Pilocytic astrocytoma of the cerebellopontine angle mimicking vestibular schwannoma: report of a rare entity.

We present a rare case of a 55-yr old patient of pilocytic astrocytoma of the cerebello-pontine angle mimicking a vestibular schwannoma. The tumor protruded into the porus acusticus causing enlargement of the internal auditory meatus, which is quite an unusual feature of glial tumours.

Syncope: Clinical Study and Outcome of Diagnostic Evaluation.

Background: Syncope is a common clinical presentation in emergency department. The diagnostic workup for syncope causes significant man-hour loss and expensive investigations. Most often the battery of investigations does not lead to any conclusive diagnosis. Materials and Methods: This was a descriptive study in which included 50 consecutive patients with the diagnosis of syncope. These patients were admitted to a tertiary care hospital between Sep 2009 to Aug 2011. Patients of both sexes above 12 years of age were included in the study. The patients were evaluated on the basis of history, clinical examination, ECG, TMT (for exertional syncope), 2DECHO, HUTT, Holter monitoring and EEG. Results: Mean age of males were 46.11 yrs and that of females were 41.33 years (confidence interval 95%). Out of 50 patients, 38 were males and 12 were females. The percentages of co morbidities in our sample population were CAD- 6.90%, CVA- 1.72%, Hypertension- 17.24%, APD- 1.72%, Dyslipidemia- 3.45%, Hypothyroidism- 3.45%, RHD with Mitral Stenosis- 1.72%, Type 2 Diabetes Mellitus- 5.17% and no co morbidities in 55.17%. Out of 50 patients 30% had some or the other diagnosis rest 70% patients had no definitive diagnosis. 90% of the patients had cardiogenic syncope and rest 10% had non-cardiogenic syncope. None of the patients in our sample population had orthostatic hypotension. In our study 15 (30%) patients had history of recurrent syncope. On evaluation with ECG, 4 patients had Bundle Branch Block rest 46 had normal ECG. In 96% of the patients 2 DECHO was normal. Holter monitoring revealed Supraventricular tachycardia only in 2 patients. Out of 15 patients of explained syncope 10 had positive HUTT (66.7%) whereas 5 had negative HUTT (33.3%); compared to 35 patients with unexplained syncope HUTT was inconclusive. Neurological evaluation revealed no abnormal EEG though it was our exclusion criteria. Conclusion: While evaluating syncope most often the battery of investigations does not lead to any conclusive diagnosis. There was male predominance in presentation. Out of 50 patients 10% had cardiogenic, 20% had neurocardiogenic and in 70% diagnosis was not established. Only 20% had HUTT positive. Echocardiography is the investigation of choice in patients of valvular heart disease. A thorough clinical evaluation is must, investigations are of limited value.

Granulomatous Hepatitis with Miliary Mottling: A Rare Cause.

Miliary mottling is most commonly seen in tuberculosis. Clinical features of tuberculosis mimic many other lung diseases. Here we report a 40 yr old male with clinical features suggestive of tuberculosis, miliary mottling on skiagram chest and granulomatous hepatitis on histopathology. Case was finally diagnosed as sarcoidosis on liver biopsy and improved on oral corticosteroid.

Toluene Poisoning Presenting as Bilateral Basal Ganglia Haemorrhage.

Toluene is an aromatic hydrocarbon that is often used as a solvent in paints, paint thinners, glues, disinfectants and as an industrial solvent for the manufacturing of pharmaceuticals, paints and chemicals. Metabolic acidosis is a recognized complication of toluene poisoning. However, we here report an unusual case of toluene poisoning presenting with bilateral intracerebral haemorrhage.

A Crossover Study Evaluating Effect of Timing of Levothyroxine on Thyroid Hormone Status in Patients of Hypothyroidism.

