Tolosa-Hunt Syndrome and Ocular Myasthenia: A Rare Coexistence or Real Association.

Tolosa- Hunt syndrome is a rare steroid responsive disorder caused by granulation tissue involving the cavernous sinus or superior orbital fissure presenting as painful ophthalmoplegia and facial pain. In this report, we describe coexistence of Tolosa-Hunt syndrome with ocular myasthenia which may point towards an autoimmune etiological basis behind the cavernous sinus granulation tissue formation and also offered therapeutic challenge to ameliorate the symptoms.

Hashimoto's Encephalopathy Presenting with Chorea.

Hashimoto's encephalopathy (HE) is a steroid-responsive relapsing neuropsychiatric disorder associated with high titers of antithyroid antibody with or without thyroid dysfunction. We report a case of HE in a 78 year old female who developed sudden onset behavioral abnormalities associated with choreiform movement of extremities. All causes of vascular, infective, metabolic, autoimmune, paraneoplastic and toxic encephalopathy were excluded. Anti-thyroid peroxidase (anti-TPO) antibody was found to be raised with very high titre. A diagnosis of HE was made. Prompt treatment with high dose steroid led to dramatic improvement of symptoms including choreiform movement.

Quality of Life and Clinical Response to On-Demand Maintenance Doses of Infliximab in Patients With Ankylosing Spondylitis.

AIM: The aim of this study was to study the effect of modified maintenance doses (MDs) of infliximab on the quality of life (QoL) of patients with ankylosing spondylitis (AS) over a period of 3 years. METHODS: Medical records of AS patients (n = 25) who received a normal induction dose but modified MDs as required were retrospectively analyzed. After induction dose and the first MD, patients were followed up every month and were treated with infliximab whenever Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score was 4 or greater. The study end points were the percentage of responders defined as reduction of 40% or greater in BASDAI score and improvement in QoL defined by mean change in SF-36 Physical Component Summary score, SF-36 Mental Component Summary score, and Ankylosing Spondylitis Quality of Life (ASQoL) values at week 6 and after the last MD (ie, at the end of 3 years) compared with baseline. RESULTS: Majority of the patients were males (n = 20), and the mean age of the analysis population was 40.6 ± 10.79 years. At the end of 6 weeks and after the last MD, BASDAI 40 scores were achieved in 100% and 92% of the patients, respectively. From baseline, the mean change in BASDAI score at the end of 6 weeks and after the last MD is -3.56 and -3.40, respectively. The overall mean change in scores (BASDAI, SF-36 Physical and Mental Component Summary, and ASQoL) versus baseline, at 6 weeks, and after the last MD was statistically significant (P < 0.0001). CONCLUSIONS: The results of the study suggest that initial induction and an on-demand MD regimen of infliximab based on BASDAI were associated with significant improvement in disease activity and QoL.

Movement disorders: Indian scenario: a clinico-genetic review.

Movement disorder (MD) is an important branch of neurology and has great potentiality in management because of improved diagnosis and therapeutic strategies. Over the last three decades, emphasis has been laid on the evaluation of various MDs in India by a limited number of interested neurologists and basic scientists. In this review, we want to highlight common problems of MDs in India with regard to epidemiology, clinical features and genetics.

Socio-demographic and Audiological Profile of the Board-Reviewed Applicants for Hearing Handicap Certification in a Tertiary Care Teaching Institute in Eastern India.

