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Background: Presence of neck nodes in cases of head neck squamous cell cancers is an adverse prognostic factor. Elective neck dissection is traditionally recommended along with primary disease resection. Sentinel lymph node (SLN) is the first draining node. Sentinel lymph node biopsy (SNB) is a minimally invasive technique to identify occult nodal metastasis in early HNSCC., Methods: The objective of this study is to determine the identification rate of SNB using methylene blue dye (MBD) in N0 neck of Oral Squamous cell carcinoma (OSCC) and estimating specificity, sensitivity, negative predictive value and positive predictive value of SNB with frozen section (FS) analysis and in comparison to post-operative histopathological examination (HPE). It is a cross-sectional study conducted at a tertiary care centre, Lucknow, India. 21 patients of N0 OSCC from January 2019 to May 2020, were included. All patients underwent peritumoral injection with MBD. Sentinel nodes were harvested and sent for FS. Depending on FS findings, appropriate neck dissection was performed., Results: SLN was identified at level Ib and II in 19 patients (90.47%). The sensitivity, specificity, PPV and NPV in identifying SLN using MBD versus FS were 100.00%, 11.11%, 15.79% and 100.00% respectively. Whereas, SLN using MBD versus HPE specimens were 100.00%, 10.52%, 10.52% and 100.00% respectively., Conclusion: Despite having 100% sensitivity, MBD alone has poor specificity. With this poor discriminatory power, it is unlikely to be employed as a diagnostic test alone. It is recommended to rely on per-operative FS for taking decision as far as extent of neck dissection in N0 neck is concerned., (Copyright © 2023 Copyright: © 2023 Indian Journal of Cancer.)

Background: In the fight against the pandemic, personal protective equipment (PPE) has played a vital role. However, working with PPE has its own difficulties and problems. The aim of this study was to find out the reasons of early doffing, that is, in doffing in emergency situations before the shift among healthcare workers (HCWs) working in PPE in the COVID areas in resource-limited settings., Methods: This cross-sectional, survey-based study was carried out on healthcare workers involved in direct care of patients with COVID-19 in tertiary care COVID center, India. The questionnaire was sent as a Google form through email and social media platforms like WhatsApp and Facebook. The data was reported as the mean ± SD for continuous variables and as the percentage for categorical variables., Findings: Among 252 healthcare workers who participated in the survey, 145 (57.5%) participants doffed early on 300 occasions. Out of these 145, 50% doffed early only once and rest doffed early multiple times. The most common reason of early doffing was found to be breach in PPE (15.33%) followed by fogging (14%) and headache (12%), and most commonly, breach was in mask or coverall/gown (32.6% each)., Conclusion: Although PPE decreases the risk of infection, it is challenging for HCWs to work in PPE leading to instances of early doffing. The most common reason for early doffing in our study was the breach in PPE and the most common component of breach was found to be mask and coverall/gown. Therefore, we suggest that the proper sizes of the PPE should be made available and proper training in donning should be imparted to HCWs working in PPE., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Occupational and Environmental Medicine.)

Background and Objective: Nearly 40-65% patients with MS develop cognitive impairment during the disease. There is no treatment clearly effective in improving the cognitive deficits. To evaluate the efficacy and safety of Rivastigmine in cognitively impaired MS patients., Materials and Methods: This was a parallel group randomized open label study with blinded end-point assessment. The patient allocation to treatment and control arm was done by telephonic contact with an independent statistician who used a computer to generate a random sequence of allocation using permuted block randomization (varying block size of 4 and 6) in 1:1 ratio. The outcome assessor was blinded to this allocation. A total of 60 patients were in included in the study (30 in each arm). Primary outcome was improvement in memory functions (using logical memory subset of Wechsler Memory Scale III, India) assessed after 12 weeks. Secondary outcomes included fatigue, depression, and safety., Results: In modified intention to treat analysis (N = 22), treatment arm showed statistically significant improvement in memory function with mean difference of 7.56 [95% CI (0.67,14.46), p 0.032] as compared to control arm. There was no statistically significant difference in outcomes such as fatigue and depression. Vomiting was the most common side effect. No major adverse events were observed in either group., Conclusion: Rivastigmine is safe and effective in improving memory functions in cognitively impaired MS patients. However, our study has a small sample size and tested only a single domain. Larger studies with a validated single comprehensive neuropsychological test are needed., Competing Interests: None

In India, children do not get diagnosed with tuberculosis (TB) for reasons such as lack of screening modality at the health-care settings, inadequate sputum sample, and low detection rate. This study aims to assess various modalities for diagnosis of pediatric TB and their cost-effectiveness. Cost-effectiveness was found for various diagnostic modalities for TB diagnosis in children of India below 15 years of age. TrueNat MTB was the intervention being compared to GeneXpert MTB and sputum microscopy. Evidence pertinent to effectiveness and cost per test, and health benefits in terms of disability adjusted life years were researched and documented. Modeling a cohort of children through a decision tree and assimilating costs and disability-adjusted life years (DALYs) at each step gave results in the form of cost-effectiveness. Interventions were compared by calculating the cost-effectiveness ratio. The results revealed that TrueNat is more cost effective (Rs. 9450/DALY averted) compared to GeneXpert MTB/RIF (Rs. 9750/DALY averted). The incremental cost effectiveness ratio of TrueNat with respect to GeneXpert was found to be Rs. 5925 per DALY averted. Diagnosis through TrueNat point of care (POC) will avert 962 more DALYs compared to GeneXpert. As is evident from the results, TrueNat does alleviate disability caused by TB in children as more DALYs are averted. At an additional cost of Rs. 5925 to avert one DALY, which is below the gross domestic product (GDP) per capita for India (for 2021, it was $2277), TrueNat can have significant health benefits., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Community Medicine.)