OBJECTIVE: Current literature shows a definite benefit of fasting state Levothyroxine administration. However, superiority of any specific timing is not yet established. Our study was designed to compare the effect of timing of levothyroxine administration, morning versus evening dose, on thyroid profile control in patients of hypothyroidism. METHODOLOGY: :A randomized double-blind crossover study was performed on 60 patients with primary hypothyroidism, euthyroid on stable levothyroxine regime of 100 µg daily, randomized into two sequence groups, morning dose first (AB sequence) versus evening dose first (BA sequence) with switch over after 6 weeks. Primary endpoints were change in thyroid function tests. RESULTS: There was an insignificant rise in TSH in morning dose first group (AB) at 6 weeks which reduced significantly in evening dose, [2.36(1.11) to 2.45(1.19) mIU/L (p=0.56)], [2.07(0.99) (p=0.006)] respectively. Levothyroxine evening dose first group (BA) showed significant reduction of TSH levels at 6 weeks followed by non significant increase [2.63(0.96) to 1.85(1.35) mIU/L, (p=0.002)], [2.14(1.16), (p=0.15)]. Group AB showed mild followed by significant rise in FT4 at 6 and 12 weeks respectively, [1.06(0.30) to 1.14(0.33) ng/dl (p=0.18)], [1.24(0.36) (p=0.008)]. FT4 of BA sequence significantly increased at 6 weeks followed by mild increase, [1.10(0.29) to 1.20(0.28) ng/dl (p=0.01)] [1.23(0.31) ng/dl (p=0.58)]. FT3 of AB revealed initial reduction (p=0.87), followed by significant rise (p=0.02). Group BA showed a significant rise (p=0.04) in FT3 followed by fall (p=0.63). CONCLUSION: Bedtime dosing of Levothyroxine showed improved thyroid hormone status control and could be a viable option in treatment of patients with hypothyroidism.

Spontaneous Pneumothorax in H1N1 Infection.

Spontaneous pneumothorax is a very rare entity in H1N1 infection unless it is co-existent with other respiratory conditions especially COPD. The other factors are old age, children below 5 years and patients with ILD. The mortality rate goes high with pulmonary illness complicated by H1N1 infection in smokers and in pregnant women. This is the first reported case of H1N1 infection with Spontaneous Pneumothorax in India.

Malignant Pleural Effusion with Filariasis.

The occurrence of microfilaria in pleural fluid is rare. Filarial lung involvement occurs in the form of Tropical Pulmonary Eosinophilia with pulmonary infiltrates and peripheral eosinophilia. We report a 74-year-old male patient, non smoker who was admitted to our hospital with breathlessness and chest discomfort of two weeks duration. He had, eosinophilia and deranged renal function. X-ray chest revealed massive left sided pleural effusion. Pleural fluid analysis revealed atypical cells and pleural fluid cytology showed microfilaria (Wuchereria bancrofti), which were also found on peripheral smear.

Axonal pathways linked to therapeutic and nontherapeutic outcomes during psychiatric deep brain stimulation.

OBJECTIVE: The underlying hypothesis of our work is that specific clinical neuropsychiatric benefits can be achieved by selective activation of specific axonal pathways during deep brain stimulation (DBS). As such, the goal of this study was to develop a method for identifying axonal pathways whose activation is most likely necessary for achieving therapeutic benefits during DBS. EXPERIMENTAL DESIGN: Our approach combined clinical data, diffusion tensor tractography, and computer models of patient-specific neurostimulation to identify particular axonal pathways activated by DBS and determine their correlations with individual clinical outcome measures. We used this method to evaluate a cohort of seven treatment-resistant depression patients treated with DBS of the ventral anterior internal capsule and ventral striatum (VC/VS). PRINCIPAL OBSERVATIONS: Clinical responders exhibited five axonal pathways that were consistently activated by DBS. All five pathways coursed lateral and medial to the VS or dorsal and lateral to the nucleus accumbens; however, details of their specific trajectories differed. Similarly, one common pathway was identified across nonresponders. CONCLUSIONS: Our method and preliminary results provide important background for studies aiming to expand scientific characterization of neural circuitry associated with specific psychiatric outcomes from DBS. Furthermore, identification of pathways linked to therapeutic benefit provides opportunities to improve clinical selection of surgical targets and stimulation settings for DBS devices.

