HEADACHES ASSOCIATED WITH PERSONAL PROTECTIVE EQUIPMENT (PPE)

HEADACHES ASSOCIATED WITH PERSONAL PROTECTIVE EQUIPMENT

Dr Sudhir Kumar MD DM

Consultant Neurologist, Apollo Hospitals, Hyderabad

drsudhirkumar@yahoo.com

Introduction

Coronavirus disease 2019 (COVID-19) caused by SARS-CoV2 is a global pandemic, which has already affected about 2.6 million people belonging to about 200 countries. Healthcare workers (HCW) working in high-risk areas (such as emergency room, isolation wards, ICU, etc) are mandated to wear personal protective equipment (PPE), including close-fitting N95 face mask and protective eyewear (mainly goggles) while attending to the patients.

Aims of the Study

A recent study was conducted at Singapore (Reference: Headache, 30 March, 2020) to study the effects of PPE in development of de novo (new onset) headaches as well as their impact on personal health and work performance. The impact of COVID 19 on pre-existing headache disorders was also investigated.

Participants in the Study

158 healthcare workers participated in the study. 78% of them were in 21-35 year age group. 70% were females. Majority were either nurses (65%) or doctors (32%). 29% had pre-existing headache disorders (19% had migraine and 10% had tension-type headache).

Main Findings of the Study

Out of 158 healthcare workers, 128 (81%) developed de novo PPE-associated headaches. Persons with pre-existing primary headaches were 4.2 times more likely to develop de novo PPE-associated headaches. People using PPE for more than 4 hours per day had a 3.9 fold higher risk of developing PPE-associated headaches.  HCW working in emergency department had a 2.4 times higher risk of developing PPE-associated headaches.

Clinical Characteristics of PPE-associated Headaches

Headaches were bilateral in location. The location of discomfort corresponded to the areas of contact from the face mask or goggles and their corresponding head straps. Discomfort was described as a sensation of pressure or heaviness of affected sites in 87% and throbbing or pulling pain in 12%.

The time interval between donning of face mask or protective eyewear and onset of headache was less than 60 minutes in most people. After removal of PPE, the headache resolved within 30 minutes.

Most people reported an attack frequency of 1-4 days in a 30-day period. The intensity of headache was mild in most. 23% reported accompanying symptoms of nausea, vomiting, phonophobia or photophobia.

Various types of Face mask and Protective eye gear

 Location of headache in association with N95 facemask and protective eyewear

About 70% did not take any painkillers. 30% took either paracetamol or NSAIDs.

83% opined that PPE-associated headaches resulted in a slight decrease in work performance.

Pathogenesis of de novo PPE-associated headaches

The proposed mechanisms care mechanical compression, hypoxemia, hypercarbia and stress.

What could mitigate the risks of PPE-associated headaches?

1.     Shorter duty shifts and resultant shorter duration PPE usage could be a better strategy, 2. Better cushioning of head straps to minimize mechanical compression over scalp, 3. Reducing stress levels among HCWs.

Key points

1.     New-onset headaches are common after using PPE (N95 mask and protective eye gears),

2.     Healthcare workers in ED and those using PPE for more than 4 hours daily have a higher chance of developing headaches.

3.     People with pre-existing headaches have a higher chance of getting headaches.

4.     Headaches begin within 60 minutes of donning PPE and subside within 30 minutes of removing PPE,

5.     Headaches affect both sides of head and are usually mild in nature,

6.     Headaches respond to paracetamol and NSAIDs,

7.     Headaches decrease the work performance,

8.     Shorter shift duration (resulting in shorter duration use of PPE) could be the way forward,

9.     Though the primary aim of PPE is to reduce the risk of virus spread and transmission, we also need to make them user friendly in future.

Dr Sudhir Kumar MD DM

COVID 19 RELATED ANXIETY DISORDER

Corona (Covid 19) Related Anxiety Disorder

Corona virus infection, better known as Covid 19 infection, which started in China about three months ago, has rapidly spread to about 150 countries. So far, about 1,50,000 people have been infected with Covid 19, out of whom about 5,500 people have died.

Various forms of media (including TV, newspaper) and social media (facebook, whatsapp, etc) are full of news and information about Covid 19 infection. Various government agencies too have started awareness campaigns about Covid 19 infections and methods to limit its spread. Countries across the world have initiated partial to total shutdown. WHO has declared Covid 19 infection as a pandemic.

A problem of this magnitude, affecting the entire world is rare and many people have not faced a similar situation in their lifetime. This has resulted in anxiety and fear of varying magnitude. Recently, pulmonologist Dr Chandrakant Tarke encountered two patients with extreme anxiety.

