Chronic nonspecific multiple-sites pain [CNMSP] of unknown etiology: Biopsychosocial method of evaluation for the primary care level.

Background: Understanding and dealing with chronic nonspecific pain (CNP) is the important entity at primary care hospital. Chronic nonspecific multiple-site pain [CNMSP] of unknown etiology creates diagnostic and therapeutic challenges for primary care physicians due to lack of guidance regarding evaluation and treatment. Aims and Objectives: To classify and formulate the evaluation, treatment strategies, and prediction of prognosis of patients with CNMSP of unknown etiology. Methods: Patients present with CNMSP of more than 3-month duration without any obvious medical cause. The biopsychosocial [BPS] model with 3P model was applied to see the biological, psychological, and social factors behind persistence. Finally, patients were classified into four groups for evaluation response to treatment and relapse rates in 12-month follow-up. Results: Of the total 243 patients of CNMSP, 243 [96.3%] were females. Sixty [24.7%] patients had short duration, and 183 [75.3%] had long duration. Headache was in 115 [47%], low back pain ± leg pain in 96 [39.4%], cervical pain ± shoulder/arm pain in 83 [34.1%], and diffuse body pain in 50 [20.5%] in various combinations. A total of 155 [63.8%] patients had high somatization-sensitization index (SSI), and 144 [59.3%] had low ferritin level. Group 1 [high SSI and low ferritin] had 37.9% of patients, group 2 [high SSI and normal ferritin] had 25.9% of patients, group 3 [low to medium SSI with low ferritin] had 21.4% of patients, and group 4 [low to medium SSI with normal ferritin] had 14.8% of patients. Response to pain symptoms was better in group 1, and relapse rate was higher in group 2. Conclusion: CNMSP of unknown etiology itself is a heterogeneous entity, and assessment based on the BPS model can be very useful to understand the treatment plan and outcome of these patients.

Endogenous defense mechanism-based neuroprotection in large-vessel acute ischemic stroke: A hope for future.

BACKGROUND: Stroke is a leading cause of morbidity and mortality worldwide and a leading cause of disability. None of the neuroprotective agents have been approved internationally except edaravone in Japanese guidelines in acute ischemic stroke. We here discuss that there are two types of endogenous defense mechanisms (EDMs) after acute stroke for neuromodulation and neuroregeneration, and if both can be activated simultaneously, then we can have better recovery in stroke. AIMS AND OBJECTIVES: We aimed to study the effect of combination of neuroprotection therapies acting on the two wings of EDM in acute large-vessel middle cerebral artery (LMCA) ischemic stroke. METHODS: Sixty patients of LMCA stroke were enrolled and randomized within 72 h into two groups of 30 patients each. The control group received standard medical care without any neuroprotective agents while the intervention group received standard medical care combined with oral citicoline with vinpocetine for 3 months with initial 1 week intravenous and edaravone and cerebrolysin injection, started within 72 h of onset of stroke. Patients were assessed on the basis of the National Institutes of Health Stroke Scale, Fugl-Meyer Assessment Score, Glasgow Coma Scale, and Mini-Mental Status Examination at admission, discharge, and after 90 days. RESULTS: The intervention group showed significant and early improvements in motor as well as cognitive recovery. CONCLUSION: Combination therapy for neuroprotection which is acting on two pathways of EDM can be useful in functional recovery after acute ischemic stroke.

Unmasking the Uncommon: A Case Report of Scrotal Epidermoid Cysts in a Nine-Year-Old Boy.