To analyze the socio-demographic and audiological profile of the applicants for hearing handicap certification in the Medical Board (henceforth, "Board") of a tertiary care teaching institute. This is a retrospective record review (March 2019-February 2020) from the archival computer database of the institutional Board. The procedure for audiological assessment prior to Board review and thereafter, the evaluation at the Board (computation of hearing impairment) for eligibility for certification was discussed. The socio-demographic profile of the applicants (age, gender, faith) and the types of hearing impairment [HI%; organic (sensorineural, mixed), non-organic (malingering)] were analyzed with relevant statistical parameters. A HI% scale was introduced to classify the severity of the hearing deficit. Of the 163 applicants, 148 had organic hearing loss (average age: 35.4 years; 1.9 times male preponderance) and 15 were malingerers (average age: 35.7 years; 14 times male preponderance). The left ear contributed more to the hearing handicap. Most applicants having sensorineural hearing loss (SNHL; n = 124) were within 10-19 years and 40-49 years (19.35% each), with 12% being ≧ 60 years (age-associated hearing loss). Of the 13 applicants of age ≦ 12 years, eight were diagnosed with brainstem evoked response audiometry, and 10 had HI score of ≥ 70%. Muslim population with SNHL tended to avail certification 1.34 times more than the Hindus. Most of the applicants with mixed hearing loss (MHL; n = 24) were in their fifth and sixth decades (29.2% each), with three times male preponderance. Among the malingerers, the average malingering impairment was 66% (median: 61%; range 44-100%). Among the SNHL population, ~ 30% had HI at 90-100% in contrast to the MHL population of whom 8% had HI at > 90% and 29% had HI at 40- < 55%. Ten applicants among the organic hearing loss group (6.76%) (two with SNHL; eight with MHL) had HI scores of < 40% and were considered ineligible for certification. The outcomes of the review provided a comprehensive account of the socio-demographic profile of the applicants for handicap certification and the type of hearing loss prevailing in a given population. These data, and the severity stratification of the hearing disability through the HI% scale would provide the policymakers and stakeholders with proper directions to work upon.

Spatiotemporal characterization of relative humidity trends and influence of climatic factors in Bangladesh.

The frequency and intensity of climate change and resulting impacts are more prevalent in South Asian countries, particularly in Bangladesh. Relative humidity (RH) is a crucial aspect of climate, and higher RH variability has far-reaching impacts on human health, agriculture, environment, and infrastructure. While temperature and rainfall have gained much research attention, RH studies have received scant attention in the research literature. This study investigated the trends and variability of RH levels in Bangladesh and the influence of other meteorological factors over the past 40 years. Variabilities in the meteorological factors were identified by calculating descriptive statistics. Innovative trend analysis (ITA) and Mann-Kendall test (MK-test) methods were utilized to assess monthly, seasonal, and annual trends. The magnitude of temperature, rainfall, and windspeed influences on RH variability were identified using Pearson's correlation, Spearman rank correlation, and Kendall correlation model. Variability analysis showed higher spatial variations in RH levels across the country, and RH skewed negatively in all stations. Results reveal that daily, monthly, seasonal, and annual trends of RH exhibited positive trends in all stations, with an increasing rate of 0.083-0.53% per year in summer, 0.43-0.68% per year in winter, and 0.58-0.31% per year in the rainy season. Both ITA and MK-test provided consistent results, indicating no discrepancies in trend results. All three models indicate that temperature, rainfall, and windspeed have weak to moderate positive influences on changing RH levels in Bangladesh. The study will contribute to decision-making to improve crop yields, health outcomes, and infrastructure efficiency.

Perspectives and early experience on endoscopic stapedotomy from a group of "traditional school" otologists.

Background: This paper evaluates endoscopic stapedotomy from the perspectives of a group of 3 surgeons, each of whose experience in endoscopic and microscopic stapedotomy is 3 years and more than 12 years, respectively.Methods: Thirty-four patients clinically diagnosed with stapedial otosclerosis were alternately assigned for unilateral, microscope- and endoscope-assisted stapedotomy following the selection criteria given. Results were evaluated with predetermined epidemiologic, preoperative, perioperative, and postoperative outcome parameters.Results: The microscope group had 12 ears with otosclerosis and the endoscope-assisted group 14. Ears found to have conditions other than otosclerosis at surgery, and patients lost to follow-up were excluded. Apart from the operative time, the difference in the results of none of the parameters was statistically significant in the two groups. The average operative times for microscope- and endoscope-assisted stapedotomy were 63 minutes and 86.5 minutes, respectively, the difference being statistically significant (P < .001).Conclusions: From the perspectives of otologists in differential positions in the learning curve for microscope- and endoscope-assisted stapedotomy, there were no statistically significant differences between the two procedures in the execution of the steps to achieve "adequate surgical exposure" and in postoperative outcomes, except for operative time.

Encountering Chronic Sore Throat: How Challenging is it for the Otolaryngologists?