Background: Solitary cysticercus granuloma (SCG) appearing as a single ring-enhancing lesion (SREL) is the most frequently encountered imaging finding in patients of neurocysticercosis (NCC) in India and during follow-up, most of SCGs resolve with or without calcifications. Recurrent SCG have been rarely reported., Objectives: The aim of our study is to report the incidence of recurrent SCG in a cohort of patients with SCG and postulate the hypothesis., Materials and Methods: This retrospective study included 278 patients with SCG meeting the criteria of NCC. Their medical records and imaging studies were analyzed., Results: Out of 278 patients, 119 patients with SCG meeting the criteria of NCC with follow-up imaging were included. 15 (12.61%) had recurrent NCC and 104 (87.4%) patients did not have any recurrence during a median follow-up of 14.23 months (range; 0.24 - 113.3) and 25.26 months (range; 3.09- 98.11) respectively. Out of 15 recurrent NCC cases, ten patients had documented imaging resolution or partial regression of previous lesion followed by occurrence of new SCG in the same location, three patients had change in morphology of lesion from solitary discrete REL to solitary conglomerate REL secondary to development of new cysticercus granuloma adjacent to old lesion patients had recurrent lesions adjacent to previous lesion and two patients had new SCG in different locations following regression of old SCGs., Conclusion: Recurrent SCGs are not uncommon in NCC and recurrence is more likely to occur at the site of initial infection and therefore may be mistaken for persistent infection or other granulomatous lesions., Competing Interests: None

Background and Purpose: Although imaging is the mainstay to differentiate ischemic stroke (IS) from intracerebral hemorrhage (ICH), these facilities are not available everywhere. The present study observed if any blood biomarker(s) could potentially help differentiate between ischemic stroke and intracerebral hemorrhage., Methods: 250 patients with acute stroke within 24 hours of onset (187 IS and 63 patients with ICH) were recruited in the present study. The blood samples were collected closest to the hospital presentation time, but within 24 hours of stroke onset. Blood was analyzed for five biomarkers [S100, glial fibrillary acidic protein (GFAP), N-methyl-D-aspartate receptor subunit antibody (NR2), interleukin 6 (IL6) and brain natriuretic peptide (BNP)] to assess discriminatory ability of each biomarker to differentiate ICH and IS., Results: S100 levels were statistically higher among patients with ICH compared with IS (8 pg/ml versus 4.2 pg/ml respectively, P = 0.003) and IL6 was higher in patients with IS compared with ICH (12.9 pg/ml vs 8.76 pg/ml, P = 0.02). The discriminatory ability to differentiate ICH from IS was better using a combination of the above two biomarkers. The overall discriminatory ability of all biomarkers were low (Area under curve for S100 65%; GFAP 56%; NR2 53%; IL6 59% and BNP 49.8%). Although the positive predictive value of each biomarker was low, the negative predictive value was higher for all biomarkers to diagnose ICH., Conclusions: S100 and IL6 are potential biomarkers for further study and validation. Newer biomarkers with higher discriminatory ability are required in the future for diagnostic use., Competing Interests: None

Background: The need to study prognosis after incidence of acute ischemic stroke (AIS) has fueled researchers to identify predictors apart from neurological, functional, or disability measures. The purpose of this study was to test and validate a newly developed clinico-biomarker assessment module in AIS and also to investigate the role of serum vascular endothelial growth factor (VEGF) after AIS., Materials and Methods: A randomized controlled study with sample size of 250 patients suffering from AIS within 2 weeks of the index event were conducted and followed up for a period of three months. Age, gender, stroke subtype, previous stroke history, dysarthria, stroke localization, wakeup strokes, and Glasgow Coma Scale (GCS) were dichotomized as present or absent using the National Institute of Health Stroke Scale (NIHSS) which consists of four subcategories. The additional serum VEGF was scored between 1 and 4 (0-200 = 1, 200-300 = 2, 300-400 = 3, and 400-500 = 4). All these were summed under a clinical biomarker (CB) module with highest score of 30., Results: The mean VEGF in 125 patients was 378.4 + 98.9 pg/ml, indicating a moderately high increase with a score of 3 on CB module. Multiple regression analysis revealed that the CB model was fit to predict prognosis and severity [R 2 = 0.86, F (23.4, 6);P = 0.001], with NIHSS subscore, prestroke status, and VEGF being very strong predictors. When only the clinical module was tested on all 250 patients, it was found that the NIHSS subscore, time to stroke onset and prestroke functional status were the most common [R 2 = 0.79; F (45,9);P = 0.005]., Conclusion: This study demonstrates that VEGF is highly upregulated in AIS with severe disability as compared to healthy controls. This biomarker is a strong predictor of severity and functionality when combined with clinical variables three months post the ishemic event., Competing Interests: None