Scrotal epidermoid cysts are rare. Intratesticular epidermoid cysts are more common than extra scrotal cysts and are the most commonest benign tumors of the testicles. Midline scrotal raphe cysts are reported, but only a few have intrapelvic extensions deep into the pelvis. A nine-year-old boy presented with a painless scrotal swelling. Magnetic resonance imaging (MRI) of the pelvis confirmed the cystic nature with an extension of the swelling up to the base of the prostate. On surgical exploration, the cyst had a tapering stalk with cranial extension up to the base of the prostate. The patient underwent an excision of the cyst and made an uneventful recovery and was asymptomatic at the end of three months of surgery. The histopathology of the lesion was typical of an epidermoid cyst. Extratesticular scrotal epidermoid cysts with pelvic extension are a rarity with less than five cases reported in the literature. Our case stands to be the youngest reported case of a scrotal epidermoid cyst based on our knowledge. Scrotal epidermoid cysts are a very rare and benign entity, and upon recognition and confirmation of the extent of spread, extratesticular scrotal cysts can safely be removed. No other management may be required with no recurrences reported.

Successful repair of interrupted aortic arch with aortopulmonary window associated with long gap oesophageal atresia and Type C tracheoesophageal fistula: challenging and rare case report.

Congenital heart diseases are most common anomalies associated with tracheoesophageal fistula (TEF) and oesophageal atresia (EA). The physiology and anatomy of heart disease is major determinant factor influencing outcome in patients with TEF/EA. We present a successfully treated case of complex congenital heart anomaly of interrupted aortic arch (IAA) with aortopulmonary window (APW) with TEF/EA.

A case series of 2,4 diethylamine poisoning - what the future holds for us.

2,4-Diethylamine (2,4-D) is a chlorphenoxy herbicide widely used in north India, marketed as 'Sohna' and 'Zura'. Multi-organ dysfunction and mortality is high in cases of accidental or suicidal ingestion owing to the lack of any antidote. We report a case series of 2,4-D poisoning from a single tertiary centre of north India managed with variable outcomes.

Vitamin E-induced coagulopathy in a young patient: a case report.

BACKGROUND: High-dose vitamin E intake is known to inhibit vitamin K-derived coagulation factor synthesis, which can cause serious bleeding events such as gastrointestinal bleeding and intracranial hemorrhage. We report a case of coagulopathy induced by marginally increased levels of vitamin E. CASE PRESENTATION: A 31-year-old Indian man presented with oral bleeding, black tarry stools, and bruising over his back. He had been taking non-steroidal anti-inflammatory drugs for low backache and vitamin E for hair loss. He had mild anemia with normal platelet count, thrombin time, and prolonged bleeding time, activated partial thromboplastin time, and prothrombin time. Serum fibrinogen was slightly raised. Mixing studies with pooled normal plasma, aged plasma, and adsorbed plasma were suggestive of deficiency of multiple coagulation factors due to acquired vitamin K deficiency. Serum phylloquinone was normal, while prothrombin induced by vitamin K absence-II level was increased. Serum alpha-tocopherol was slightly raised. Upper gastrointestinal endoscopy showed multiple gastroduodenal erosions. A final diagnosis of vitamin E toxicity-related coagulopathy was made. The patient responded well to pantoprazole, vitamin K supplementation, multiple fresh frozen plasma transfusions, and other supportive treatments besides the discontinuation of vitamin E supplementation. The coagulation parameters normalized, and the patient was discharged with complete resolution of symptoms and remained asymptomatic during the follow-up for 6 months. CONCLUSIONS: Vitamin E-related inhibition of vitamin K-dependent factors with coagulopathy may occur even at marginally increased levels of serum vitamin E. This risk becomes significant in patients receiving other drugs that may increase the risk of bleeding.

Association between iron deficiency anemia and chronic daily headache: A case-control study.