Kernel Flow: a high channel count scalable time-domain functional near-infrared spectroscopy system.

SIGNIFICANCE: Time-domain functional near-infrared spectroscopy (TD-fNIRS) has been considered as the gold standard of noninvasive optical brain imaging devices. However, due to the high cost, complexity, and large form factor, it has not been as widely adopted as continuous wave NIRS systems. AIM: Kernel Flow is a TD-fNIRS system that has been designed to break through these limitations by maintaining the performance of a research grade TD-fNIRS system while integrating all of the components into a small modular device. APPROACH: The Kernel Flow modules are built around miniaturized laser drivers, custom integrated circuits, and specialized detectors. The modules can be assembled into a system with dense channel coverage over the entire head. RESULTS: We show performance similar to benchtop systems with our miniaturized device as characterized by standardized tissue and optical phantom protocols for TD-fNIRS and human neuroscience results. CONCLUSIONS: The miniaturized design of the Kernel Flow system allows for broader applications of TD-fNIRS.

A clinical study on Virechana Karma (therapeutic purgation) over the gut flora with special reference to obesity.

BACKGROUND: Altered gut flora is associated with the pathogenesis of both intestinal and extra­intestinal disorders. Aetiology of obesity is associated with mechanisms such as short chain fatty acid production, stimulation of hormones, chronic low­grade inflammation, lipoprotein and bile acid metabolism and increased endocannabinoid. Receptor system tone have been suggested to explain the role of gut microbiota of obesity. The Panchakarma (Ayurvedic purification methods) claims the management of metabolic disorders hence this work provides the target specific evidence for the clinical studies. The proposed project is aimed to explore the particular molecular mechanism and, to make this therapy more evidence based. Hence, it was hypothesized that Panchakarma­based intervention such as Virechana Karma (therapeutic purgation) may influence microbiota and help in the management of the obesity. MATERIALS AND METHODS: The study was conducted to explore the effect of Virechana Karma over the gut flora; therefore, total of 19 patients with Madhyama Koshtha diagnosed with obesity were included and received the intervention. Before and after Virechana, a stool sample was collected and processed for the enterobacterial repetitive intergenic consensus ­polymerase chain reaction to find the changes over the facultative aerobic bacteria. RESULTS: It was found that Virechana is effective in the management of the obesity as it helps to reduce colonization of aerobic bacteria. After Virechana and after follow­up also, it showed the correction of the gut flora dysbiosis, thus initiated the weight loss mechanism in the body, resulting in diminution in the signs and symptoms of obesity. CONCLUSION: Virechana is effective in the management of the obesity due to reduction in the Escherichia coli colonization and is effective over the gut flora dysbiosis.

Tracking the mechanisms of deep brain stimulation for neuropsychiatric disorders.

Deep brain stimulation (DBS) has recently emerged as a potential treatment for medically intractable neuropsychiatric disorders. Pilot clinical studies with encouraging results have been performed with DBS of the ventral anterior internal capsule (VAIC) and subgenual cingulate white matter (Cg25WM) for the treatment of obsessive-compulsive disorder and depression. However, little is known about the underlying response of individual neurons, or the networks they are connected to, when DBS is applied to the VAIC or Cg25WM. This review summarizes current understanding of the response of axons to DBS, and discusses the general brain network architectures thought to underlie neuropsychiatric disorders. We also employ diffusion tensor imaging tractography to better understand the axonal trajectories surrounding DBS electrodes implanted in the VAIC or Cg25WM. Finally, we attempt to reconcile various data sets by presenting generalized hypotheses on potential therapeutic mechanisms of DBS for neuropsychiatric disease.

Correlation of Vitamin D with metabolic parameters in polycystic ovarian syndrome.