Background: Acute ischemic stroke therapy is time sensitive, and optimum treatment is missed due to pre-hospital and/or in-hospital delay., Materials and Methods: A prospective observational (before and after) study was conducted for 1 year.The study period was defined as phase-I or pre-education phase, phase-II or immediate post-education phase, and phase-III or delayed post-education phase, with each phase lasting for 4months. All consecutive stroke patients presenting within 12 hours of stroke onset were enrolled. Baseline and outcome data including acute stroke care quality matrices and functional outcomes were collected., Results: A total of 264 patients were enrolled. All acute stroke care quality matrices improved significantly (P ≤ 0.01) with a median door to imaging time (DTI) of 114, 35, and 47 minutes in the three phases consecutively. In phase-II, proportions of patients imaged within 25 minutes of arrival increased by 35%. Mean door to needle (DTN) time were 142 ± 49.7,63.7 ± 25.1, and 83.9 ± 38.1 minutes in the three consecutive phases. Patients with DTN < 60 minutes of arrival increased by 63%. Modified Rankin score (mRS) at 3 months improved significantly in all ischemic stroke patients (P = 0.04) and patients with mRS of 0-2 increased by 22%., Conclusions: Stroke education to emergency department (ED) staff is an effective method to improve acute stroke care., Competing Interests: None

Background and Objectives: The objective of the present study was to evaluate the skin-epidural space distance as assessed by ultrasonography and conventional loss of resistance (LOR) technique and to find the correlation of epidural depth with body mass index (BMI)., Methods: Ninety-eight patients of either sex, American Society of Anesthesiology I/II, BMI <30 kg/m 2 requiring lumbar epidural for surgery were enrolled. The epidural space was assessed with a curvilinear ultrasound (US) probe, 2-5 MHz, in the transverse plane at L3-L4 intervertebral space. Thereafter, the epidural depth from skin was assessed with conventional LOR method while performing the epidural. The needle depth (ND) was measured using a sterile linear scale, and any change in the needle direction or intervertebral space was noted., Results: The patients were demographically similar. Depth of epidural space measured by US depth (UD) was 3.96 ± 0.44 cm (range 3.18-5.44 cm) and by ND was 4.04 ± 0.52 cm (range 2.7-5.7 cm). The Pearson's correlation coefficient (r) between UD and ND was 0.935 (95% confidence interval: 0.72-0.92, r 2 = 0.874, P < 0.001), and Bland-Altman analysis revealed the 95% limits of agreement -0.494-0.652 cm., Conclusion: The present study demonstrates a good correlation between UD and ND and shows that the preprocedural US scan in transverse plane provides accurate needle entry site with a high success rate in single attempt for lumbar epidurals in patients with a BMI <30 kg/m 2 ., Competing Interests: There are no conflicts of interest.

Background and Aims: The aim of the study was to evaluate the effectiveness of epidural volume extension (EVE) technique in terms of sensory and motor block characteristics along with hemodynamic parameters as a part of combined spinal-epidural anesthesia (CSEA)., Materials and Methods: A total of 60 patients undergoing hip surgeries were assigned to one of the two groups containing 30 patients each. Group I (the CSE-EVE group) patients were anesthetized using CSE with EVE and Group II (the CSE group) patients were anesthetized using CSE without EVE, using the same technique and low dose of intrathecal hyperbaric bupivacaine. Sensory block characteristics were recorded using pinprick method, whereas motor blockade was assessed by modified Bromage scale., Results: There was a statistically significant difference between the two groups regarding the level of maximum sensory block ( P < 0.001), as Group I showed sensory block level extending to up to T4, whereas in Group II, it was limited to below T6. Time required for maximum sensory blockade was faster in Group I, ranging from 7 to 12 min (mean ± standard deviation [SD]: 9.83 ± 1.72), whereas in Group II, it ranged from 9 to 15 min (mean ± SD: 12.33 ± 1.83; P < 0.001). Two-segment regression was faster in Group II, ranging from 50 to 70 min (mean ± SD: 60.0 ± 6.30), whereas in Group I, it ranged from 80 to 105 min (mean ± SD: 89.67 ± 8.19; P < 0.001). The time required to reach the maximum motor block was faster in Group I, ranging from 2 to 4 min (mean ± SD: 2.67 ± 0.84), whereas in Group II, the time ranged from 2 to 6 min (mean ± SD: 3.50 ± 1.31; P < 0.001)., Conclusion: CSEA with EVE is associated with early onset of sensory and motor blockade, high level of sensory block, and longer time of two-segment regression while maintaining hemodynamic stability due to decreased dose of intrathecal local anesthetic., Competing Interests: There are no conflicts of interest.

Purpose: To study the retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) changes on optical coherence tomography in early multiple sclerosis (MS) patients., Methods: A prospective cohort study was conducted at a tertiary care center. Patients of early MS (expanded disability status scale <3) with or without optic neuritis (ON) and idiopathic ON were included. Twenty age-matched individuals were taken as controls. Changes in RNFL and GCL thickness were evaluated along with the correlation with visual function parameters such as visual acuity, contrast sensitivity, and visual evoked response at first visit and again at six months., Results: Forty-four patients of MS with or without ON (24 and 20 patients respectively), 29 patients with idiopathic ON, and 20 healthy controls constituted the cohorts. Mean LogMAR best-corrected visual acuity was found to be significantly reduced in all groups except fellow eyes (FE) of ON group. Mean values of average RNFL thickness and values in superior, temporal, and inferior quadrant were significantly reduced. Similarly, overall mean values of average GCL-inner plexiform layer (IPL) thickness and values in superior, superonasal, superotemporal, inferonasal, and inferotemporal quadrant were significantly reduced in all groups except FE of ON group (P < 0.05). All the visual parameters significantly correlated with GCL + IPL thickness., Conclusion: GCL + IPL thickness is a more sensitive clinical structural marker than RNFL in early MS with/without ON and ON patients and correlates with all the visual parameters better than RNFL thickness.