OBJECTIVE: We aimed to determine the association between iron deficiency anemia and chronic daily headache. METHODS: This case-control study was conducted in a tertiary care center in Dehradun, India. One hundred patients with chronic daily headache were randomly selected for the study with an equal number of controls. Subsets of chronic daily headache were diagnosed as per the 3rd edition of the International Classification of Headache Disorders. The study participants were assessed for iron deficiency anemia. RESULTS: The mean age of the patients was 51.1 ± 22.1 years. Male: female ratio was 1:1.08. Chronic migraine was present in 62 (62%), tension-type headache in 23 (23%), and new daily persistent headache in 15 (15%) patients. The majority (96%) of patients had chronic daily headache of mild to moderate severity. Chronic daily headache was of long duration in all patients. Sixty-four (64%) patients had anemia of which 51 (51%) patients had iron deficiency anemia. Iron deficiency anemia showed a significant association with chronic daily headache (p < 0.001), but not with its type, subtype, and duration. Severe iron deficiency anemia had a significant association with the severity of chronic daily headache (p = 0.021). Serum iron, ferritin, total iron-binding capacity, and transferrin saturation also had a significant association with chronic daily headache (p < 0.05 for each), but not with its type, subtype, duration, and severity. Logistic regression analysis showed that iron deficiency anemia, total iron-binding capacity, and transferrin saturation had an independent association with chronic daily headache (p < 0.05 for each). CONCLUSIONS: Iron deficiency anemia had an independent association with chronic daily headache. Severe iron deficiency anemia was related to the severity of chronic daily headache.

Experience with Low-Dose Sodium Valproate in Idiopathic Generalized Epilepsy Patients: A Long-Term Follow-Up Study on Selective Cohort from North India.

Background Idiopathic generalized epilepsy (IGE) is found in 20 to 30% of all patients presenting with seizures. Most of the patients require lifelong drug treatment. Efficacy and tolerability are important issues while selecting the most appropriate drug for a person with IGE. Objective The aim of this study was to look for usefulness of small dose valproate (<1,000 mg/day) in long-term treatment of IGE patients. Methods Diagnosis of IGE made with standard criteria among all patients presenting with seizures. Patients put on full doses of valproate (>1,000 mg/day) in first year, then reduction started in next year in patients with full seizure remission, and finally maintained on lowest possible dose of valproate. Lowest dose was defined as the minimum dose without seizures (between 200 and 900 mg/day). Patients, who were refractory on monotherapy, were put on add-on drug and followed for remission and reduction in doses of valproate at minimum possible dose. Results IGE was diagnosed in 21% of all patients presenting with seizures. Among 420 patients of IGE 368 (87.5%) were started on high-dose valproate monotherapy, 155 (42.1%) were responsive to single drug while 213 (57.9%) had been given add-on drug either lamotrigine or clonazepam or both. After minimum 3-year follow-up, 298 (81%) could be managed on low-dose valproate (<1,000 mg) without any relapse during 12 to 80 months follow-up. Conclusion Significant number of patients with IGE can be managed on low-dose valproate with good seizure control and less side effects.

A case of recurrent stroke with underlying adenocarcinoma: Pseudo-cryptogenic stroke.

Stroke is the most common neurological disorders leading to early death. Early recognition of underlying mechanisms and etiology of stroke is important to prevent recurrence, mortality and disability. The term cryptogenic stroke or embolic stroke of undetermined sources is used where no etiology could be detected. We are describing this rare case of "recurrent stroke with undetermined etiology" finally proved to have an uncommon underlying etiology.

Prevalence of atrial fibrillation in acute ischemic stroke patients: A hospital-based study from India.

BACKGROUND: Secondary stroke prevention is as important as the treatment of acute ischemic stroke in regards to halt neurological disability and to lower down mortality due to recurrent episodes. The effective secondary prevention depends on finding the specific risk factors leading to cerebro-vascular insult. AIMS AND OBJECTIVES: We aimed this study to find prevalence of persistent/Paroxysmal AF in stroke patients from single center hospital based study. METHODS: Hospital based study enrolled all prospective patients of acute ischemic stroke from January 2016 to December 2018. All patients were subjected to test for risk factors analysis after detail clinical history and examination of these patients. Following variables were recorded; age, gender, stroke territory, stroke severity by NIHSS (National Institute of Health Stroke Scale), LDL-C (Low Density Lipoprotein - cholesterol) of more than 100 mg/dl, HBA1C (Glycosylated Hemoglobin) of more than 6.5, Homocystine of more than 15 Mc Mol/L, 2D-Echocardiographic abnormalities, electrocardiography/24 hour Holter Monitoring, cerebral angiography of brain and neck findings and outcome of patients in 90 days follow-up based on Modified Rankin Scale. RESULTS: Total 246 patients (69.5% men and 30.5% women) of Acute Ischemic stroke were recorded during study period. Mean age was 61.4 years, with 31 (12.4%) patients were below 45 years. Atrial fibrillation (AF) was detected either on conventional ECG or 24 hour Holter monitoring in 62 (25.2%) patients. CONCLUSION: Stroke with AF is found in 25% patients, more common in elderly, female large atrial size and associated with poor outcome.