BACKGROUND: Polycystic ovarian syndrome (PCOS) and hypovitaminosis D are the two most common endocrine disorders in young women leading to many adverse metabolic consequences. We evaluated the correlation of 25-hydroxy Vitamin D (25OHD) with metabolic parameters and insulin resistance in PCOS. MATERIALS AND METHODS: We included 100 PCOS patients (age 18-40 years, duration >6 months) serially, in this cross-sectional study. We excluded patients with past use of insulin sensitizers and hormone therapy. All patients underwent a physical examination, body fat estimation, and a single fasting blood sample was analyzed for the biochemical parameters. The patients were divided into 2 groups as per the 25OHD level: Group 1 (Deficient, <30 ng/mL) and Group 2 (normal). The data were analyzed using appropriate statistical methods, and a P < 0.05 was considered statistically significant. RESULTS: The study population had a mean age of 28.6 ± 6.3 years, body mass index (BMI) 30.4 ± 6.1 kg/m2 and body fat of 39.1 ± 13%. A total of 90 women had 25OHD deficiency, and hypovitaminosis D was observed more in younger, obese patients. Patients with hypovitaminosis D had a higher BMI (P = 0.0124), low- high-density lipoprotein (P = 0.0094), calcium (P ≤ 0.0001), and elevated testosterone (P = 0.0412) in comparison with normal 25OHD patients. None of the metabolic parameters showed significant correlation with 25OHD (P > 0.05). CONCLUSION: Hypovitaminosis D is very common in PCOS patients and exacerbates the metabolic abnormalities. It is essential to screen all the PCOS patients for 25OHD deficiency, and further large-scale studies are required to confirm our findings.

Creating and parameterizing patient-specific deep brain stimulation pathway-activation models using the hyperdirect pathway as an example.

BACKGROUND: Deep brain stimulation (DBS) is an established clinical therapy and computational models have played an important role in advancing the technology. Patient-specific DBS models are now common tools in both academic and industrial research, as well as clinical software systems. However, the exact methodology for creating patient-specific DBS models can vary substantially and important technical details are often missing from published reports. OBJECTIVE: Provide a detailed description of the assembly workflow and parameterization of a patient-specific DBS pathway-activation model (PAM) and predict the response of the hyperdirect pathway to clinical stimulation. METHODS: Integration of multiple software tools (e.g. COMSOL, MATLAB, FSL, NEURON, Python) enables the creation and visualization of a DBS PAM. An example DBS PAM was developed using 7T magnetic resonance imaging data from a single unilaterally implanted patient with Parkinson's disease (PD). This detailed description implements our best computational practices and most elaborate parameterization steps, as defined from over a decade of technical evolution. RESULTS: Pathway recruitment curves and strength-duration relationships highlight the non-linear response of axons to changes in the DBS parameter settings. CONCLUSION: Parameterization of patient-specific DBS models can be highly detailed and constrained, thereby providing confidence in the simulation predictions, but at the expense of time demanding technical implementation steps. DBS PAMs represent new tools for investigating possible correlations between brain pathway activation patterns and clinical symptom modulation.

Assessment of Quality of Life in Patients With Skin Disorders Undergoing Ayurvedic Panchakarma (Biopurification) as Management.

BACKGROUND: Chronic skin conditions can have a negative impact on one's quality of life, affecting their physical, functional, and emotional well-being. Whereas biopurifactory measures (panchakarma) of Ayurveda claims to provide better quality of life after treatment. Hence current study is planned to provide evidence in patients with skin disorders, undergoing Ayurvedic treatment. METHODOLOGY: Sixty patients with skin disorder, who underwent purification therapies like therapeutic emesis and therapeutic purgation, were randomly placed in 2 groups to assess quality of life. Quality of life assessment was done with the help of Skindex-29 among the patients before and after Ayurvedic purification therapy. Thereafter, the quality of life assessment was done on the first follow-up. RESULTS: A statistically significant improvement in the quality of life domains-emotions, functioning, and symptoms-after the Ayurvedic management was observed with P value <.001. CONCLUSION: Study concludes that there is improvement in quality of life among patients with skin disease after undergoing Ayurveda purification therapies.

Role of Ayurveda in the conservative management of avascular necrosis of the femoral head: A case study.