Osteomyelitis of mandible, if it affects the neonate presents as a diagnostic and therapeutic challenge to the clinician. Symptoms and signs are often non-specific, and the consequences of a missed diagnosis could lead to long-lasting functional limitations. A rare case of a 52 days old infant with osteomyelitis of the mandible following natal tooth extraction is presented in this report. The diagnosis, pathogenesis and management have been explained. The accompanying review briefly summarizes the main clinical, pathophysiological and radiological aspects of the condition and gives an update on the treatment., Competing Interests: There are no conflicts of interest

Background: In-hospital care of stroke patients can reduce the risk of death and disability. There is an emerging evidence for the routine use of care pathways (CPs) for acute stroke management. Our aim was to develop evidence-based CPs and test the hypothesis that acute stroke management by CPs is superior to that provided by conventional care., Materials and Methods: An acute stroke CP was designed in accordance with the recent American Stroke Association (ASA)/American Heart Association (AHA) stroke guidelines and the Indian Academy of Neurology (IAN) stroke management guidelines in India. A total of 162 acute stroke patients, who were managed within 72 hours of onset of their symptoms, were enrolled prospectively in two groups-the stroke care pathway (CP) arm (n = 77) and the conventional care (CC) arm (n = 85). The incidence of aspiration pneumonia, complications during the hospital stay, and death or dependency at discharge and at 90 days were among the main outcomes of our study., Results: The CP arm had a lower incidence of aspiration pneumonia (AP) in comparison with the CC arm (6.5% vs. 15.3%, risk ratio [RR] = 0.42, 95% confidence interval [CI] = 0.16-1.14, P = 0.062). The CP group had a decreased risk of requirement of mechanical ventilation (7.8% vs. 17.6%, odds ratio [OR] = 0.39, 95% CI = 0.14-1.07, P = 0.05). Barthel and modified Rankin Scale scores were similar in both the groups, but death at 90 days was significantly lesser in the CP arm (7.8% vs. 20%, P = 0.022). This benefit was most prominent in the Glasgow Coma Scale (GCS) subgroup scoring 9-15 (RR = 0.16, 95% CI = 0.03-0.71). There were no significant differences in the other outcome measures., Conclusion: Stroke CPs reduce the incidence of aspiration pneumonia, the need for mechanical ventilation, and the risk of death, when assessed at a follow-up of 90 days.

Context: Surgery for the rheumatoid cervical spine has been shown to stabilize the unstable spine; arrest/improve the progression of neurological deficit, help neck pain, and possibly decelerate the degenerative disease process. Operative intervention for the rheumatoid spine has significantly changed over the last 30 years., Aims: The purpose of this study was to review all cases of cervical rheumatoid spine requiring surgical intervention in a single unit over the last 30 years., Materials and Methods: A prospectively-maintained spine database was retrospectively searched for all cases of rheumatoid spine, leading to a review of indications, imaging, Ranawat and Myelopathy Disability Index measures, surgical morbidity, and survival curve analysis., Results: A total of 224 cases were identified between 1981 and 2011. Dividing the data into three time-epochs, there has been a significant increase in the ratio of segment-saving Goel-Harms C1-C2: Occipitocervical fixation (OCF) surgery and survival has increased between 1981 and 2011 from 30% to 51%. Patients undergoing C1-C2 fixation were comparatively less myelopathic and in a better Ranawat class preoperatively, but postoperative outcome measures were well-preserved with favorable mortality rates over mean 39.6 months of follow-up. However, 11% of cases required OCF at mean 28 months post-C1-C2 fixation, largely due to instrumentation failure (80%)., Conclusion: We present the largest series of surgically managed rheumatoid spines, revealing comparative data on OCF and C1-C2 fixation. Although survival has improved over the last 30 years, there have been changes in medical, surgical and perioperative management over that period of time too confounding the interpretation; however, the analysis presented suggests that rheumatoid patients presenting early in the disease process may benefit from C1 to C2 fixation, albeit with a proportion requiring OCF at a later time.

Background: Malignant middle cerebral artery (MCA) infarction is associated with high mortality and morbidity. Decompressive hemicraniectomy (DH) reduces mortality significantly but evidence for long-term functional benefit is sparse and contradictory., Materials and Methods: A total of 60 patients with malignant MCA infarction were prospectively enrolled. 36 (60%) patients underwent DH and 24 (40%) patients received best medical therapy alone. Both groups were followed-up for 1 year for improvement in disability and aphasia using modified Rankin score (mRS) and Western Aphasia Battery respectively. Good outcome was defined as mRS ≤ 3. Secondary analysis using mRS ≤ 4 was also performed., Results: An absolute risk reduction of 45% was observed in mortality at 1 year; 38% (14/36) in the surgical group died versus 83% (20/24) in the medical group. Good outcome at 1 year was achieved in 20% (7/35) patients in the surgical group compared with none in the medical group (P = 0.025). Repeated measures regression suggested increased proportion of patients improving over time (discharge, 3, 6 and 12 months). Surgery reduced the odds of moderate to severe disability (mRS ≥ 4) by 93.5% (odds ratio: 0.064, 95% confidence interval: 0.01-0.045, P = 0.006)., Conclusions: DH in malignant MCA infarction not only reduces mortality but also increases chances of a better functional outcome. The benefit of surgery in motor and aphasia recovery is progressive and sustained until 1 year.