Both patients were women, aged 23 and 30 years respectively, from Hyderabad, India. They presented with mild cold and no other significant symptoms. They had no risk factors to develop Covid 19 infection (no history of travel to Covid 19 affected countries or exposure to a Covid 19 infected patient). They had extreme fear that they were suffering from corona virus infection. They had developed obsessive trait of washing their hands multiple times with sanitizers despite staying at home and no exposure to outside. Clinical examination was normal except for hyperventilation. The fear had started after the news about Covid 19 infection in India started flashing on Indian TV channels. The fear became extreme on listening to Covid 19 awareness caller tune initiated by Government of India (which started with coughing sounds, followed by steps to prevent Covid 19 spread).
A diagnosis of anxiety disorder induced by fear of having contracted Covid 19 infection was made. Women were counselled and referred to psychiatrist for further management.

With increase in the number of Covid 19 cases across the world and the disruption resulting due to it, we are likely to come across many more people suffering from Covid 19 related anxiety disorder. As a health care professional we need to be aware of it, promptly diagnose it (clinical diagnosis suffices) and advise appropriate treatment (counselling, referral to psychiatrist/psychologist).

Steps to prevent Covid 19 related anxiety

1 .Avoid seeking constant updates about Covid 19 from TV channels or social media (updating twice a day- morning and evening- should be sufficient),

2. Do not constantly discuss about Covid 19 with your family, friends and colleagues,

3. Focus on the positive aspects of Covid 19- more than 80% have mild infections and more than 90% survive this infection,

4. Take steps to prevent Covid 19 (as already outlined across various media platforms)

5. Go for walks, exercise and engage in leisure activities (music, gardening, etc)

6. Consult a healthcare professional if you develop anxiety or fear related to Covid 19

Dr Sudhir Kumar MD DM (Neurologist), Apollo Hospitals, Jubilee Hills, Hyderabad
Dr Chandrakant Tarke MD DM (Pulmonologist), Apollo Hospitals, Jubilee Hills, Hyderabad

IDIOPATHIC INTRACRANIAL HYPERTENSION

IDIOPATHIC INTRACRANIAL HYPERTENSION

What is Idiopathic intracranial hypertension (IIH)?

IIH is a condition characterized by raised intracranial pressure (ICP) of unknown etiology. It is also known as benign intracranial hypertension or pseudotumor cerebri.

What are the common symptoms of IIH?

The commonest symptom of IIH is headache. In some cases, visual blurring or double vision may occur.

What is the dreaded complication in patients with IIH?

If IIH is left untreated, there is a threat to vision. Partial or complete loss of vision may occur. In many of these cases, vision may not revert to normal even after treatment.

How is the diagnosis of IIH confirmed?

The diagnostic criteria for IIH, including those of the Dandy criteria as described by Dandy in 1937 and later modified, are as follows (source: Medscape)

·       There are symptoms and signs of increased intracranial pressure

·       There are no localizing neurologic signs (with the exception of a unilateral or bilateral sixth nerve paresis)

·       Cerebrospinal fluid (CSF) may show increased pressure, but there are no cytologic or chemical abnormalities

·       Neuroimaging reveals no structural cause or hydrocephalus

·       No other causes of increased intracranial pressure found through workup

Subsequent additions to these criteria include the following

·       The diagnostic lumbar puncture should be performed with the patient in the lateral decubitus position

·       Magnetic resonance venography should be included to rule out intracranial venous sinus thromboses

What are the common abnormalities of IIH on MRI/MR Venogram brain?

Brain MRI with gadolinium contrast venogram is the imaging modality of choice, as it can effectively rule out meningitis/meningeal infiltrates, hydrocephalus, mass lesions, cerebral venous sinus thrombosis, etc. In addition, there are certain abnormalities, which are typically seen in patients with IIH:

·      Partial empty sella

·      Flattening of posterior globe

·      Distension of perioptic subarachnoid space

·      Vertical tortuosity of orbital optic nerve

What is the role of lumbar puncture in the diagnosis of IIH?

Lumbar puncture should be done in left lateral decubitus. It confirms the elevated ICP, opening pressure >200 mm water. Lumbar puncture also helps in excluding meningitis.

What is the mainstay of treatment?

Medical treatment with diamox (acetazolamide) is the primary treatment to be started in patients with IIH. Starting dose should be 500-1000 mg per day and a maximum dose of 4 grams per day can be used. Common side effects include paresthesia and tingling.

Diamox to lower intracranial pressure is indicated when there is 

1) visual field loss on automated perimetry, 

2) transient visual obscurations, 

3) binocular diplopia, or 

4) pulsatile tinnitus.

