
1.      Efficacy of botox in migraine has been proven in research and clinical practice.
2.      Botox is fairly safe and the side effects are negligible.
3.      Botox injections need to be repeated once in 3-6 months, so, the patient compliance is better and they can get rid of daily tablets.

Facts regarding Botox injections in a patient with migraine
·        There are fixed points over the scalp, where the injections are given (irrespective of the site of head pain).
·        These locations include front of head, over eyebrows, temple region, back of head and neck muscles.
·        Injections are given by a neurologist, who is trained in the botox procedure.
·        It is given by insulin syringe and needle, and is given in the superficial tissues (scalp muscles, which are hardly a few mm beneath the skin).
·        Topical (surface anesthetic) creams are used, so, the injection does not hurt much and is almost painless.
·        The whole procedure can be completed in an office (Outpatient) set up and is completed in 15-20 minutes.
·        Patient can leave for office or home immediately after the botox procedure.
·        A total dose of 155 units of botox is used in chronic migraine.
Are there any side effects of botox injections?
·        This is the same botox that is used in cosmetic procedures and several million patients have received botox for neurological problems as well (such as writer’s cramp, dystonia, blepharospasm, post-stroke spasticity, hyperhidrosis, etc).
·        It is among the safest injections, and has no serious side effects.
·        Mild pain at the injection site may be felt (just as is felt with any injections).
·        Mild bruising (and redness) and swelling may occur at the injection site.
·        Mild eyelid droop may occur, which improves in a few days on its own.

My experience with Botox in migraine
  • I see about 15-20 new cases of migraine per month, and have seen thousands of patients in the past 18 years of my medical practice.
  • About 20-30% of them either do not improve with oral preventive tablets or they have side effects with them. Some people find it difficult to take tablets on a daily basis for a long period of time.
  • For this group of patients, botox injection therapy is the most ideal. I see 2-3 patients per month, who are eligible to receive botox therapy in chronic migraine. About 1-2 per month receive them. In the past two years, I have given botox to about 40 patients with chronic migraine.
  • About 95% patients report benefit after botox therapy and in most cases, oral tablets are not required after botox.
  • None of them reported any adverse or side effects with botox.
I would like to share an interesting experience with one of the patients. Mrs Nazia (name changed) from Dubai came in June 2012 for botox therapy in migraine. I gave her the injections on OP basis on the usual sites, including forehead. She had no side effects with botox. She came back for review three months later and reported that she was totally headache-free. However, she wanted a repeat botox injection. I was surprised. I asked her if she has no headache, then why does she want botox! She said, after botox, her husband has started to give her more attention and love, as her face has also improved (then, I realized that she wanted it for cosmetic effects). She also told me that three of her colleagues at her office want the botox to be given by me (but only for cosmetic reasons). I had a tough time, referring them to a cosmetic surgeon for the same.

If you want any further information regarding botox therapy in migraine, please email me at drsudhirkumar@yahoo.com

Dr Sudhir Kumar MD (Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Jubilee Hills, Hyderabad
Phone-0091-40-23607777/60601066

Friday, October 12, 2012

IVIG (Immunoglobulin) THERAPY IN NEUROLOGY

IVIG THERAPY IN NEUROLOGY

Introduction

Neurology is one area, where we see patients who are critically ill, and require emergent and aggressive medical care for better outcomes. This branch of Neurology is also called NEURO CRITICAL CARE. I have a lot of passion for neuro critical care. Here, time is crucial. One has to make the diagnostic and treatment plans as fast as possible, so as to start the best treatment at the earliest, and I love that.

IVIG (INTRAVENOUS IMMUNOGLOBULINS)

IVIG belongs to the group of medicines, called as immunotherapy. This is used in illnesses, which are due to involvement of immune system. In many conditions, antibodies are produced in the body, which can harm, leading to diseases. In these diseases, IVIG treatment can be life-saving.

IVIG Treatment in Neurology

IVIG is required in the following neurological diseases:

1. Guillain Barre syndrome (GBS)- In this illness, patients have paralysis of both hands and legs and may get difficulty in breathnig also.

2. Myasthenia Gravis- In this condition, patients have drooping of eyelids, difficulty in speaking and swallowing, weakness of hands and legs and breathing problem.

3. Multiple sclerosis (MS)- In severe cases of MS, IVIG is useful.

4. CIDP- Chronic inflammatory demyelinating Polyradiculoneuropathy- In this condition, there is weakness of both legs and hands. When steroids do not work, IVIG may be required.

