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Stroke is a major cause of death worldwide. Prompt treatment and decision-making is essential for good outcomes. The two major therapeutic approaches for acute ischemic stroke are thrombolytics and neuroprotectants. Piracetam, a nootropic drug aims to increase cerebral blood flow, enhance oxygen extraction, restore membrane fluidity and modulate neurotransmission. Likewise, citicoline has been shown to positively influence cerebral plasticity and neurorepair processes. The present article aims to offer insights on the current management of acute stroke and to position piracetam and its combination with citicoline in the management of acute stroke and post-stroke sequelae based on an expert panel discussion.
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Susceptibility to low temperature stress is the major threat to papaya cultivation. Here, we studied a low temperature stress tolerance in papaya plant. We have investigated the effect of different low temperature regimes, 28°/18°C (day/night) to 16°/06°C (day/night) with a gradual decrease of 2°C on every two days and one set with direct exposure to the low temperature of 18°/08°C (day/night), called the acclimatized plant, in five diverse papaya genotypes (Pusa Nanha, Red Lady P-7-2, P-7-9, and P-7-14) and cold tolerant wild relative of cultivated papaya genotype (Vasconcellea cundinamarcensis V.M. Badillo) under controlled regulated conditions. It was observed that there were significant variations in the physiological and biochemical parameters like photosynthetic gas exchange parameters, chlorophyll content, fluorescence parameters, relative water content (RWC), membrane stability index (MSI), total sugars content, total soluble proteins content, lipid peroxidation, and proline accumulation in leaf tissues. Maximum stomatal conductance, chlorophyll fluorescence, RWC, MSI, total sugars, total soluble proteins, proline and lowest MDA contents were observed in Vasconcellea cundinamarcensis followed by inbred P-7-9 as compared to other genotypes under low temperature stress. Among all the papaya genotypes, P-7-9 showed more adaptability to low temperature stress and it further give new insights for developing low temperature tolerant papaya genotypes, especially under changing climate situations.
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Objective: To evaluate the persistence of antibodies three years after primary vaccination with typhoid conjugate vaccine (TCV) of either Cadila Healthcare Ltd. (Cadila-TCV) or Bharat Biotech International Ltd. (Bharat-TCV) administered in a previous phase II/III study, and to study the booster dose response to Cadila-TCV. Methods: This was an open-label, phase IV extension study conducted in tertiary care and multispecialty hospitals in India. 112 subjects (Cadila-TCV-57, Bharat-TCV-55) who had participated in previous study were enrolled. Of these, eligible subjects received a single-dose of Cadila-TCV and were followed-up for 28 days post-booster. Primary outcome was persistence of antibodies 3 years after primary vaccination and seroconversion (?4-fold rise in antibody titre from baseline) 28 days postbooster. Safety was based on reported adverse events (AEs) post-booster. Results: The baseline GMT reported in the current study was significantly higher than pre-vaccination GMT reported in the previous study. 89/112 (79.5%) subjects had antibody titer ?10 IU/mL at baseline; eligible subjects (n=17) who had baseline antibody titre <10 IU/mL were administered booster dose. All the vaccinated subjects showed seroconversion post-booster. The GMTs reported at 10 days and 28 days post-booster were significantly higher as compared to GMTs reported after primary vaccination in previous study. 4 (23.5%) vaccinated subjects reported 9 AEs; all were solicited and of mild/moderate intensity. Conclusion: There was a significant persistence of immunogenicity after primary vaccination with both the TCVs, and robust immune response after booster vaccination with Cadila-TCV.
