Mollaret's Syndrome: A Case Report.

Benign recurrent aseptic meningitis is a rare condition characterized by recurring, self-limited episodes of aseptic meningitis. Meningeal irritation typically occurs first, accompanied by fever and mononuclear cell pleocytosis. The diagnosis is only made after other known causes of lymphocytic meningitis have been excluded. Resolution typically occurs within two to seven days without residual neurological deficit. Aseptic meningitis is most frequently caused by viruses; Mollaret's meningitis has been linked to the herpes simplex virus 2 (HSV 2). It is unclear if prophylactic medication is indicated for these patients. We describe a patient who was experiencing her seventh episode of aseptic meningitis.

Adjuvant Priming Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Obsessive-Compulsive Disorder: In Search of a New Paradigm!

OBJECTIVES: Repetitive transcranial magnetic stimulation (rTMS) is used as a therapeutic option for obsessive-compulsive disorder (OCD) in both clinical and research settings. There has been no consensus with regard to target area and other parameters, although 1-Hz rTMS over the supplementary motor area (SMA) is found to be promising. Priming stimulation, which involves high-frequency followed by low-frequency rTMS, has been shown to enhance neural response to low-frequency rTMS. Hence, this study was conducted to investigate the effect of adjunctive priming rTMS over the SMA in treatment-resistant OCD. METHODS: Thirty patients with OCD who were symptomatic after an adequate selective serotonin reuptake inhibitor trial were randomized into 2 groups: one group receiving active priming stimulation (6-Hz rTMS at 80% resting motor threshold) followed by 1-Hz rTMS (priming rTMS group) and the other receiving sham stimulation followed by 1-Hz rTMS (rTMS-only group). Both groups received 10 sessions of such interventions for 2 weeks. Both the rater and patients were blind to the treatment allocation. Assessments were done using the Yale-Brown Obsessive Compulsive Scale, Hamilton Rating Scale for Depression, Hamilton Rating Scale for Anxiety, and Clinical Global Impression-Improvement scale at baseline, 2 weeks, and 4 weeks. RESULTS: Both groups showed a significant improvement in all domains of psychopathology over time. The priming rTMS group was better than the rTMS-only group in reducing the Yale-Brown Obsessive Compulsive Scale compulsion score (P < 0.023) as well as scores of the Hamilton Rating Scale for Anxiety, Hamilton Rating Scale for Depression, and Clinical Global Impression-Improvement scale. None developed any adverse effects requiring medical attention. CONCLUSIONS: Priming rTMS over the SMA is safe and has favorable effects in OCD. It seems to have a predominant effect on the reduction of compulsions, presumably rectifying the impaired response inhibition in patients with OCD.

Direct Diagnostic Tests for Lyme Disease.

Borrelia burgdorferi was discovered to be the cause of Lyme disease in 1983, leading to seroassays. The 1994 serodiagnostic testing guidelines predated a full understanding of key B. burgdorferi antigens and have a number of shortcomings. These serologic tests cannot distinguish active infection, past infection, or reinfection. Reliable direct-detection methods for active B. burgdorferi infection have been lacking in the past but are needed and appear achievable. New approaches have effectively been applied to other emerging infections and show promise in direct detection of B. burgdorferi infections.

Excised Femoral Heads in Hip Fracture Patients: Is Osteoporosis Worse Than Cancer?

Introduction Annually 80,000 hip fractures are treated at an estimated cost of two billion pounds. The 2011 guidance from the Royal College of Pathologists recommended all specimens where there is fracture through or below the articular surface should be examined to exclude/ identify an underlying cause (pathological fracture). The questions posed in this study are three-fold. Firstly, how does our practice for hip fracture patients comply with the above audit standards? Secondly, what is the prognostic significance of a past medical history of malignancy on survival? Thirdly, is there any other prognostic survival difference attributable to the diagnosis concluded from the histological analysis of the excised femoral head specimens? Methods A retrospective analysis of all hip fractures receiving joint arthroplasty was undertaken between January 2011 and March 2014. Mortality was recorded for a minimum follow-up of 30 months post-operatively. Each excised femoral head was histologically examined by a single consultant histopathologist, and all pre-operative X-rays were reviewed by a consultant radiologist. Histological diagnoses were recorded, and statistical analysis including Kaplan-Meier survival was performed. Results A total of 327 consecutive fractures were identified. Out of 187 specimens sent for analysis, only two revealed metastatic deposits in patients with known disseminated malignancy. A previous medical history of malignancy did not confer a significant increase in mortality over a five-year postoperative period (p = 0.42). A histological diagnosis of osteoporosis significantly increased mortality over a five-year postoperative period (p = 0.004). A comparative analysis found that patients with a histological diagnosis of osteoporosis had the poorest survival. Conclusion A histological femoral head analysis may diagnose previously undiagnosed osteoporosis, allowing the clinician to intervene in a disease process, which if left untreated, can lead to a significant increase in mortality.