Avascular necrosis (AVN) of the femoral head is the most common type of necrosis affecting the bones. Management of AVN aims at the preservation of structure, function and relief of from pain. Many surgical procedures such as drilling and insertion of bone grafts, modified Whitman or Colonna reconstruction and insertion of prosthesis are carried out to remedy the condition but all these procedures are costly with the prognosis being poor. Signs and symptoms of Avascular necrosis are nearer to asthivaha srotodusti vikara (disorders of musculoskeletal origin) and can be considered with gambhira avastha (chronic stage). An effort has been made in the present study to evaluate the efficiency of Ayurvedic formulations in the conservative management of AVN of the femoral head. A case of AVN with bilateral femoral head was treated with ruksana (Drying therapy) followed by sodhana (bio purification) and brhmana (rejuvenation). Patient was observed for complications during whole course of treatment, untoward complications were not seen. Patient was observed for symptomatic improvements based on assessment done by the questionnaire over graded signs and symptoms before and after treatment. The results were encouraging. The therapy provided marked relief from pain, tenderness, stiffness and improvement in the gait. Conservative management of AVN through Ayurvedic principles provides significant relief and improves quality of life.

A Clinico-analytical Study on Seed of Wrightia antidysenterica Linn. as a Therapeutic Emetic Agent (Vamaka Yoga) in the Management of Psoriasis.

OBJECTIVES: Wrightia antidysenterica Linn. (WA) is male variety Kutaja stated to be potent therapeutic emetic agent in skin disorders. Expulsion of doshas through oral route is termed as Vamana Karma (VK) (therapeutic emesis). However, so far, its utility for Vamana is not explored in detail, therefore there is a need to revalidate the utility of WA for Vamana. Hence, the above study was conducted to ascertain the efficacy as a therapeutic emetic agent (vamaka yoga) in the management of psoriasis along with quality control and standardization of this herb. MATERIALS AND METHODS: The drug was standardized as per analytical procedures in Pharmacopeias. Thirty patients of psoriasis fulfilling inclusion criteria were taken for the study and Vamana with WA was conducted. Criteria were prepared to assess the signs and Symptoms of psoriasis. VK was assessed using the classical Lakshanas (features) such as Anthiki shudhi (Ending symptoms of emesis), Vaigiki shudhi (features of vomiting bouts), Maniki shudhi (Quantitative and qualitative purification), complications. RESULT: VK with WA showed significant relief in parameters of psoriasis such as scaling, itching, candle grease sign (P < 0.001), and psoriasis area and severity index score (P = 0.001). In VK with WA, mean number of Vegas (vomiting bouts) was 6.91. 66% patients showing quantitative purification between 301 and 600 ml. 73.33% showed all Symptoms of purification. 73.33% patients showed Kaphanta vamana (Moderate expulsion of desire humor). In the level of biopurification, 66.66% patients showed moderated purification. No complication was noted with moderate drug palatability. CONCLUSION: Pharmacopeial analytical study showed its standardized values for testing the drug used for the study. It is proved as potent therapeutic emetic agent with no complication showed its clinical benefits over skin disorder like psoriasis. SUMMARY: Seeds of Wrightia antidysenterica (WA) Linn. free from any foreign matter were selected for the study. Loss on drying revealed 6.535% moisture content; total ash indicating of total inorganic content was found to be 5.12%; acid insoluble ash is the acid insoluble part of total ash, mainly silica, WA showed 0.393% acid insoluble ash; ethanol and water soluble extractive is indicative of percentage active constituents were found to be 25.66 and 20.854%, respectively. High-performance thin layer chromatography fingerprinting profiles of WA under 254 nm showed the presence of 7 spots (all in green) at Rf values ranging from 0.21 to 0.88. Under 366 nm there were 4 prominent spots (all in fluorescent) at Rf 0.49 to 0.82 and, when scanned under white light 620 nm following derivatization with vanillin sulfuric acid 6 spots (in different colors) were evident at Rf 0.28 to 0.58. Among these spot with Rf of 0.58 was common when visualized under all the three methods. Rf values by densitometric scan of WA showed 12 peaks at 254 nm and 5 peaks at 366 nm. However, in clinical trial, it was found to be a potent emetic agent without any complication. Abbreviations Used: WA: Wrightia antidysenterica; Linn.; VK: Vamana karma; BT: Before treatment; FP: Freidman's P value; CHS: Chi-square value; NR: Negative ranks; PR: Positive ranks; N: Sample number, AS: Austipz sign; CG: Candle grease test; SSL: Samyak Snigdha Lakshana.