Background: Intracerebral hemorrhage (ICH) is associated with high mortality and morbidity. Various clinical and imaging predictors of mortality have been observed in previous studies., Aims: To study factors associated with in-hospital mortality in patients with ICH and observe the disability status of patients [assessed by modified Rankin scale (mRS)] at the time of discharge., Design: Prospective observational study., Materials and Methods: All consecutive patients with acute hypertensive ICH admitted during the study period were enrolled. Data recorded included: Demographics, clinical, biochemical and cranial computed tomography (CT) findings. Primary outcome was defined as either death or survival within the hospital. mRS was used to assess outcome at discharge., Results: Of the total 214 patients with ICH (193 supratentorial and 21 infratentorial), 70 (32.7%) patients died during the hospital stay. On bivariate analysis, low Glasgow Coma Scale (GCS) score, ventilatory assistance, higher hematoma volume, midline shift, hydrocephalus and intraventricular hematoma (IVH) were associated with mortality. ICH grading scale (ICH-GS) and ICH scores were higher in patients who died (P < 0.0001). Ninety-five (44.6%) patients underwent a neurosurgical intervention; 66 (45.8%) patients among the survivors compared with 29 (41.4%) among those who died (P = 0.54, Odds Ratio (OR) 0.83, 95% Confidence Interval (CI) 0.46-1.48). Independent predictors of mortality included a higher baseline hematoma volume ( P = 0.04 OR 1.01, 95% CI 1.00-1.02), lower GCS ( P = 0.01 OR 2.57, 95%CI 1.25-5.29), intraventricular extension of hematoma ( P = 0.007 OR 2.66, 95% CI 1.26-5.56) and ventilatory requirement (P < 0.0001 OR 8.34, 95%CI 2.75-25.38). Among survivors (n = 144), most were disabled [mRS 0-3, 7 (4.8%) and mRS 4-5, 137 (95.13%)] at discharge., Conclusions: Low GCS, higher baseline ICH volume, presence of IVH and need for ventilatory assistance are independent predictors of mortality. Most of the patients at discharge were disabled. Surgery did not improve mortality or outcome.

Objectives: To determine an association between socioeconomic status and in-hospital outcome in Indian patients with stroke., Materials and Methods: Retrospective hospital-based cohort study. The hospital stroke register was used for this study. The independent variables were demographic job status, education, cardiovascular risk factors, comorbidities and the score on the Glasgow Coma Scale (GCS). The outcome variables were mortality and Barthel's index (BI) score at discharge., Results: Data of 599 consecutive patients comprising 370 men (54.3%) and 229 women (33.6%) was available for analysis. Their mean age was 55.63±15.36 years. Age, diagnosis (ischemic or hemorrhagic), midline shift, smoking and GCS were significantly associated with mortality and BI score (P<0.05). There was a statistically significant association between employment status and BI at discharge (P=0.03) in univariate analysis. In multivariate analysis, joblessness was associated with lower BI at discharge (P=0.02) after adjustment for GCS motor score and stroke subtype., Conclusion: Our study shows that in patients with stroke, lower employment status is associated with poor outcome at discharge from the hospital. The association is independent of other prognostic factors.

Background: Recovery in stroke is mediated by neural plasticity. Neuro-restorative therapies improve recovery after stroke by promoting repair and function. Mirror neuron system (MNS) has been studied widely in humans in stroke and phantom sensations., Materials and Methods: Study subjects included 20 patients with chronic stroke and 10 healthy controls. Patients had clinical disease-severity scores, functional magnetic resonance imaging (fMRI) and diffuse tensor imaging (DTI) at baseline, 8 and at 24 weeks. Block design with alternate baseline and activation cycles was used with a total of 90 whole brain echo planar imaging (EPI) measurements (timed repetition (TR) = 4520 ms, timed echo (TE) = 44 ms, slices = 31, slice thickness = 4 mm, EPI factor 127, matrix = 128 × 128, FOV = 230 mm). Whole brain T1-weighted images were acquired using 3D sequence (MPRage) with 120 contiguous slices of 1.0 mm thickness. The mirror therapy was aimed via laptop system integrated with web camera, mirroring the movement of the unaffected hand. This therapy was administered for 5 days in a week for 60-90 min for 8 weeks., Results: All the patients showed statistical significant improvement in Fugl Meyer and modified Barthel Index (P < 0.05) whereas the change in Medical Research Council (MRC) power grade was not significant post-therapy (8 weeks). There was an increase in the laterality index (LI) of ipsilesional BA 4 and BA 6 at 8 weeks exhibiting recruitment and focusing principles of neural plasticity., Conclusions: Mirror therapy simulated the "action-observation" hypothesis exhibiting recovery in patients with chronic stroke. Therapy induced cortical reorganization was also observed from our study.