Evaluation of the Effect of Regional Anaesthesia on Microvascular Free Flaps.

OBJECTIVE: Multiple factors influence the success of microvascular free flap surgeries. Anaesthesia is an important factor to maximise the success rate of microvascular free flaps both by controlling haemodynamics and improving the perfusion of free vascularised tissue. The debate on the usefulness of regional and general anaesthesia for free tissue transfer is ongoing. This retrospective study was conducted to evaluate the effects of regional anaesthesia and other perioperative factors on outcomes of microvascular free flaps. METHODS: This retrospective observational study was conducted on 165 patients undergoing microvascular free flap surgeries between January 2014 and December 2015 after obtaining approval from the Institutional Ethics Committee (Nizams Institute Ethics Committee, Nizams Institute of Medical Sciences, India). Perioperative variables analysed included the type of surgery, indication, ASA physical status, type of anaesthesia, perioperative haemodynamics, fluids used, duration of surgery, re-explorations, blood transfusion and duration of hospital stay. The primary outcome measure was to assess the effect of regional anaesthesia on the success of free flap. RESULTS: Multivariate analysis identified the type of anaesthesia and preoperative haemodynamics as independent risk factors for predicting the failure of flap with an odds ratio of 0.208 and 7.469, respectively. A subgroup analysis of 55 acute trauma patients revealed preoperative haemodynamic instability as an individual independent risk factor for graft failure with an odds ratio of 11.90. CONCLUSION: The results of this study emphasise the importance of the choice of anaesthesia and preoperative optimisation in improving the success of free flap surgeries.

Correlation between ultrasound-guided subglottic diameter and little finger breadth with the outer diameter of the endotracheal tube in paediatric patients - A prospective observational study.

BACKGROUND AND AIMS: Selection of an appropriate endotracheal tube (ETT) in paediatric patients is a challenging situation. The purpose of this study was to compare whether measurement of subglottic diameter with ultrasound or the age-old little finger width correlates better with the outer diameter (OD) of the ETT used for intubation. METHODS: Following approval from the Institutional Ethics board and a written informed consent from parent or guardian, this prospective observational study was carried out on 60 American Society of Anesthesiologists physical status I and II patients aged 6 months-8 years, scheduled for elective surgery under general anaesthesia requiring oral endotracheal intubation. Preoperatively ultrasound-guided subglottic diameter (USGD) and little finger breadth (LFB) measurements were taken. On the day of surgery, intubation was done with an uncuffed ETT, whose OD was noted. The concordance and agreeability between two techniques for estimation of the OD of the ETT were measured by Lin's concordance correlation coefficient. Further, the bias and precision between the techniques and the inter-changeability of the techniques were assessed by using Bland and Altman and Mountain plotting, respectively. RESULTS: Lin's concordance correlation coefficient between USGD and LFB with the OD of the ETT was found to be 0.29 (0.13-0.41) and 0.46 (0.29-0.6), respectively. CONCLUSION: Overall, neither USGD nor LFB can be used as a reliable tool to predict the OD of the ETT. Registered in Clinical Trial Registry of India. REF/2016/08/011955.

Advances in Serodiagnostic Testing for Lyme Disease Are at Hand.

The cause of Lyme disease, Borrelia burgdorferi, was discovered in 1983. A 2-tiered testing protocol was established for serodiagnosis in 1994, involving an enzyme immunoassay (EIA) or indirect fluorescence antibody, followed (if reactive) by immunoglobulin M and immunoglobulin G Western immunoblots. These assays were prepared from whole-cell cultured B. burgdorferi, lacking key in vivo expressed antigens and expressing antigens that can bind non-Borrelia antibodies. Additional drawbacks, particular to the Western immunoblot component, include low sensitivity in early infection, technical complexity, and subjective interpretation when scored by visual examination. Nevertheless, 2-tiered testing with immunoblotting remains the benchmark for evaluation of new methods or approaches. Next-generation serologic assays, prepared with recombinant proteins or synthetic peptides, and alternative testing protocols, can now overcome or circumvent many of these past drawbacks. This article describes next-generation serodiagnostic testing for Lyme disease, focusing on methods that are currently available or near-at-hand.