Objective To explore and diagnose the underlying causes of chronic, recalcitrant sore throat. Methodology In this descriptive, cross-sectional study spanning 3 years (January 2014-December 2016), 1580 patients with chronic sore throat (>12 weeks duration, despite conventional medication) were evaluated for the possible cause(s) in a tertiary care teaching institute of eastern India, through proper history, appropriate investigations, and a self-designed algorithm. Results The common causes for chronic sore throat were chronic tonsillopharyngitis, gastroesophageal reflux disorder, submandibular sialadenitis, and laryngopharyngeal reflux disorder, respectively. Allergy, psychiatric illnesses, oral submucous fibrosis, systemic comorbidities (diabetes mellitus, hypothyroidism, uremia, arthritides), stylalgia, Koch's pneumonitis, recurrent aphthous ulcers, and dietary deficiencies formed the other major causes. There was a minimal female preponderance, the female: male ratio being 1.25. About 39% patients were chronic smokers, and 31% addicted to alcohol. Forty-three (2.72%) patients were reactive to HIV 1/2. Conclusion The study provided with a detailed account of the heterogeneous etiology of chronic sore throat, and an overall structured idea on how to approach to its work-up and diagnosis. Proper history taking and appropriate structured investigations are the keys. Chronic tonsillopharyngitis, gastroesophageal reflux disorder, submandibular sialadenitis, and laryngopharyngeal reflux disorder were the chief causes of chronic sore throat.

Quantitative dimensions of histopathological attributes and status of GSTM1-GSTT1 in oral submucous fibrosis.

Oral submucous fibrosis (OSF) is a precancerous condition of the oral cavity and oropharynx and a significant number of such cases transform into oral squamous cell carcinoma (OSCC). Presently, diagnosis of OSF is done mainly through qualitative histopathological techniques and in the level of diagnostic molecular biology no specific genetic marker is evident. Keeping these facts in mind this study evaluates histopathological changes in the epithelium and subepithelial connective tissue of OSF through quantitative digital image analysis in respect to specific candidate features and analyses null mutations in the GSTM1 and GSTT1 by PCR amplification. The analysis revealed that there are subtle quantitative differences in the histological images of OSF compared to NOM. The thickness of the epithelium and cell population in its different zones, radius of curvature of rete-ridges and connective tissue papillae were decreased but length of rete-ridges and connective tissue papillae, fibrocity and the number of cellular components (predominantly inflammatory cells) in the subepithelial connective tissue were increased in OSF. The PCR study revealed that there is no significant difference in the allelic variants in GSTM1 between OSF and normal, while GSTT1 null gene showed significantly higher frequencies in this precancerous condition. This study establishes a distinct quantitative difference between normal oral mucosa (NOM) and OSF in respect to their histological features and GST null gene frequencies.

Development, Characterization and Electromechanical Actuation Behavior of Ionic Polymer Metal Composite Actuator based on Sulfonated Poly(1,4-phenylene ether-ether-sulfone)/Carbon Nanotubes.

This paper presents the development of new cost-effective hybrid-type sulfonated poly(1,4-phenylene ether-ether-sulfone) (SPEES) and functionalized single-walled carbon nanotubes (SWNT) based actuators produced by the film-casting method followed by chemical reduction of Pt ions as electrodes. The preparation of SPEES was investigated in details and sulfonation of polymer was characterized by ion exchange capacity (IEC), Fourier-transform infrared (FTIR) and degree of sulfonation measurements. SPEES having degree of sulfonation of 126% was blended with SWNT and used to fabricate IPMC actuator. The chemical composition and detailed structure of SPEES-SWNT ionic polymer membranes were confirmed by FTIR, EDX and transmittance electron microscopy (TEM) analysis. Scanning electron microscopy (SEM) micrographs revealed the homogeneously distributed layers of Pt electrodes on the surfaces of IPMC membrane. The electrochemical and electromechanical properties of SPEES-SWNT-Pt-based IPMC actuator shows a better actuation performance than conventional IPMC actuators in terms of higher IEC, Proton conductivity, higher current density, electrochemical impedance spectroscopy (EIS), and large bending deflection. The robust, flexible and mechanically strong membranes prepared by the synergistic combination of SPEES and SWNT may have considerable potential as actuator materials for robotic and biomimetic applications.