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Background: Mental health problem is a major public health issue all over the world including India. In India, mental disorders are the leading contributors to significant morbidity and disability amongst those affected. With changing health pa?erns among Indians, mental behavior and substance use disorders are coming to the forefront in health care delivery systems. Objec?ve: This study was aimed to assess the diagnos?c pa?ern of psychiatric morbidity among the pa?ents a?ending psychiatric outpa?ent department in a private medical college. Methodology: This cross-sec?onal study was carried out in the Department of Psychiatry in Prathima Ins?tute of Medical Sciences located at Karimnagar, Telangana, India. For this study, a total of 442 new subjects a?ending Psychiatry Outpa?ent Department (OPD) from August 2020 to July 2021 were taken. All the informa?on including longitudinal histories of pa?ents was recorded in files and the diagnosis was made following Diagnos?c and Sta?s?cal Manual of Mental Disorders-Fi?h Edi?on (DSM 5). Sociodemographic parameters and family history of mental illness were collected from the record file of the individual pa?ent. Results: In the present study, among the different age groups, the majority (28.05%) of the study subjects were of the age ranging from 21-30 years. The distribu?on according to gender was (62.89%) males and (37.10%) females. The majority of the study subjects belonged to the rural background (69.45%), educated up to 10th standard (28.73%), self-employed (29.86%), married (67.42%), belonged to Hindu religion (85.74%), and with a monthly family income of 5,000 to 10,000 (38.68%). The majority of the study subjects were diagnosed with Major depressive Disorders (28.05%), followed by anxiety disorders (17.87%) and Substance-Related and Addic?ve Disorders (16.96%). Conclusion: This study provides informa?on about the prevalence of psychiatric morbidity among pa?ents a?ending outpa?ent department in a private medical hospital in Northern Telangana. It helps in assessing the pa?ern of psychiatric problems and taking necessary steps to plan for better management of mental health care in the near future.
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BACKGROUND Postgraduate residents’ ability to understand and effectively manage their finances is variable. We conducted this study to assess the awareness of personal financial literacy among Indian residents. METHODS We circulated a web-based cross-sectional Google Forms multiple-choice questionnaire having questions in three categories including financial awareness, current financial status and plans among 400 Indian residents. RESULTS A total of 215 Indian residents (53.75%) responded to the survey (men 80.9%, unmarried 74.4% and pursuing broad specialties 83.3%). The majority were unaware of stocks, special student/doctor loans, tax planning, life insurance, professional indemnity and tax/financial planning. The majority opined that personal finance and investing should be taught at medical school/residency. A financial pyramid based on the hierarchy of needs is proposed. CONCLUSION Lack of financial literacy and planning was seen among the majority of Indian residents. Our study highlights this gap in the medical curriculum and the need for formal structured financial education during training.
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The most widely prescribed drugs for the treatment of a variety of dermatoses are Topical corticosteroids (TC). These medications are approved for the treatment of inflammatory and pruritic manifestations of dermatologic disorders due to their powerful symptom-relieving impact. Clobetasol propionate (CP) is the most popular (TC) used to relieve itching, redness, and oedema caused by a variety of skin disorders. Anti-inflammatory, anti-pruritic, and vasoconstrictive characteristics are all present in it. CP works by binding to cytoplasmic glucocorticoid receptors and activating glucocorticoid receptor-mediated gene expression, resulting in the production of anti-inflammatory proteins while suppressing the production of inflammatory mediators. The formulation is free from known contact allergens, such as propylene glycol, short-chain alcohols, and sorbitol-based emulsifiers, and has demonstrated hypoallergenic effects. The efficacy, safety, and clinical experience of utilizing CP 0.025% cream for the treatment of various dermatologic disorders are discussed in this case series
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Median nerve is formed by lateral root from lateral cord and medial root from medial cord of brachial plexus.Formation of median nerve occur in front or lateral to axillary artery in axilla. In the present study we observed anatomical variations of median nerve formation in the brachial plexus. We examined formalin fixed 60 upper limbs from 30 adult cadavers (15 males and 15 females) which were above the age 40 years from the department of Anatomy. All the cadavers were dissected on both sides according to Cunningham’s Manual of Practical Anatomy. Normal formation of median nerve by two roots noted in 42 (70.0%) of upper limb specimen. Variation of median nerve formation noted in 18 (30.0%) upper limb specimen. Three roots taking part in the formation of median nerve in 13 (21.7%) upper limb specimen where additional root coming from lateral cord of brachial plexus. Four roots taking part in formation of median nerve in 3 (5.0%) upper limb specimen, where additional roots coming from lateral cord and posterior cord of brachial plexus. Lateral root crossed the axillary artery anteriorly to join with medial root lying medial to axillary artery. The median nerve formed medial to third part of axillary artery. Additional communication with musculocutaneous nerve with median nerve seen in 2 (3.3%) upper limb specimen. Knowledge of such anatomical variations is of interest to the anatomist and clinician alike. Surgeons who perform procedures involving neoplasm or repairing trauma need to be aware of these variations. Median nerve variation may lead to confusions in surgical procedures and axillary brachial plexus nerve block anesthesia.