Effect and Mechanism of Virechana Karma (Therapeutic Purgation) Over Fructose-Induced Metabolic Syndrome: An Experimental Study.

BACKGROUND: Panchakarma (biopurification methods) is one of the modes of ayurveda to treat disorders of the body. Virechana karma (therapeutic purgation), one among the Panchakarma, is a purification process that is commonly used to treat metabolic disorders like obesity and diabetes mellitus. Hence this study was planned to provide evidence through animal experiments. METHODS: Albino rats were subject to Virechana karma (therapeutic purgation) to evaluate the influence of therapy and its mechanism over fructose-induced metabolic syndrome. RESULTS: Results show that Virechana is effective in the management of the metabolic syndrome with decrease in the fecal fat content, fasting blood glucose, serum triglyceride, and reduced fatty changes in liver, heart, and kidney in comparison with the positive control group. CONCLUSION: Experimental evaluation showed decrease in fatty acid in the storage like liver, kidney, heart, and muscle adipose tissue can indirectly increase the insulin sensitivity in insulin receptor present at skeletal muscles.

Three-dimensional segmentation and skeletonization to build an airway tree data structure for small animals.

Quantitative analysis of intrathoracic airway tree geometry is important for objective evaluation of bronchial tree structure and function. Currently, there is more human data than small animal data on airway morphometry. In this study, we implemented a semi-automatic approach to quantitatively describe airway tree geometry by using high-resolution computed tomography (CT) images to build a tree data structure for small animals such as rats and mice. Silicon lung casts of the excised lungs from a canine and a mouse were used for micro-CT imaging of the airway trees. The programming language IDL was used to implement a 3D region-growing threshold algorithm for segmenting out the airway lung volume from the CT data. Subsequently, a fully-parallel 3D thinning algorithm was implemented in order to complete the skeletonization of the segmented airways. A tree data structure was then created and saved by parsing through the skeletonized volume using the Python programming language. Pertinent information such as the length of all airway segments was stored in the data structure. This approach was shown to be accurate and efficient for up to six generations for the canine lung cast and ten generations for the mouse lung cast.

Quantitative analysis of axonal fiber activation evoked by deep brain stimulation via activation density heat maps.

BACKGROUND: Cortical modulation is likely to be involved in the various therapeutic effects of deep brain stimulation (DBS). However, it is currently difficult to predict the changes of cortical modulation during clinical adjustment of DBS. Therefore, we present a novel quantitative approach to estimate anatomical regions of DBS-evoked cortical modulation. METHODS: Four different models of the subthalamic nucleus (STN) DBS were created to represent variable electrode placements (model I: dorsal border of the posterolateral STN; model II: central posterolateral STN; model III: central anteromedial STN; model IV: dorsal border of the anteromedial STN). Axonal fibers of passage near each electrode location were reconstructed using probabilistic tractography and modeled using multi-compartment cable models. Stimulation-evoked activation of local axon fibers and corresponding cortical projections were modeled and quantified. RESULTS: Stimulation at the border of the STN (models I and IV) led to a higher degree of fiber activation and associated cortical modulation than stimulation deeply inside the STN (models II and III). A posterolateral target (models I and II) was highly connected to cortical areas representing motor function. Additionally, model I was also associated with strong activation of fibers projecting to the cerebellum. Finally, models III and IV showed a dorsoventral difference of preferentially targeted prefrontal areas (models III: middle frontal gyrus; model IV: inferior frontal gyrus). DISCUSSION: The method described herein allows characterization of cortical modulation across different electrode placements and stimulation parameters. Furthermore, knowledge of anatomical distribution of stimulation-evoked activation targeting cortical regions may help predict efficacy and potential side effects, and therefore can be used to improve the therapeutic effectiveness of individual adjustments in DBS patients.