Comparison of volume control and pressure control ventilation in patients undergoing single level anterior cervical discectomy and fusion surgery.

BACKGROUND AND AIMS: Pressure control and volume control ventilation are the most preferred modes of ventilator techniques available in the intraoperative period. The study compared the intraoperative ventilator and blood gas variables of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) in patients undergoing single level anterior cervical discectomy and fusion (ACDF). METHODS: After obtaining Institutional Ethical Committee approval and informed consent, sixty patients scheduled for single level ACDF surgery performed in supine position under general anaesthesia were included. Group V (30 patients) received VCV and Group P (30 patients) received PCV. The primary objective was oxygenation variable PaO2/FiO2 at different points of time i.e. T1-20 min after the institution of the ventilation, T2-20 min after placement of the retractors and T3-20 min after removal of the retractors. The secondary objectives include other arterial blood gas parameters, respiratory and haemodynamic parameters. NCSS version 9 statistical software was used for statistics. Two-way repeated measures for analysis of variance with post hoc Tukey Kramer test was used to analyse continuous variables for both intra- and inter-group comparisons, paired sample t-test for overall comparison and Chi-square test for categorical data. RESULTS: The primary variable PaO2/FiO2 was comparable in both groups (P = 0.08). The respiratory variables, PAP and Cdynam were statistically significant in PCV group compared to VCV (P < 0.05), though clinically insignificant. Other secondary variables were comparable. (P > 0.05). CONCLUSION: Clinically, both PCV and VCV group appear to be-equally suited ventilator techniques for anterior cervical spine surgery patients.

Distal third humeri fractures treated using the Synthes™ 3.5-mm extra-articular distal humeral locking compression plate: clinical, radiographic and patient outcome scores.

BACKGROUND: Conventional management protocols for distal humeral extra-articular fractures (e.g. conservative, double columnar plating) are often associated with complications. We aimed to describe our experience of using the Synthes™ 3.5-mm extra-articular distal humeral locking compression plate for treatment of extra-articular distal humeral fractures. METHODS: We prospectively studied 23 consecutive patients who underwent fixation, in a tertiary trauma centre, over 2 years. Data, including patient demographics, duration of follow-up, patient satisfaction, visual analogue score (VAS), Oxford Elbow Score, and final outcome on discharge, were collected and analyzed. RESULTS: Of the 23 patients (12 males, 11 females; mean age 47.5 years; range 18 years to 89 years), all fractures united radiologically and clinically after the index procedure, with a mean time to fracture union of 15.7 weeks (range 9 weeks to 34 weeks) and a mean time to discharge of 17.8 weeks (range 13 weeks to 34 weeks). Oxford Elbow Score was 36.5 (range 11 to 48) at 4.6 months postoperatively; at 20 months follow-up, it was 40 (range 14 to 48) and the VAS was 8.5 (range 5 to 10). One patient had radial nerve neuropraxia pre-operatively, and one postoperatively, and both recovered uneventfully 3 months postoperatively. Neither superficial, nor deep infections were observed in this cohort. CONCLUSIONS: The present study reports satisfactory outcome with the usage of the Synthes plate for extra-articular fracture management. It has become the technique of choice in our centre because it provides excellent results.

Caregivers burden of patients with schizophrenia and bipolar disorder: a sectional study.

BACKGROUND: Caregiving has been identified as a basic component of human nature and a primary element of close relationship. This study aims to assess the extent and pattern of burden felt by the caregivers of patients with schizophrenia in comparison with bipolar disorder. MATERIALS AND METHODS: Fifty-two patients with schizophrenia and fifty-one patients with bipolar disorder attending the outpatient department were assessed in the study. The burden among the caregivers was assessed using Burden Assessment Schedule. RESULTS: The caregivers of schizophrenia group had significantly higher total burden score as compared to caregivers of bipolar disorder. Caregivers of schizophrenia experienced significantly higher burden in area of external support, caregivers routine, and other relations. CONCLUSION: The extent of burden among families of schizophrenic patients is more than those of bipolar disorder. The families of patients with bipolar disorder do also experience considerable burden. The pattern of burden among families of schizophrenia and bipolar disorder is almost identical in most of the domains except for external support, caregivers routine, and other relations.

Prevalence of traumatic dental injuries to the anterior teeth among three to thirteen-year-old school children of Tamilnadu.