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BACKGROUND Improving patient safety (PS) is critical to optimizing healthcare delivery. There is a need to develop curricula or incorporate PS concepts in health professionals’ (HPs) education, in both theoretical and practical training. Consequently, there is a need to measure the perception of HPs regarding various PS competencies imparted to them during their training. The Health Professional Education in Patient Safety Survey (H-PEPSS) is a tool that measures HPs’ self-reported PS competence and was designed to reflect six sociocultural areas central to PS. The tool has been validated in Canada but not in India. We did a confirmatory factor analysis (CFA) and psychometric validation of the H-PEPSS in the Indian context. METHODS The sample comprised 240 HPs. We used the maximum likelihood estimation method on AMOS V20 (SPSS Inc.) to carry out a CFA of the tool. We used the normed fit index, Tucker–Lewis index, comparative fit index, standard root mean square residual, root mean square residual and root mean square error of approximation to evaluate the model fit. Internal consistency and reliability of the six factors of the model were examined using Cronbach’s alpha. Convergent validity of the model was examined using average variance extracted and composite reliability. Discriminant validity was examined using the Fornell and Larcker criterion and the heterotrait–monotrait method. RESULTS The results indicate a good fit. The H-PEPSS was found to be reliable and valid for assessing PS competencies among HPs. Comparison of the results with the results of the Canadian setting confirmed external validity. CONCLUSION The 16-item H-PEPSS has good psychometric properties for use in the Indian context. The 23-item HPEPSS was found to be reliable and valid for assessing PS.
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Methods@#A total of 18 mice were divided into injured (n=12) and non-injured (n=6) groups. The disc height index (DHI%) at coccygeal 4–5 level was measured by computed tomography (CT) scan for all mice. Coccygeal 4–5 discs of the injury group were injured using a 32G needle fixed to a novel tool and confirmed by CT. The non-injury group underwent no procedure. DHI% was measured by CT at 2-, 4-, and 6-week post-injury, and all mice tails were sectioned for histopathology grading of disc degeneration at the respective time intervals. @*Results@#The injured group showed significant variation in DHI% at 2, 4, and 6 weeks, whereas there was no change in the noninjured group. Histopathologic evaluation with Safranin O stain showed a worsening of the disc degeneration score at 2, 4, and 6 weeks in the injured group, but in the non-injured group there was no change. Percutaneous needle injury technique with our novel tool provided 100% accuracy and uniform degeneration. @*Conclusions@#A simple, easily reproducible mouse model for disc degeneration was created using a simple, cost-effective, novel tool and technique, its advantage being high precision and user friendly.