Comparison of Subjective Sleep Quality of Long-Term Residents at Low and High Altitudes: SARAHA Study.

STUDY OBJECTIVES: To study the effect of altitude on subjective sleep quality in populations living at high and low altitudes after excluding cases of restless legs syndrome (RLS). METHODS: This population-based study was conducted at three different altitudes (400 m, 1,900-2,000 m, and 3,200 m above sea level). All consenting subjects available from random stratified sampling in the Himalayan and sub-Himalayan regions of India were included in the study (ages 18 to 84 years). Sleep quality and RLS status were assessed using validated translations of Pittsburgh Sleep Quality Index (PSQI) and Cambridge Hopkins RLS diagnostic questionnaire. Recent medical records were screened to gather data for medical morbidities. RESULTS: In the total sample of 1,689 participants included, 55.2% were women and average age of included subjects was 35.2 (± 10.9) years. In this sample, overall 18.4% reported poor quality of sleep (PSQI ≥ 5). Poor quality of sleep was reported more commonly at high altitude compared to low altitude (odds ratio [OR] = 2.65; 95% CI = 1.9-3.7; P < .001). It was more frequently reported among patients with RLS (29.7% versus 17.1% without RLS; P < .001). Other factors that were associated with poor quality of sleep were male sex, smoking, chronic obstructive pulmonary disease (COPD), and varicose veins. Binary logistic regression indicated that COPD (OR = 1.97; 95% CI = 1.36-2.86; P < .001), high altitude (OR = 2.22; 95% CI = 1.55-3.18; P < .001), and RLS (OR = 1.66; 95% CI = 1.12-2.46; P = .01) increased the odds for poor quality of sleep. CONCLUSIONS: This study showed that poor quality of sleep was approximately twice as prevalent at high altitudes compared to low altitudes even after removing the potential confounders such as RLS and COPD.

High prevalence of restless legs syndrome/Willis Ekbom Disease (RLS/WED) among people living at high altitude in the Indian Himalaya.

BACKGROUND: At high altitude, prevalence of restless legs syndrome has been found to be greater than expected in small population-based studies, which did not use validated tools for identification of RLS. However, it is not known as to whether this increased prevalence is associated with altitude or increased risk factors for RLS in these populations or errors in identification of RLS. METHOD: This population based, door-to-door study was conducted at low altitude (400 m above sea level) and high altitudes (1900-2000 m and 3200 m above sea level) using random stratified sampling in Himalayan and sub-Himalayan region of India. Subjects between 18 and 84 years were screened for restless-legs-syndrome using the validated Cambridge-Hopkins RLS diagnostic questionnaire. Medical comorbidities were ascertained from their medical records. Their anthropometric measurements were obtained and wake resting oxygen saturation was monitored using finger pulse-oximeter. Physical activity during leisure time was evaluated by using the Goldin leisure time exercise questionnaire. RESULTS: A total of 1689 subjects were included. Average age of the included subjects was 35.2 years; 55.2% were women. RLS was identified in 9.4% subjects with higher prevalence among women (13.6% women vs. 4.1% men; P < 0.001). RLS was significantly more prevalent at higher altitudes (12.2% at 1900-2000 m and 11.8% at 3200 m) compared to low altitude (2.5% at 400 m). The low altitude prevalence matched that reported in prior studies of RLS in India. Subjects with medical disorders sometimes related to RLS (eg, peripheral neuropathy, COPD, varicose veins and anemia) also had higher prevalence of RLS. Binary logistic regression controlling for female gender, number of pregnancies, peripheral neuropathy, varicose veins, anemia showed that high altitude independently significantly increased the likelihood of RLS (OR: 5.4, 95% CI: 2.8, 10.4). CONCLUSION: RLS is about five times more prevalent at high than low altitudes even when controlling for effects of other medical conditions associated with increased risk of RLS.