5. Epilepsy- In certain cases of epilepsy, such as West syndrome (seen in children), refractory status epilepticus (where fits do not respond to usual treatment), etc, IVIG therapy can be life-saving.


My Experience with IVIG Therapy

I have been using IVIG since 1995 (about 17 years now). I have given IVIG in all the above-mentioned indications and my experience with this medicine has been very good.
I remember several patients who came in states of severe disability and they recovered well.

One case, I would like to share with you. There was a young 25-year-old software professional Ms Reena (name changed) from Chennai, who had developed severe GBS. She rapidly worsened, became totally paralysed in whole body, and could not breathe. She was put on ventilatory support for the same. As she was not responding to the treatment, their family consulted me. I advised them to shift her to Apollo Hyderabad under my care. She was treated with a course of IVIG, ably supported by our excellent ICU doctors and nurses. She showed gradual improvement and was discharged from hospital after one month. She had little movements of hands and legs at discharge, could not speak, and required feeding through a nasal tube. I advised them to continue physiotherapy. She came back after two months to my OPD for a review. I was pleasantly surprised to see her totally normal. When I asked her if she had any problem, she replied- "yes- my nails have become dark, what to do to make them better?" I could not stop smiling to see the extent of recovery.

There are several similar cases that come to mind, when I look back at more than 500 patients during the past 17 years, who were treated with IVIG under my care and showed excellent recovery.

Dose of IVIG

The standard dose of IVIG is 0.4 grams per kg body weight per day for five days (a total of 2 grams per kg body weight). For ex- a person with body weight of 75 kg would require 150 gms total dose of IVIG (30 grams per day for five days).

It is given as drip (infusion) in the hand veins, slowly over 4-6 hours (just how we give glucose or saline drip).

Cost of IVIG

IVIG is costly, as it is prepared from the plasma (a part of blood) of healthy volunteers. As the source of healthy plasma is scarce, IVIG also is scarce product. A typical vial of 5 gm would cost Rs 15000-20,000/ (USD 300-400). So, a person requiring 150 grams may need to spend Rs 4,50,000-Rs 6,00,000 (USD 9000-12000).

Side effects of IVIG

IVIG is fairly safe product. In some cases, minor allergic reactions may occur. This can include fever, chills, etc. This can be well managed with simple medicines and decreasing the rate of IVIG infusion.

If you require any further information about IVIG treatment, please send an email to me- drsudhirkumar@yahoo.com

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Jubilee Hills, Hyderabad
Phone- 0091-40-23607777/60601066
email: drsudhirkumar@yahoo.com

Tuesday, August 7, 2012

STRESS AND MEMORY LOSS

STRESS AND MEMORY LOSS
Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Hyderabad