Does weight loss help in patients with IIH?

Yes, a weight loss of 5-10% can lead to substantial reduction in reducing symptoms of IIH and papilledema.

Do patients with IIH need surgery?

There are a group of patients that need surgery. Patients with severe papilledema with impending threat to visual loss or those presenting with loss of vision require an early surgery. Another group of patients who may need surgery are those that continue to worsen despite being on adequate doses of acetazolamide.

What are the surgical options in IIH?

1.     Optic nerve sheath fenestration

2.     CSF diversion procedures such as theco-peritoneal or ventriculo-peritoneal shunt surgery.

Dr Sudhir Kumar MD DM

Consultant Neurologist

Apollo Hospitals, Hyderabad

drsudhirkumar@yahoo.com

MIGRAINE IN CHILDREN

MIGRAINE IN CHILDREN

What is migraine?

Migraine refers to a condition where the sufferer gets repeated headaches.

What are the other symptoms of migraine?

People may have nausea or vomiting associated with headaches. They also do not like noise or light during the headache episodes. Some children with migraine may not have headache and they may present with only repeated abdominal pain. 

Do children suffer from migraine?

Yes, children do suffer from migraine. 10-25% of children may suffer from migraines. Before puberty, migraine is more common in boys. After puberty, it becomes more common in girls.

What is the earliest age when migraine can affect children?

Migraine has been reported in children as early as 18 months old. About half of the children with migraine have their first attack before the age of 12 years.

What is the cause of migraine in children?

In most cases, there is a combination of genetic and environmental factors. Children with one parent with migraine has 50% chance of getting it, whereas children whose both parents have migraine have 75% chance of getting migraine. Most children with migraine have at least one close family member suffering from it.

How does migraine affect children’s quality of life?

Migraine in children can be as disabling as in adults. Children with migraine miss school twice as often as compared to those without migraine. They also suffer from anxiety, depression, and mood swings, and may not be able to focus in studies. They may also not enjoy sports and other recreational activities.

How is the diagnosis of migraine confirmed in children?

In most cases, the patient’s history and clinical examination are enough to make a diagnosis of migraine. However, in some cases, a brain scan may be needed to exclude other causes.

How is migraine treated in children?

Migraine can be effectively treated in children with medications.

For acute severe headaches, helpful medicines include paracetamol, ibuprofen and triptans (such as sumatriptan, zolmitriptan and rizatriptan).

To prevent headache episodes in future (migraine prophylaxis), propranolol, Flunarizine, topiramate or valproic acid may be used.

What measures can the children take to reduce the headache episodes?

1. Sleep adequately,

2. Eat food on time,

3. Avoid stress,

4. Certain triggers such as cakes, chocolates, Chinese food, too much TV/phone use, can be avoided/reduced. 

DR SUDHIR KUMAR MD DM

Senior Consultant Neurologist

Apollo Hospitals, Hyderabad

04023607777

drsudhirkumar@yahoo.com

https://www.facebook.com/bestneurologist

FREQUENTLY ASKED QUESTIONS ABOUT HEADACHE

FREQUENTLY ASKED QUESTIONS ABOUT HEADACHES

Headache is a common disorder. A large number of people suffer from headaches. Migraine and tension headaches are the commonest causes of headaches. They are not life-threatening, however, they cause significant disability, as pain impairs the quality of life. In some cases, headaches can be caused by serious causes, such as brain tumor, brain hemorrhage, brain fever, etc. 

The current interview focuses on the common causes of headache. How should we diagnose migraine? It can be diagnosed based on symptoms in most cases. When should one consult a doctor for headache? When should one do a brain scan? How do we treat headaches? To get answers to these and other questions, please watch this interview. The link of the youtube video with the interview is:

https://youtu.be/VgBvamY5kS0

Feel free to post your comments or ask any queries.


Dr Sudhir Kumar MD DM (Neurology)
Senior Consultant Neurologist,
Apollo Hospitals, Hyderabad
04023607777
drsudhirkumar@yahoo.com
https://www.facebook.com/bestneurologist/

FREQUENTLY ASKED QUESTIONS ABOUT EPILEPSY (HINDI)

FREQUENTLY ASKED QUESTIONS ABOUT EPILEPSY

Epilepsy is a common neurological illness. It can be easily diagnosed and treated. People suffering from epilepsy can lead normal lives after treatment. Despite this, there are lot of misconceptions about this disease. There is a social stigma attached to epilepsy and epileptic patients. 

In this interview (in Hindi language), I have discussed the symptoms, diagnostic techniques and treatment options for people suffering from epilepsy. The link to youtube video is given below:


https://youtu.be/BzAzkOxecJs


Please go through this video interview to learn more about epilepsy. Feel free to post your comments and queries.