Mortality in ischemic stroke score: A predictive score of mortality for acute ischemic stroke.

OBJECTIVE: This prospective study was planned to formulate and evaluate a predictive score for in-hospital mortality in cases of acute ischemic stroke. MATERIALS AND METHODS: In this study, 188 consecutive patients of ischemic stroke were included over 19 months. Only patients with renal failure and malignancy were excluded from the study. All patients were subjected to clinical evaluation along with Glasgow Coma Scale (GCS), National Institute of Health Science scale (NIHSS) score, and modified Rankin score (mRS). Investigations total leukocyte count (TLC), capillary blood sugar at admission, high-sensitivity C-reactive protein (HS-CRP), and troponin I, electrocardiogram, and neuroimaging were performed. The patients were followed up till their outcome in the hospital, and patients who expired were grouped as "mortality group" and the rest as "discharged group." One-way anova analysis was carried out among the significant parameters to identify independent predictors of mortality in cases of ischemic stroke. RESULTS: After statistical analysis, it was found that late presentation to the hospital, pyrexia (temperature >99F), low diastolic blood pressure at the time of admission, hypoxia (saturation of oxygen <94%), NIHSS score >15, mRS >3, GCS <8, hyperglycemia (random blood sugar >200 mg/dL), raised TLC, and HS-CRP (>10 mg/L) are positive predictive factors of mortality in cases of ischemic stroke. Based on the above findings, a simple and easily applicable mortality in ischemic stroke (MIS) score is developed. CONCLUSION: This MIS score system will help the clinicians in better management of the patient and improved counseling the relatives of patients with ischemic stroke.

Effects on auditory function of chronic exposure to electromagnetic fields from mobile phones.

The widespread use of mobile phones has given rise to apprehension regarding the possible hazardous health effects of high-frequency electromagnetic fields (EMFs) on auditory function. We conducted a study to investigate the effects of long-term (>4 yr) exposure to EMFs emitted by mobile phones on auditory function. Our study population was made up of 40 healthy medical students-31 men and 9 women, aged 20 to 30 years (mean 22.7). Of this group, 31 subjects typically held their phone to the right ear and 9 to the left ear; the non-phone-using ear served as each subject's control ear. The phone-using subjects were also split into two groups of 20 based on the duration of their daily phone use (≤60 min vs. >60 min). All subjects underwent pure-tone audiometry, speech audiometry, impedance audiometry, and brainstem evoked response audiometry (BERA), and comparisons were made between the phone-using ear and the control ear and between the shorter and longer duration of daily use. We found no statistically significant differences in high-frequency pure-tone average between the phone-using ears and the control ears (p = 0.69) or between the shorter- and longer-duration phone-using ears (p = 0.85). Moreover, statistical analysis of BERA findings revealed no significant differences between the phone-using ears and the control ears in terms of wave I-III, III-V, and I-V interpeak latencies (p = 0.59, 0.74 and 0.44, respectively). None of the subjects reported any subjective symptoms, such as headache, tinnitus, or sensations of burning or warmth behind, around, or on the phone-using ear. We conclude that the long-term exposure to EMFs from mobile phones does not affect auditory function.

The dilemma of arranged marriages in people with epilepsy. An expert group appraisal.