CONTEXT: Dental trauma has become an important attribute of dental public health. The primary requisite before actively dealing with such problems is to describe the extent, distribution, and associated variables with the specific condition. AIMS: The aim of the present study was to assess the prevalence and distribution of traumatic dental injuries (TDI) to anterior teeth among 3 to 13 years old Chidambaram school children. SETTINGS AND DESIGN: A cross-sectional study was conducted. Data was collected through a survey form and clinical examination. MATERIALS AND METHODS: A total of 3200 school children in the age group of 3-13 years were selected from 10 schools of Chidambaram, Tamilnadu. Information concerning sex, age, cause of trauma, number of injured teeth, type of the teeth, lip competence, terminal plane relationship and the molar relationship were recorded. STATISTICAL ANALYSIS USED: The statistical software EPIINFO (Version 6.0) was used for statistical analysis. In the present study, P≤0.05 was considered as the level of significance. RESULTS: The trauma prevalence in the present study was 10.13%. Children with class I type 2 and mesial step molar relationship exhibited more number of dental injuries. Enamel fracture was the most common injury recorded. Only 3.37% of the children had undergone treatment. CONCLUSION: The high level of dental trauma and low percentage of children with trauma seeking treatment stresses the need for increased awareness in Chidambaram population.

Evaluation of bachmann bundle pacing versus right atrial pacing in prevention of atrial fibrillation after coronary artery bypass surgery.

BACKGROUND: In patients undergoing coronary artery bypass surgery (CABGS), occurrence of atrial fibrillation (AF) is common in the postoperative period and is associated with increased morbidity with longer intensive unit care (ICU) and hospital stay. Prevention with antiarrhythmic drugs is of limited success and associated with significant side effects. Therefore alternative approaches, such as Bachmann Bundle pacing, are required. METHODS AND RESULTS: 154 consecutive patients, mean age 58±8.8 years, including 134 males and 20 females, were randomized to three groups; Group I : No pacing n= 54, Group II : RA pacing n= 52, Group III : Bachmann Bundle pacing n= 48. All the groups were well matched with regard to age, left atrial size, ejection fraction and use of beta blockers. Patients in Groups II and III were continually paced at a rate of 100 beats per minute (bpm) or at 10 bpm more than patients' intrinsic heart rate. All the patients were monitored for 72 hours by telemetry and occurrence of AF was noted. Incidence of AF was 0% (none of 48 patients) in Group III as compared to 16.6% in Group I (9 of 54 patients) (p 0.003) and 12.5% in Group II (5 of 52 patients) (p 0.03). There was a trend towards shorter ICU stay in Group III (3.9 days) as compared to Group II (4.5 days) and Group I (4.1 days). Among the three groups, the reduction in mean P wave duration also was greater in Bachmann bundle paced group. CONCLUSION: In patients undergoing CABGS, Bachmann bundle pacing is superior to right atrial / no pacing in the post operative period for preventing occurrence of AF and reducing ICU stay, commensurate with a reduction in mean P wave duration on surface ECG.

A study of the effects of LY2216684, a selective norepinephrine reuptake inhibitor, in the treatment of major depression.

The current study sought to test the efficacy and safety of the novel selective norepinephrine reuptake inhibitor LY2216684 compared to placebo in patients with major depressive disorder (MDD). Escitalopram was used as a control for assay sensitivity. Adult outpatients with MDD, confirmed at screening by the Mini International Neuropsychiatric Interview, a Self-Rated Quick Inventory of Depressive Symptomatology (QIDS-SR) score of at least 12 and a Clinical Global Impression-Severity Score of at least 4, were randomly assigned to LY2216684 (N=269), placebo (N=138), or escitalopram (N=62). Efficacy, safety, and tolerability outcomes were compared during 8 weeks of double-blind treatment. LY2216684 plasma concentrations were measured. LY2216684 did not show statistically significant improvement from baseline compared to placebo in the primary analysis of the Hamilton depression rating scale (HAM-D(17)) total score. Escitalopram demonstrated significant improvement compared to placebo on the HAM-D(17) total score, suggesting adequate assay sensitivity. Both LY2216684 and escitalopram showed statistically significant improvement from baseline on the patient-rated QIDS-SR total score compared to placebo. Headache, nausea, constipation, dry mouth, and insomnia were the most frequently reported adverse events in the LY2216684 group. A 3-6 beats per minute mean increase from baseline in pulse rate was observed in the LY2216684 group. LY2216684 plasma concentrations increased as the dose increased from 3 mg to 12 mg. The results of this initial investigation of LY2216684's efficacy suggest that it may have antidepressant potential. More definitive data to confirm this is necessary. Its safety profile does not preclude further clinical development.