Background: Patients with Guillain-Barré syndrome (GBS) require assisted ventilation frequently. However, no single factor can predict ventilator requirement., Aims: To identify clinical variables which could predict the need for mechanical ventilation in GBS., Settings and Design: Tertiary hospital-based retrospective and prospective study., Materials and Methods: One hundred and thirty-eight GBS patients studied were divided into two groups ventilated (Group 1) and non-ventilated (Group 2). Parameters assessed included age, gender, associated illness(es), antecedent events, first symptom at onset, time from onset to bulbar involvement, confinement to bed and peak disability, upper limb power and reflexes at nadir, presence of facial weakness, neck muscle weakness and autonomic dysfunction., Statistical Analysis: Multivariate predictors of ventilation were assessed using logistic regression analysis., Results: There were 53 patients in Group 1 and 85 in Group 2. The mean age in the two groups was comparable. On bivariate analysis, simultaneous weakness of upper (UL) and lower (LL) limbs as the initial symptom (P<0.001); UL power less than Grade 3/5 at nadir (P<0.001); presence of neck and bulbar weakness (P<0.001); shorter duration from onset to bulbar weakness and confinement to bed (P=0.001) and bilateral facial involvement (P<0.01) were more frequently associated with the need for ventilation. Preserved reflexes in UL at nadir was significantly associated with absence of the need for mechanical ventilation (P<0.01). On multivariate analysis, factors independently associated with the need for mechanical ventilation included simultaneous motor weakness in UL and LL as the initial symptom (P=0.02), UL power<3/5 (Medical Research Council grade) at nadir (P=0.013) and presence of bulbar weakness (P<0.001). Preserved reflexes in the UL at nadir was independently associated with a lesser need for ventilation (P=0.001)., Conclusions: Comprehensive assessment of clinical features may predict the need for mechanical ventilation in patients of GBS.

Background: Minocycline is a semisynthetic derivative of the tetracycline group of antibiotics, which have neuroprotective effects. In animal stroke models, minocycline had shown promising evidence to improve clinical and functional outcomes., Objective: To analyze the effect of oral minocycline in acute ischemic stroke patients., Materials and Methods: This was a randomized single-blinded open-label study. The study group received oral minocycline 200 mg/day for 5 days and the control group received oral vitamin B capsules. Baseline assessment included the following: National Institute of Health Stroke Scale (NIHSS) score, modified Barthel Index (mBI), modified Rankin Scale (mRS) score, Magnetic Resonance Imaging (MRI) of brain including Diffusion Weighted Imaging (DWI), chest X-ray, and routine laboratory investigations. The clinical scales were repeated at days 1, 7, and 30. The end point was outcomes at 3 months (90 days). Statistical analysis was done with SPSS 11.5 (P<0.05). Paired t-test and multiple-measures Analysis Of Variance (ANOVA) were used., Results: Fifty patients with acute ischemic stroke were included in the study. Of these, 23 patients received minocycline and 27 patients received placebo i.e., vitamin B capsules. NIHSS score in patients receiving minocycline had shown statistically significant improvement at day 30 and 90 as compared with the controls. Similarly, mRS scores and BI showed significant improvement in patients receiving minocycline at three months as compared to the control group. No mortality, myocardial infarctions, recurrent strokes, and hemorrhagic transformations were noted in both groups., Conclusions: Patients with acute ischemic stroke had significantly better outcome with minocycline treatment as compared with those administered placebo. The above findings suggest that minocycline can be helpful in reducing the clinical deficits after acute ischemic stroke.

It is important to consider several differential diagnoses in a patient presenting with altered sensorium following surgery. Fat embolism syndrome (FES) is a serious condition that needs to be excluded. Although criteria for diagnosis of FES are available, all patients may not satisfy them. We discuss a patient who presented with an incomplete triad of the FES, where the diagnosis was supported by transcranial doppler monitoring of microembolic signals and magnetic resonance imaging.

Background: Limb girdle muscular dystrophy (LGMD) type 2A is caused by mutation in the gene encoding for calpain-3 resulting in total or partial loss of protein. Diagnosis of LGMD2A, the most prevalent form of LGMD, is established by analyzing calpain-3 protein deficiency or CAPN3 gene mutation. Since there is no data from India regarding the incidence of LGMD2A, this study was undertaken., Aims: To study the frequency of LGMD2A in Indian population on the basis of protein analysis by immunoblotting and to correlate pathological and clinical features with protein analysis., Settings and Design: One hundred and seventy-one muscle biopsies of clinically suspected LGMD, unclassified muscular dystrophy or myopathy were analyzed in a tertiary national referral centre for neurosciences. Materials and Methods : Histopathological, immunohistochemical and enzyme histochemical analysis of muscle biopsies was performed followed by protein analysis for calpain-3 and dysferlin by immunoblotting., Results: Immunoblot identified 75 patients (43.8%) with calpain-3 deficiency, of which 36 (45%) had complete loss and 39 (55%) had partial loss of calpain-3 protein. In patients with LGMD phenotype alone, the incidence of LGMD2A was 47%. The biopsies of these patients displayed variety of morphological changes ranging from dystrophic pattern with presence of active fibre necrosis, regeneration and lobulated fibres to end stage muscle disease. The mean age of presentation and disease onset was 24 and 18 years respectively., Conclusions: This series of 75 patients is probably the first confirmed cases of LGMD2A (calpainopathy) from India. Our study suggests that LGMD2A is the most frequent form of LGMD in India, similar to the Western data, thus, highlighting the importance of immunoblotting for an accurate diagnosis.