INTRODUCTION: Matrimony remains a challenging psychosocial problem confronting people with epilepsy (PWE). People with epilepsy are less likely to marry; however, their marital prospects are most seriously compromised in arranged marriages. AIMS: The aim of this study was to document marital prospects and outcomes in PWE going through arranged marriage and to propose optimal practices for counseling PWE contemplating arranged marriage. METHODS: A MEDLINE search and literature review were conducted, followed by a cross-disciplinary meeting of experts to generate consensus. RESULTS: People with epilepsy experience high levels of felt and enacted stigma in arranged marriages, but the repercussions are heavily biased against women. Hiding epilepsy is common during marital negotiations but may be associated with poor medication adherence, reduced physician visits, and poor marital outcome. Although divorce rates are generally insubstantial in PWE, divorce rates appear to be higher in PWE undergoing arranged marriages. In these marriages, hiding epilepsy during marital negotiations is a risk factor for divorce. CONCLUSIONS: In communities in which arranged marriages are common, physicians caring for PWE are best-equipped to counsel them about their marital prospects. Marital plans and aspirations should be discussed with the family of the person with epilepsy in a timely and proactive manner. The benefits of disclosing epilepsy during marital negotiations should be underscored.

Prevalence of Sleep Disorders Among Primary School Children.

OBJECTIVE: To screen symptoms of sleep disorders among primary school children. METHODS: Four schools from urban area and four rural schools were included in this study. Symptoms of sleep disorders were assessed using the validated Hindi version of Childhood Sleep Habit Questionnaire in 8-13 y old children. Comparison was made between urban and rural group and between boys and girls. Descriptive statistics was calculated. RESULTS: Mean age of the subjects included in this study was 8.9 ± 1.5 y. Boys and girls were equally distributed, however, rural sample was smaller. More than one awakening each night was found in 12.2 % children. In the whole group, prevalence of bed-wetting was 8.7 %, sleep-talking 20.9 %, sleep-walking 3.2 %, teeth grinding 15.4 % and night terrors 8.4 %. Daytime sleepiness was reported by 25.5 % and napping by 56.4 %. 17.3 % used to fall asleep in unusual circumstances and the teacher or the friend in 6.9 % students noticed it. Snoring was reported by 11.4 % children, and 6.3 % reportedly struggled to breathe during sleep. Domicile and gender did not affect prevalence of parasomnia, however, symptoms of sleep apnea were more frequent among rural children. Daytime sleepiness was more common among rural children as compared to urban. CONCLUSIONS: Symptoms of sleep disorders are prevalent among primary school children. Common disorders are parasomnia, sleep apnea and daytime sleepiness.

Sleep-patterns, co-sleeping and parent's perception of sleep among school children: Comparison of domicile and gender.

This study was aimed at assessment of sleep schedule, pre-sleep behavior, co-sleeping and parent's perception of sleep of school going children. METHOD: Four schools each, from urban and rural area were included. Sleep patterns were assessed using the validated Hindi version of Childhood-Sleep-Habit-Questionnaire. Comparison was made between urban and rural group and between boys and girls. Interaction of gender, domicile and school-type was examined on the sleep patterns. RESULTS: This study included 831 school children with mean age of 8.9 years. Nearly half of the subjects were boys in this study. Urban children outnumbered those from rural area. Total sleep time on weekdays was 8.3 h that increased to 9.5 h on weekends. Rural children spent more time in sleep than urban children on weekdays and weekends. A higher proportion of urban children felt sleepy during the day. Television watching before bedtime was more common in urban settings. Room sharing was more common among rural children. Nearly 65% rural parents as compared to 77.5% urban parents reported that their child was sleeping sufficient enough. Gender did not affect sleep-schedule and parent's perception regarding their child's sleep. Interaction between gender, domicile and school-type did not have any significant effect on sleep patterns. CONCLUSION: Television watching before bedtime was more common among urban school children and they had shorter total sleep time. They had signs of sleep deprivation. Room sharing was more common among rural children. Despite longer sleep time, parents of rural children felt the need for more sleep.