Introduction
Memory is one of the most important functions of human brain. A good memory is important in all stages of life. A child’s learning ability and scholastic performance depends a lot on his memory. Similarly, in adults, a good memory is vital to perform the job well. Normal memory is also required in day-to-day life activities. For example- a housewife depends on her memory of recipes to prepare a good meal. After having seen the importance of memory in our lives, it is easy to appreciate the hardships one would go through if there is memory loss. Memory loss, along with impairment of other brain functions, is also referred to as dementia.
Causes of memory loss
Memory loss occurs due to a dysfunction in brain. The commonest causes of memory loss are:
  1. Alzheimer’s disease (AD): AD is the most common cause of dementia in the world. It is a degenerative disease of the brain and commonly affects older people.
  2. Brain strokes- Strokes occur due to a lack of blood supply to the brain. These occur in people with risk factors such as smoking, diabetes, high BP and high cholesterol.
  3. Infections- such as HIV, syphilis, brain fever (meningitis, encephalitis)
  4. Nutritional deficiencies- such as vitamin B12 deficiency
  5. Endocrine disorders- such as hypothyroidism (lack of thyroid hormone)
  6. Head injury
  7. Brain tumors
  8. Stress and depression.
Stress and memory loss
Mental stress, anxiety, depression and other psychiatric disorders are important causes of memory loss today. In anxiety and stress, there is no structural damage of the brain (as compared to AD or brain strokes, where structural damage occurs). Therefore, a bran scan (CT or MRI) is often normal in stress-related memory loss; however specific findings on MRI brain occur patients with AD and brain strokes.  
Biochemical basis of stress-related memory loss
Stress or anxiety leads to several biochemical changes in the brain. During periods of stress, chemicals like adrenaline and cortisol are released. Adrenaline prepares an individual for “fight or flight response”, typically seen during acute stress/anxiety. Adrenaline promotes the release of cortisol. Both adrenaline and cortisol can adversely affect the memory. The major difference between the two is that cortisol stays in the blood and brain for a longer time than adrenaline. The effect of adrenaline is so powerful that our brain gets fogged out for some time during stress. You could see an individual looking blank and staring into vacuum. Only when the levels of adrenaline drop after stress is reduced does he come back to reality. So, one can imagine that if a person is under chronic stress and thus under the chronic influence of adrenaline and cortisol, it can lead to dysfunction and/or damage to brain. Cortisol is known to cause damage of hippocampus (the seat of memory in brain). An excess of cortisol can impair the hippocampus in such a way that one is unable to form a new memory, and not able to retrieve any existing information too.
            Here, one should remember that not all stress is bad for brain. Small periods of stress (such as stress of getting the project completed within the stipulated deadlines) could have a beneficial effect on brain functions. These brief stressful stimuli could keep the brain in an aroused state for sometime, thereby increasing its efficiency. So, the key is not to completely eliminate the stress but to ensure that it is brief. One should constantly practice means to reduce stress levels such as with practising yoga and meditation.
Effect of stress related memory loss
Chronic stress and subsequent memory loss not only affects the individual who is suffering, but it also impacts the life of immediate circle of relationships. For example, the person is unable to fulfill the roles of a father/mother or husband/wife. The person is irritable, which could further increase on forgetting important things. The person loses interest in sex and other pleasurable activities. This can lead to marital discord, sometimes resulting in divorce/separation. At work too, the person lags behind and is unable to complete tasks on time. Important assignments may be forgotten leading to serious problems for the organization. Affected persons may lose the job.
How can the immediate circle of people help the affected individual?
First of all, it is important to recognize that the person is suffering from stress and stress-related memory loss. Family and friends would be the first ones to notice any deviation from normal in the individual. If a person is found looking lost, or having a worried look all the time or taking longer time to complete simple tasks, one should suspect stress-related memory loss. It may be important to discuss the issue with close family members so that the reasons for stress can be identified. Common stressors include exams/studies, peer pressure, fear of getting reprimanded by the teacher/parents (in children) and interpersonal problems, job-related stress and marital discord (in adults). The affected person should be taken to a psychiatrist/neurologist for evaluation and proper diagnosis.
Differences between memory loss arising from shock and long-term mental trauma
Effects of acute stress or shock on memory differ from that of the long-term stressful events. Acute stress or shock is a sudden onset brief event and the physiological changes are not ongoing, whereas in long-term stress, the physiological changes persist for longer duration. Acute stress can have mixed effects on memory. Some studies report better memory after a brief stress. However, for this to happen, the context for stress and desired memory should be regarding the same topic. Shock also has a specific influence on memory. Most people are not able to recall the events that happened just prior to the shock; however, they are able to remember the place/details regarding the shock itself.
            Long-term stress has more negative influence on memory. Children who are victims of abuse or bullying have difficulty in learning and they perform poorly at school. This effect may persist in their adulthood too. People subjected to chronic stress also find it difficult to adapt to new situations.
Manifestations of stress-induced memory loss in children and adults
The pattern of stress-induced memory loss differs in children from that of adults. In infants and children, the brain is not fully developed and hence any effect of stress can have long-lasting effects. Studies have shown that children who experienced prolonged stress during infancy/early childhood developed memory loss and cognitive difficulties starting in middle age (similar to that occurring in very elderly). In adults, stress mainly affects new learning ability and working memory; however the long-term memory may remain relatively spared.
Is stress-induced memory loss temporary or permanent?
This depends on the type of stress and duration of stress. Typically, after a short-term stress, memory loss is mild and temporary and one can expect a complete improvement. However, after long-term stress, memory can be chronically impaired. This is because, prolonged presence of cortisol (as seen with prolonged stress) can cause severe damage to the hippocampus and prefrontal cortex, brain parts most essential for good memory functions.
Conclusions
Stress in addition to causing diseases like high BP, headaches, and increasing the risks of heart attack and brain stroke, has detrimental effects on memory too. The negative effects on memory of chronic stress are more severe that of acute stress. Memory loss is mediated by the effects of negative effects of prolonged cortisol exposure on hippocampus. Memory loss due to stress can occur at all ages, somewhat more severe in children. Therefore, every attempt should be made to reduce the stress, and prevent it from becoming chronic.

(Note: This article was first published in B Positive magazine, May 2012 issue)

DR SUDHIR KUMAR MD (Medicine), DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
Phone: 0091-40-23607777/60601066
Email: drsudhirkumar@yahoo.com