Dr Sudhir Kumar MD DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad
04023607777
drsudhirkumar@yahoo.com
https://www.facebook.com/bestneurologist/

MYASTHENIA GRAVIS

MYASTHENIA GRAVIS

Introduction

Myasthenia gravis is an uncommon auto-immune disease, characterised by muscle weakness.

Common symptoms of Myasthenia Gravis

Myasthenia gravis presents with symptoms due to weakness of various muscles. 

Common presentations of this include:

1. Drooping of one or both eyelids (usually, there is a difference in the degree of eyelid drooping). Drooping of eyelid is also called as ptosis. 

2. Double vision, on looking up, down, left, right or sideways.

3. Slurring of speech or nasal twang in voice,

4. Difficulty in chewing food,

5. Difficulty in swallowing food, or nasal regurgitation of liquids, 

6. Weakness of arms or legs,

7. Breathing difficulty,

8. Difficulty in holding neck straight (tends to droop forwards)

Please note

The sensations are normal in the affected parts of body.

Urinary and bowel control is preserved. 

Please also note

1. Symptoms may vary at different times of day, most often they are worse in evenings,

2. There is fatiguability, symptoms get worse on repeating the same movements,

3. There may be periods (days to weeks) of remission, when all symptoms seem to disappear, only to return back later. 

The following factors may trigger or worsen exacerbations:

• Bright sunlight
• Surgery
• Immunization
• Emotional stress
• Menstruation
• Intercurrent illness (eg, viral infection)
• Medication (eg, aminoglycosides, ciprofloxacin, chloroquine, lithium, phenytoin, beta-blockers, statins)

How do we confirm the diagnosis of myasthenia gravis?

1. Clinical symptoms, as described above make us suspect a diagnosis of MG, 

2. Tensilon test- where tensilon (edrophonium) injection is given, after which there is temporary improvement of symptoms such as ptosis,

3. Repetitive nerve stimulation- This test in done in the electrophysiology laboratory, where the muscle fatigue is shown (by seeing reduced amplitude with repeated stimulation of muscles),

4. Anti-Acetylcholine receptor antibody levels are elevated in about 80% of people. These antibodies are supposed to be released from thymus gland (located behind the upper chest wall in the centre). These antibodies prevent the action of acetylcholine on the muscles, making them weak. 

5. CT scan of chest is done to look for enlargement or tumor in thymus gland. 

6. Other less common antibodies seen in some patients with MG are anti-straited muscle antibody, anti-MuSK antibody, and anti-striational antibody.

What is the medical management of Myasthenia Gravis?

The medical management is classified into two categories:

1. Symptomatic treatment- to improve the symptoms. Pyridostigmine is commonly used.

We usually start a dose of 60 mg two times daily, and the maximum dose can be unto 720 mg per day.

Common side effects include increased salivation, abdominal pain and cramps, diarrhoea, muscle twitchings, etc.

2. Definitive treatment- is used to suppress the antibodies.

Steroids are commonly used. 

Other agents used are azathioprine, mycophenolate, cyclosporine, methotrexate, and cyclophosphamide.

3. In patients with myasthenic crisis (severe disease requiring feeding tube due to swallowing problem), or requiring mechanical ventilation (due to respiratory distress), PLASMAPHERESIS (blood is purified, and antibodies are removed, something similar to dialysis) or IV IMMUNOGLOBULINS (injections are given by drip over five days) are required.

4. THYMECTOMY- the best and permanent treatment for MG is thymectomy operation. In this, the thymus gland located behind the sternum bone (chest wall) is removed by operation. This removes the source of antibodies and the disease gets cured in most people.

What is the outcome of myasthenia gravis after treatment?

Earlier, the disease had a high morbidity and mortality, as treatments were not available. However, now, with good treatments available, more than 95% people do well and are fully cured.

I hope this articles helps people with myasthenia gravis as well as their caregivers. I would be pleased to answer any further queries. 

Please send email at drsudhirkumar@yahoo.com 

If anyone prefers ONLINE CONSULTATION, please visit http://bit.ly/Dr-Sudhir-kumar

DR SUDHIR KUMAR MD (INTERNAL MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HEALTH CITY

Phone (for appointment): 0091-40-23607777 (extension 6634/3011)

Email: drsudhirkumar@yahoo.com 

Online consultation: http://members.tripod.com/sudhirkumar_5/neurologist/id6.html

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.

2. 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.

4. 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.

5. 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.

6. 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.

7. 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

drsudhirkumar@yahoo.com