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Methods@#A total of 18 mice were divided into injured (n=12) and non-injured (n=6) groups. The disc height index (DHI%) at coccygeal 4–5 level was measured by computed tomography (CT) scan for all mice. Coccygeal 4–5 discs of the injury group were injured using a 32G needle fixed to a novel tool and confirmed by CT. The non-injury group underwent no procedure. DHI% was measured by CT at 2-, 4-, and 6-week post-injury, and all mice tails were sectioned for histopathology grading of disc degeneration at the respective time intervals. @*Results@#The injured group showed significant variation in DHI% at 2, 4, and 6 weeks, whereas there was no change in the noninjured group. Histopathologic evaluation with Safranin O stain showed a worsening of the disc degeneration score at 2, 4, and 6 weeks in the injured group, but in the non-injured group there was no change. Percutaneous needle injury technique with our novel tool provided 100% accuracy and uniform degeneration. @*Conclusions@#A simple, easily reproducible mouse model for disc degeneration was created using a simple, cost-effective, novel tool and technique, its advantage being high precision and user friendly.
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Background@#Epidural analgesia failure episodes can be reduced by catheter fixation techniques with a lower incidence of catheter migration. In this clinical study, we compared the roles of two epidural catheter tunneling techniques for the prevention of epidural catheter migration. @*Methods@#Patients undergoing major abdominal surgery were randomized into three groups of 50 patients each based on the method used to secure the epidural catheter. In the control group (CG), the epidural catheter was secured without tunneling. Tunneling groups 1 and 2 (TG1 and TG2) were defined as tunneling with and without a catheter loop, respectively. The primary outcome measure was the migration of the epidural catheter, while the secondary outcome measures were the adequacy of analgesia and signs of inflammation. All patients were followed up by the acute pain service team twice daily in the postoperative period until the epidural catheter was removed. The results were analyzed by the one-way analysis of variance (ANOVA), chi-square test, and Fisher’s exact test. P values 0.050). @*Conclusions@#Catheter migration was significantly reduced by tunneling without a catheter loop in TG2 as compared to the other two groups. Therefore, we suggest routine use of tunneling without a catheter loop technique in anesthesia practice and look forward to future studies with larger sample sizes.
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Introduction: Benign prostatic hyperplasia (BPH) is an extremely common condition in elderly men and is a major cause ofbladder outflow obstruction. An enlarged prostate may also be incidentally found on imaging of the pelvis or on rectal examination.Lower urinary tract symptoms (LUTSs) are one of the commonest presentations in urology clinics. Clinical diagnosis of BPHis made by the assessment of international prostate symptom score (IPSS), prostate size or volume, and reduced urinary flowrate. Uroflowmetry is one of the simplest and non-invasive urodynamic investigations used in the measurement of urinary flowrate using a flowmeter for the evaluation of obstructive LUTS. The IPSS is widely used to assess the severity of LUTS in menwith bladder outlet obstruction and to evaluate the response to medical or surgical therapy for benign prostatic obstruction.Materials and Methods: This prospective study was conducted on patients with LUTS to evaluate: (1) Prostate size onultrasound, (2) correlate prostate size with IPSS, and (3) correlate prostate size with uroflowmetry. A total of 60 patients wereincluded in the study attending the outpatient department of general surgery in Government Doon Medical College betweenJune 2018 and September 2019.Result: Our study states that maximum flow rate and prostate volume show a positive significant correlation having P < 0.01.Considering all the three grades of BPH, a positive correlation was found between prostate volume and maximum flow rate. Asignificant correlation was found between mean prostate volume and maximum flow rate signifying that the higher the prostatevolume, the lower the maximum flow rates. The statistical analysis of prostate volume versus IPSS showed strongly significantcorrelation between the two parameters. Mean prostate volume was higher in patients with PSS of 18–35. It denotes that higherthe prostate volume higher is severity index in patients with BPH.Conclusion: On the basis of data, which were obtained after evaluation of 60 patients with BPH, it can be concluded thatprostate volume and its relationship with peak flow of output can help predict the degree and cause of obstruction. The higherthe prostate volume, the higher the possibility of the cause to be obstructive due to BPH. Uroflowmetry, IPSS, and ultrasoundare non-invasive, easy, and cheap investigation in evaluation of LUTS, mainly due to BPH.