Immunological contact urticaria is a hypersensitivity reaction that appears on the skin following contact with an eliciting substance. Recent advances in our understanding of the molecular mechanism and pathogenesis of this reaction have altered its classification, diagnosis, and treatment. We discuss classification, epidemiology, diagnosis, testing, and treatment options that are available to patients with contact urticaria.

Basilar artery thrombosis has high morbidity and mortality. Though intra-arterial thrombolytics have proven efficacy in the treatment of acute basilar artery occlusion, the elevation of procoagulant factors in the blood after intra-arterial thrombolysis could result in subsequent thrombus formation and clinical deterioration. Glycoprotein IIb/IIIa inhibitors have been shown to reduce this elevation in procoagulants. We present a pilot study of three cases of acute basilar artery occlusion treated with a combination of intra-arterial thrombolytics and Gp IIb/IIIa inhibitor with remarkable clinical recovery seen in all the patients.

A 40-year-old male presented with acutely oncoming neuropsychiatric symptoms in the form of extrapyramidal disturbances, personality change, behavior changes and urinary incontinence. One month prior to this symptomatology, he had been found unconscious in his closed room where a coal fire was burning overnight. He recovered completely in two days with supportive therapy. Magnetic resonance imaging during this presentation showed bilateral white matter changes suggestive of demyelination. Tc99m-ECD SPECT study revealed hypoperfusion in bilateral frontal region. He was managed conservatively and eventually made a nearly complete recovery. Repeat SPECT study revealed marked improvement in tracer uptake correlating with his improvement. Delayed neuropsychiatric syndrome after acute carbonmonoxide poisoning is a rare and distinct entity. This case report discusses the various aspects of this disease entity.

Background: Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries. Prothrombin time (PT), platelet count and activated partial thromboplastin time (aPTT) may not be feasible within the time window., Aim: To evaluate the safety and efficacy of thrombolysis in selected patients without the coagulation profile., Design: Open, nonrandomized, observational study., Materials and Methods: Fifty-four stroke patients were classified using TOAST criteria (large artery atherosclerotic = 13; cardioembolic = 12; small vessel occlusion = 22; other determined etiology =three; undetermined etiology = four). The mean time to reach emergency was 2.4h (1.15-3.4), the mean door to CT, 24 min (10-47) and the door to recombinant tissue plasminogen activator (r-tPA) injection, 26.8 min (25-67). The NIHSS scores ranged from 11 to 22 (mean = 15.5 +/- 2.7). Patients with history of liver or renal disease or those on anticoagulants were excluded. The PT, aPTT and platelet count were not done. Recombinant tissue plasminogen activator was administered at a dosage of 0.9 mg/Kg., Results: Thirty-five patients (65%) significantly improved on NIHSS at 48 h (> or =4 points) (mean change = 10; range= 4-17). At one month, 43 (79%) improved on Barthel Index (mean change = 45%). One each developed small frontal lobe hemorrhage and recurrent stroke; one died of aspiration; and eight showed no improvement., Conclusions: Hyperacute thrombolysis was found useful and safe in selected patients with AIS even without the coagulation studies.

It is estimated that 5-10% of women of reproductive age have polycystic ovarian syndrome (PCOS). While insulin resistance is not part of the diagnostic criteria for PCOS, its importance in the pathogenesis of PCOS cannot be denied. PCOS is associated with insulin resistance independent of total or fat-free body mass. Post-receptor defects in the action of insulin have been described in PCOS which are similar to those found in obesity and type 2 diabetes. Treatment with insulin sensitizers, metformin and thiazolidinediones, improve both metabolic and hormonal patterns and also improve ovulation in PCOS. Recent studies have shown that PCOS women have higher circulating levels of inflammatory mediators like C-reactive protein, tumour necrosis factor-alpha, tissue plasminogen activator and plasminogen activator inhibitor-1 (PAI-1). It is possible that the beneficial effect of insulin sensitizers in PCOS may be partly due to a decrease in inflammation.

Currently, inflammation is considered to be the central player in the pathogenesis of atherosclerosis. It leads to the formation of multiple plaques in the arterial beds including coronary vasculature. Recent studies using the latest imaging techniques have shown that in patients with acute coronary syndromes (ACS) multiple plaques are ruptured and have thrombus formation on them. Various factors make these plaques unstable, these include structural components of plaque like thin fibrous cap, high lipid content of the plaque core and inflammation, both localized and generalized. It has been shown that most of the ACS are caused by plaques causing non-critical stenosis as seen on traditional X-ray angiography. Also, the phenomenon of remodelling makes angiography a poor technique for plaque visualization. Hence newer modalities are required to identify these "vulnerable plaques". Intravascular ultrasound (IVUS), thermography and Magnetic Resonance Imaging (MRI) are a few such promising techniques. Here we review the invasive and non-invasive modalities that can be helpful in the identification of these plaques before they become unstable and cause ACS, and also the available therapies to stabilize these plaques.

A patient with small cell lung cancer presented with a rare presentation of an acute onset pancerebellar dysfunction. His clinical condition markedly improved following the surgical removal of the tumor and chemo- and radiotherapy.