An overview of Indian research in bipolar mood disorder.

This review has been done after careful research of articles published in indian journal of psychiatry with the search words of manic depressive psychosis and bipolar mood disorder. Many articles in the following areas are included: 1) ETIOLOGY: genetic studies: 2) ETIOLOGY - neuro psychological impairment: 3) Adult bipolar disorder 4) Epidemological 5) Clinical picture - phenomenology: 6) Course of bipolar mood disorder: 7) Juvenile onset bipolar affective disorder 8) Secondary mania: 9) Clinical variables and mood disorders: 10) Disability: 11) Comorbidity: 12) TREATMENT: biological 13) Recent evidence: 14) Pharmacological evidence in special population. Though there seems to be significant contribution, there are still lot of areas which need careful intervention. The findings in various studies from the indian point of view are reviewed.

Land plants and DNA barcodes: short-term and long-term goals.

Land plants have had the reputation of being problematic for DNA barcoding for two general reasons: (i) the standard DNA regions used in algae, animals and fungi have exceedingly low levels of variability and (ii) the typically used land plant plastid phylogenetic markers (e.g. rbcL, trnL-F, etc.) appear to have too little variation. However, no one has assessed how well current phylogenetic resources might work in the context of identification (versus phylogeny reconstruction). In this paper, we make such an assessment, particularly with two of the markers commonly sequenced in land plant phylogenetic studies, plastid rbcL and internal transcribed spacers of the large subunits of nuclear ribosomal DNA (ITS), and find that both of these DNA regions perform well even though the data currently available in GenBank/EBI were not produced to be used as barcodes and BLAST searches are not an ideal tool for this purpose. These results bode well for the use of even more variable regions of plastid DNA (such as, for example, psbA-trnH) as barcodes, once they have been widely sequenced. In the short term, efforts to bring land plant barcoding up to the standards being used now in other organisms should make swift progress. There are two categories of DNA barcode users, scientists in fields other than taxonomy and taxonomists. For the former, the use of mitochondrial and plastid DNA, the two most easily assessed genomes, is at least in the short term a useful tool that permits them to get on with their studies, which depend on knowing roughly which species or species groups they are dealing with, but these same DNA regions have important drawbacks for use in taxonomic studies (i.e. studies designed to elucidate species limits). For these purposes, DNA markers from uniparentally (usually maternally) inherited genomes can only provide half of the story required to improve taxonomic standards being used in DNA barcoding. In the long term, we will need to develop more sophisticated barcoding tools, which would be multiple, low-copy nuclear markers with sufficient genetic variability and PCR-reliability; these would permit the detection of hybrids and permit researchers to identify the 'genetic gaps' that are useful in assessing species limits.

Simplifying collection of corneal specimens in cases of suspected bacterial keratitis.

Identification of the causative organisms in suspected bacterial keratitis traditionally involves collecting multiple corneal scrapes, which are plated directly onto different solid agar culture media. Difficulties have been reported with this practice, so the development of a simpler diagnostic method in suspected bacterial keratitis would be useful. It is unclear whether a single corneal scrape sent to the microbiology laboratory in a liquid transport culture medium (indirect method) is as reliable for the diagnosis of bacterial keratitis as inoculation of multiple scrapes directly onto agar plates (direct method). To investigate this, bacterial recovery was assessed following transfer and transport of different concentrations and types of bacteria from an artificially contaminated surgical blade into brain heart infusion (BHI). Bacterial recovery rates between the proposed (indirect) and standard (direct) method were then compared after the in vitro inoculation of pig corneas and following specimen collection in patients with presumed bacterial ulcerative keratitis. Recovery of bacteria from contaminated surgical blades was found to be the same from both solid and liquid culture media. There was no significant difference in the numbers of positive cultures from solid (direct) and liquid (indirect) culture media, both in the experimental pig cornea inoculation study (P = 0.34) and in experiments with patients with clinical infections (P = 0.4), with an 85.2% agreement between methods (kappa = 0.61, P < 0.0001). In conclusion, therefore, the collection of two corneal scrapes, one used for Gram staining and the other transported in BHI followed by plating and subculturing in an enrichment medium, provides a simple method for the investigation of presumed bacterial keratitis.