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Background: Post-herpetic neuralgia is difficult to treat. Divalproex sodium (valproic acid and sodium valproate in molar ratio 1:1) has been used successfully in the management of various painful neuropathies., Aim: To study the effectiveness and safety of divalproex sodium in the management of post-herpetic neuralgia., Design: Randomized double-blind placebo-controlled trial., Methods: We enrolled 48 consecutively attending out-patients with post-herpetic neuralgia, out of whom three were excluded (two had insufficient pain, one withdrew consent). Quantification of pain was by Short Form-McGill pain questionnaire (SF-MPQ), visual analogue scale (VAS), present pain intensity score (PPI) and 11 point Likert scale (11 PLS) at the beginning of the study, after 2 weeks, 4 weeks and at the end of the study (8 weeks). We also assessed patients' global impression of change by questionnaire at the end of the study., Results: After 8 weeks treatment with 1000 mg/day divalproex sodium, there was significant reduction in pain: SF-MPQ, 20.47 +/- 2.29 to 11.90 +/- 6.52 (p < 0.0001); PPI 4.0 +/- 0.52 to 1.95 +/- 1.29 (p < 0.0001); VAS 70.17 +/- 9.21 to 31.27 +/- 29.74 (p < 0.0001) and 11 PLS 6.97 +/- 0.73 to 3.63 +/- 2.34 (p < 0.0001) in comparison to placebo (means +/- SEM). The 'global impression of change' questionnaire showed much or moderate improvement in pain in 58.2% of patients receiving divalproex vs. 14.8% of those receiving placebo. The drug was well tolerated by all patients, except one who developed severe vertigo after 10 days of treatment., Discussion: Divalproex sodium provides significant pain relief in patients of post-herpetic neuralgia, with very little incidence of adverse reactions. These data provide a basis for longer trials in a larger group of patients.

Background: Various drugs are effective in the management of painful diabetic neuropathy, but none is completely satisfactory. We previously found sodium valproate to be effective and safe in a short-term study., Aim: To test the effectiveness and safety of sodium valproate in the management of painful diabetic neuropathy over 3 months., Design: Randomized double-blind placebo-controlled study., Methods: Consecutive attending patients with type 2 diabetes mellitus with painful neuropathy were asked to participate in the trial: 48 agreed. Five were excluded: three with HbA(1c) > 11, one with too low a pain level and one who withdrew consent. The remaining 43 were given either drug (group A) or placebo (group B). Each patient was assessed clinically. Quantitative assessment of pain was done by McGill Pain Questionnaire, Visual Analogue Score and Present Pain Intensity, at the beginning of the study, after 1 month and after 3 months. Motor and sensory nerve conduction velocities were measured initially and after 3 months. Liver function tests and other adverse drug-related effects were assessed periodically., Results: Of the 43 patients, four dropped out: one in group A and three in group B. There was significant improvement in pain score in group A, compared to group B, at 3 months (p < 0.001). Changes in electrophysiological data were not significant. The drug was well-tolerated by all patients, except one, who had raised serum AST and ALT levels after 1 month of treatment, and whose treatment was discontinued., Discussion: Sodium valproate is well-tolerated, and provides significant subjective improvement in painful diabetic neuropathy.

Background: According to the WHO, signs of hepatic dysfunction are unusual, and hepatic encephalopathy is never seen in malaria. However, in recent years, isolated cases have been reported from different parts of world., Aim: To identify the evidence for hepatocyte dysfunction and/or encephalopathy in jaundiced patients with falciparum malaria., Design: Prospective observational study., Methods: We studied 86 adult patients of both sexes who had malaria with jaundice (serum bilirubin > 3 mg%). The main outcome measures were: flapping tremor, deranged psychometric test, level of consciousness, serum bilirubin level, serum aspartate transaminase (AST) and alanine transaminase (ALT) levels, blood ammonia level, viral markers for hepatitis, ultrasonography of liver and gall bladder and electroencephalography (EEG)., Results: The range of serum bilirubin was 3-48.2 mg% (mean +/- SD 10.44 +/- 8.71 mg%). The ranges of AST and ALT levels were 40-1120 IU/l (294.47 +/- 250.67 IU/l) and 40-1245 IU/l (371.12 +/- 296.76 IU/l), respectively. Evidence of hepatic encephalopathy was seen in 15 patients. Asterexis was observed in 9 patients, impaired psychometric tests in 12 and altered mental state in 13. Arterial blood ammonia level was 120-427 meq/l (310 +/- 98.39 meq/l). EEG findings included presence of large bilateral synchronous slow waves, pseudo burst suppression and triphasic waves. Four patients died due to multiple organ dysfunction; the others made rapid recoveries., Discussion: There is strong evidence of hepatocyte dysfunction and hepatic encephalopathy in some of these patients, with no obvious non-malarial explanation. Current guidelines may need to be revised.

We assessed the efficacy of rifampicin in the treatment of cutaneous leishmaniasis (oriental sore) using a double-blind placebo-controlled study. We studied 46 patients with cutaneous leishmaniasis, of whom 23 received rifampicin (group A) and another 23 received placebo (group B) for a period of 4 weeks. Each patient was assessed clinically for size of lesion, type of lesion, duration of lesion, number of lesions, and distribution of lesions, initially, and at the end of 1 week, 2 weeks and 4 weeks. Biochemical tests including enzyme studies were done to detect any toxic effects of the drug. Group A patients received rifampicin 1200 mg/day in two divided doses and group B patients received two doses of an identical placebo capsule. Seventeen (73.9%) of the 23 patients receiving rifampicin had complete healing. Two (8.6%) had partial healing and four (17.3%) showed no response, whereas out of 23 patients receiving placebo one patient (4.3%) showed complete healing, eight (34.7%) patients showed partial healing and 14 (60. 98%) patients showed no healing or exacerbation of lesion. The difference was statistically significant in favour of response to rifampicin. This dose of rifampicin was well-tolerated and no side-effects were seen in any patient. In cases of cutaneous leishmaniasis where injectable treatment is not feasible or not acceptable, as in cases of multiple lesions, rifampicin is a better alternative oral treatment. It is simple to administer, cheap, more effective and less toxic than other available oral drugs, and well-tolerated by patients.

We studied 424 adults with falciparum malaria admitted over 28 months. They were divided into three groups: cerebral malaria (n = 214); severe non-cerebral malaria (n = 58); and uncomplicated malaria (n = 152). Fundus examination was done daily from admission to discharge, and weekly thereafter in those with persistent changes. All patients were treated by a protocol based on WHO guidelines. Ophthalmoscopic abnormalities were: retinal haemorrhages, 40 (9.43%) (25 cerebral malaria, 10 severe non-cerebral and five uncomplicated malaria); papilloedema, 17 (7.94%) cerebral malaria and two uncomplicated malaria; blurring of disc margins, 25 (11.68%) cerebral and seven non-cerebral; retinal oedema, six (2.80%) cerebral and five non-cerebral malaria; disc pallor, five patients all with cerebral malaria; vitreous haemorrhage and hard exudate in one patient each, both cerebral malaria. Retinal haemorrhage was associated with cerebral malaria and severe non-cerebral malaria, especially with severe anaemia (p < 0.001), as compared to uncomplicated malaria (p < 0.01). The association of papilloedema and cerebral malaria was highly significant compared to severe non-cerebral malaria (p < 0.001). None of these findings was associated with statistically significant mortality, except disc pallor in cerebral malaria (p < 0.05).