Tetanus is a potentially life threatening disease affecting nearly 50,000 to 1 million people world wide every year. Four major clinical forms of tetanus are described i.e. generalized, cephalic, localized and neonatal. Neonatal tetanus is particularly common in developing countries, due to unhygienic child birth practices, social taboos and improper immunization of pregnant mothers. Management of this disorder involves a team approach and aims at eradicating focus of infection, neutralizing the toxin, controlling spasms and dysautonomia and providing adequate ventilatory and supportive care. Metronidazole may be the preferred antibiotic although penicillin is still used frequently. Adequate wound debridement is necessary to prevent spore germination. Spasms are usually managed by sedatives like diazepam and neuromuscular blocking agents. Magnesium sulphate is an attractive substitute and may be tried if ventilatory facilities are unavailable. Use of baclofen is potentially advantageous but cannot be routinely prescribed. Dysautonomia is difficult to manage and requires therapy with benzodiazepines, morphine, magnesium sulphate, adrenergic blockers and recently tried baclofen therapy. Supportive care including ventilatory assistance are highly essential for successful outcome of the patients. It is imperative that complications are diagnosed early and managed appropriately. Immunization is extremely effective and is the key to prevention. Adequate steps and measures should be taken to increase awareness of this potentially preventable disease.

Acute amebic meningoencephalitis caused by free-living amebae naegleria fowleri is extremely rare and uniformly fatal with only seven survivals reported till date. An interesting case of naegleria meningitis diagnosed by wet mount cytology of cerebrospinal fluid (CSF) and treated with amphoterecin B, rifampicin and ornidazole with complete recovery is presented. In cases of suspected pyogenic meningitis, if CSF staining, antigen detection or culture is negative for bacteria, a wet mount cytology of CSF for naegleria is suggested. Early treatment with amphoterecin B and rifampicin may improve survival.

Hypertrophic pachymeningitis is a unique clinical entity characterised by fibrosis and thickening of the duramater with resulting neurological dysfunction. Three cases of this entity are described. Presenting features were headaches and cranial neuropathies in two patients and predominantly cerebellar dysfunction in the third. One of the patients also had evidence of spinal involvement. Lower cranial nerves were chiefly involved in two patients whereas optic nerve was the predominantly affected nerve in one. Except for the presence of rheumatoid arthritis in one of the patients, we could not document clinical or biochemical evidence of any predisposing infective, inflammatory or infiltrative condition in the other two. All three patients had characteristic changes on imaging suggestive of thickened and enhancing duramater. Although variable steroid responsiveness was seen in all the three patients, tendency towards steroid dependence was evident. The clinical presentations, causes, radiological features, management options and differential diagnosis of this unique clinical syndrome have been discussed.

Vertebral artery dissection is an important cause of brain stem stroke, especially in the young. Dissections of carotid and vertebral arteries in neck account for about 20% of strokes in young compared with 2.5% in the elderly. Three patients of vertebral artery dissection related to indirect neck trauma are described. The first patient developed the symptoms while dancing, the second after a trivial fall and the third while he was on a dental chair. None of them had a direct severe neck trauma or concomitant risk factor like hypertension, connective tissue disease or migraine. Clinical symptomatology was similar in all the patients and included occipito-nuchal pain, headache and brain stem dysfunction chiefly in the posterior inferior cerebellar artery (PICA) territory. One of the patients also had associated ischaemic myelopathy. MRA and DSA confirmed dissection in all with a predominant steno-occlusive picture. Cases of so called trivial neck movement/torsion related dissection have been described previously but have not received any major importance. Usually classified as 'spontaneous' or 'traumatic', there is a possible ambiguity in literature about appropriate terminology. We emphasise that a history of such subtle precipitating events be taken while diagnosing young patients with brain stem strokes, to recognise this clinical entity. Although mechanisms are not absolutely clear, yet there seems to be an important relationship between arterial dissection and neck movements or minor trauma.

This study was aimed at establishing a single step method for production of brain abscess in the rat utilizing Staphylococcus aureus inoculum, prepared from a clinical specimen. Adult Wistar rats were stereotactically inoculated with 1 ul of multidrug resistant Methicillin sensitive Staphylococcus aureus inoculum. A dilute non-standardized inoculum and a standardized inoculum containing 1 million organisms/ul were utilized. Rats were sequentially sacrificed from 24 hours to 24 days. Gross and histopathologic studies with H & E, avidin biotin conjugate (ABC) immunoperoxidase technique using monoclonal anti glial fibrillary acidic proteins (GFAP) antibody and Gram's stain were performed. No abscess was formed with the dilute non-standardized inoculum. The overall success rate was 32.14 percent. Cerebritis was evident in the 24 hour specimen. An acute abscess was seen by day 4, and although fibroblasts were noticed on day 10 a well defined capsule was seen only by day 16 when gliosis became evident.Clusters of Gram positive cocci were demonstrable in all specimens. Cultures from abscess specimens yielded pure Staphylococcus aureus growth with a similar drug sensitivity as the parent inoculum.

Sixty three consecutive patients with posterior fossa medulloblastoma were studied retrospectively. Fifty one patients were below 15 years of age and there was male predominance (3:1). Eighty percent of the patients had been symptomatic for less than 6 months. Features of raised intracranial pressure was the commonest clinical presentation. The tumour was placed in midline in 85 cases. Sixty patients had hydrocephalus and a preoperative CSF shunt was carried out in 49 patients. A gross total resection are carried out in 59 patients and a partial resection in 3 patients. Tumour biopsy alone was performed in one patient. The operative mortality was 12.6. Nine patients developed remote metastasis. Specimens from fifty seven patients were studied for evidence of astrocytic differentiation which was seen in 31. No correlation was found between the 2 year survival and presence of astrocytic differentiation.