Novel ionic polymer-metal composite actuator based on sulfonated poly(1,4-phenylene ether-ether-sulfone) and polyvinylidene fluoride/sulfonated graphene oxide.

In the present work, sulfonated graphene oxide and sulfonated poly(1,4-phenylene ether-ether-sulfone) were blended with polyvinylidene fluoride to create a novel ionic polymer-metal composite actuator with enhanced performance. An ionic polymer-metal composite membrane in the protonated form was prepared by casting a composite blend of sulfonated poly(1,4-phenylene ether-ether-sulfone), polyvinylidene fluoride and sulfonated graphene oxide onto a plating of platinum metal as the electrode. The degree of sulfonation of poly(1,4-phenylene ether-ether-sulfone) was characterized using ion-exchange capacity measurements. Energy dispersive X-ray and transmittance electron microscopy analyses were carried out to analyze the chemical composition and detailed structure. Deposition of the platinum electrode and the surface morphology of the proposed ionic polymer-metal composite actuator were assessed using scanning electron microscopy analysis. The electrical properties were measured using cyclic voltammetry, linear sweep voltammetry and proton conductivity. These measurements confirmed the better actuation performance of the fabricated ionic polymer-metal composite actuator compared to other expensive ionic polymer-based actuators, in terms of its high ion-exchange capacity, good proton conductivity, high current density and large bending deflection. The robust, flexible and mechanically strong membrane actuator, fabricated via the synergistic combination of sulfonated poly(1,4-phenylene ether-ether-sulfone), polyvinylidene fluoride and sulfonated graphene oxide, has considerable potential as an actuator material for robotic, bio-mimetic and other applications.

A Curious Case of Ankylosing Spondylosis and Motor Neuron Disease: A Mere Coincidence or Correlation?

Ankylosing spondylitis (AS) is a chronic (progressive) painful inflammatory rheumatic disease with genetic predisposition. Genetic susceptibility and common expression cause susceptibility to other inflammatory diseases such as psoriasis, ulcerative colitis, and Crohn's disease. However, cases of motor neuron disease (MND) in patients of biologically treated patients of AS have been rarely reported. AS does not follow the same course in everyone; even among affected members of one family, the outcome varies. Here, we present a case of an unusual AS without expression of human leukocyte antigen-B27 genetic marker who subsequently develops amyotrophic lateral sclerosis the most common form of MND. This mere correlation of one noncurable disease with one potentially treatable chronic rheumatological condition adds our knowledge to existing literature.

Anti-Neutrophil Cytoplasmic Antibody (ANCA)-Negative Small Vessel Vasculitis: A Rare Cause of Pulmonary Renal Syndrome.

Pulmonary renal syndrome (PRS) is characterized by both diffuse alveolar haemorrhage and glomerulonephritis as pathological features. Several immunologic and non-immunologic mechanisms including anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis, anti-glomerular basement membrane disease, and systemic lupus erythematosus are commonly involved in the pathogenesis of the syndrome. We herein present a 60-year-old woman, non-smoker, who presented with fever, polyarthralgia, and the spreading of generalized purpuric rashes. The patient displayed rapid deterioration over the following two weeks marked by progressive declining renal function followed by haemoptysis. The patient was subsequently diagnosed with PRS, which was confirmed by the radiological evidence of alveolar haemorrhage and the histopathological evidence of pauci-immune glomerulonephritis. All immune markers including ANCA were negative. The patient was successfully treated with hemodialysis and immunosuppressive therapy. ANCA-negative vasculitis is a rare entity and even more rare as an etiology of PRS. An early diagnosis of this disease and its timely intervention is crucial.

Immunodiagnosis of the primary brain tumor (glioma) by the endogenous lectin.

BACKGROUND: A sugar-binding protein, lectin, was identified in the cystic fluid of brain tumor (glioma). METHODS: The protein was purified by high performance liquid chromatography. RESULTS: The molecular weight of the lectin was 29 kDa. The activity of the purified protein was inhibited strongly by p-nitro-beta-D-galactose and asialofetuin. The lectin activity was not Ca(2+)- or Mg(2+)-dependent. The antiserum of this pure lectin specifically cross-reacted in the cerebrospinal fluid (CSF) of glioma tumor patients. The same antibody had no reaction with CSF of other neurological patients, normal rat brain tissue extract, oncofetal antigens such as alpha fetoprotein (AFP), carcinoembryonic antigen (CEA), plant lectins, and other body fluids like plural and ascites. CONCLUSIONS: This antilectin antibody may be useful in the evaluation of patients with primary brain tumor (glioma).

Acute hepatitis B presenting as Guillain-Barré syndrome.

Guillain-Barré syndrome associated with acute hepatitis B virus infection is rare. We report a 56-year-old man who presented as Guillain-Barré syndrome in the absence of icterus and was subsequently shown to have acute hepatitis B. He improved on conservative therapy.

Fenofibrate-induced myopathy.

Fenofibrate induced myopathy is a rare adverse event. We present a case of muscle pain and quadriparesis following administration of 200mg of fenofibrate for 35 days. Patient gradually improved after stopping the drug. As per our knowledge, this is probably the first case report of fenofibrate induced myopathy from India.

Cystic squamous cell carcinoma of the neck: could a second metastatic focus help?

Squamous cell carcinoma of the neck presenting clinically as predominantly cystic lesion has often been considered as branchiogenic carcinoma in the past. However, such cystic lesions presently constitute a distinct form of head-neck metastasis, and a co-existent second metastatic focus could supposedly help distinguish them from branchiogenic carcinoma. We here present a case where, although the primary remained elusive, the associated spinal metastasis precluded us from diagnosing a cystic squamous cell carcinoma as branchiogenic carcinoma. Thus a second metastatic focus, if found, could add to the existing knowledge to distinguish between a cystic squamous cell carcinoma and the so-called branchiogenic carcinoma, especially when the primary could not be found.

Ameloblastic carcinoma of mandible: facts and dilemmas.

Ameloblastic carcinoma is a rare malignant odontogenic tumor and is considered as the malignant counterpart of ameloblastoma with features of both benign and malignant histology. It may arise de novo or from a long-standing ameloblastoma and is locally aggressive with a propensity for metastasis. With limited documentation, little is known about its pathobiogenesis, with no universal guidelines for management. For clinicians, differentiating ameloblastic carcinoma from ameloblastoma and malignant ameloblastoma in a patient presenting with a suspicious jaw tumor is a challenge due to overlapping clinical features, inconclusive cytology/biopsy reports, different management approaches and inadequate follow-up. Proper knowledge of the disease entity and a high index of suspicion are essential. Here we elaborate the dilemmas in diagnosis and management of ameloblastic carcinoma through presentation of a representative case in a 56-year-old man presenting with a tumor in the mandible.

A comparative study of efficacy and safety of lornoxicam versus tramadol as analgesics after surgery on head and neck.

To assess efficacy and safety of lornoxicam as analgesic after surgery on head and neck in comparison to tramadol. Forty five patients undergoing operations on head and neck were recruited and randomly assigned to two parallel groups-lornoxicam and tramadol, both given intramuscular on the first post-operative day followed by oral tablets for the consecutive 4 days. Treatment was given single blind. 10 cm visual analog scale (VAS) pain score and wound tenderness assessed by a 3-point ordinal scale were the primary efficacy parameters. Use of rescue medication and percentage of subjects having at least 50 % pain relief by 48 h were also compared as secondary parameters. The groups were comparable at baseline regarding age, sex and VAS score. There was steady decline in VAS pain score from baseline to study end in both the groups, indicating good analgesic efficacy with either drug. Between groups comparisons of VAS score showed no significant difference at any time point. Between groups comparisons of wound tenderness also showed no significant difference. Five patients on lornoxicam and one patient on tramadol experienced at least 50 % pain relief at 48 hours compared to baseline while five patients from the lornoxicam group and eight from the tramadol group required rescue medicine. The tolerability of lornoxicam appeared to be significantly superior to tramadol, with less number of patients experiencing adverse drug reactions. Lornoxicam is safe, effective and comparable to tramadol for relieving postoperative pain after operations on head and neck.