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Cerebral palsy (CP) is a form chronic motor disability in children. It is a non-progressive disorder of posture and movement, often associated with epilepsy and abnormalities of speech, vision and intellect. It results from a defect or lesion of growing brain before or during birth or in postnatal period. The damage to brain is permanent and cannot be cured but the consequences can be minimized. Cerebral palsy (CP) is a disorder of development in which abnormalities of motor function are the main characteristic features. Severity varies from mild to severe. Cerebral palsy is a very challenging disability for parents and professionals. Cerebral palsy is a heterogeneous group of disorders caused by intrapartum asphyxia and exposure to maternal infection such as chorioamnionitis, sepsis, urinary tract infection, and prematurity. The incidence of Cerebral Palsy is 2 to 2.5 per 1000 live births. During the past twenty years, there have been increases in the incidence and prevalence of CP that may be associated to enhanced records of cases, advances in neonatal health care and other factors.METHODSThis cross-sectional study was conducted in the Department of Paediatrics, Darbhanga Medical College & Hospital, Laheriasarai, Darbhanga, Bihar, from October 2018 to September 2019. A total of 100 Cerebral Palsy cases coming from various districts to inpatient and outpatient department of hospital were selected.RESULTSIn this study a total 100 CP children up to 12 years of age was included. 60% were boys and 40% were girls. The causes of CP included birth asphyxia (47%), prematurity (22%), pyogenic meningitis (8%), genetic (7%), neonatal sepsis (6%), intracranial bleed (5%), and idiopathic (5%). Among these cases, spastic type (65%), ataxic (15%), dyskinetic (10%) and mixed (10%) varieties were found. Among spastic, quadriplegic subtype was seen in 69%, diplegia in 23%, and hemiplegia in 8%. Comorbidities associated with CP patients were speech problem (80%), pain (75%), cognitive disability (50%), hip displacement (30%), seizure (25%), behavioural disorders (25%), sleep disturbances (20%), visual impairment (19%) and hearing impairment (4%).CONCLUSIONSPerinatal asphyxia is a leading and preventable cause of cerebral palsy. Spastic type was the most common type and in spastic type, quadriplegic subtype was most common. Mental retardation, speech problems, pain, cognitive disability, hip displacement and seizure were the major co-morbidities in children with cerebral palsy. Early diagnosis and appropriate management are important in such children to limit morbidity.
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Background: India has the maximum burden of both non MDR tuberculosis (TB) and Multidrug-Resistant (MDR) TB, as per data reported in Global TB Report 2018 and tuberculosis is remains one of the most common cause of pleural effusions.Methods: This was a cross-sectional study conducted in Department of Respiratory Diseases and a total of 110 patients with pleural effusion were included in the study, which were enrolled for treatment from July 2018 to June 2019.Results: One hundred and ten patients with pleural effusion were enrolled during the study period. There were 65 males (59%) and 45 (40.9%) females. The overall mean age for males and females were 44.4±18.84 years (35-87 years) and 38.28±17.66 years (35-87 years) respectively. Tuberculous Pleural Effusion group (TPE) seen in 82 patients. Right sided pleural effusion (69.5 %) were more common than left sided (30.4 %). In TPE group the mean pleural fluid ADA level were 86.41±38.08 IU/L (range: 14-195 IU/L). The Malignant Pleural Effusion (MPE) group included 21 patients. In MPE group the mean pleural fluid ADA level were 34.10±32.88 IU/L (range: 8-144 IU/L). The difference in pleural fluid ADA levels between TPE and MPE group was statistically highly significant.Conclusions: Tuberculous pleural effusion was the most common cause of pleural effusion in present study and observed in 74.5% cases.
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Introduction: CAPD is one of the renal replacement therapieswhich is gaining popularity in the developing world especiallyIndia. This study was aimed to study the clinical profile andcomplication of Complications of Continuous AmbulatoryPeritoneal Dialysis (CAPD).Material and Methods: Patients on CAPD at our center wereevaluated for their clinical profile, complication and outcomeon follow-up.Results: A total of 100 patients were included in the study.There were 66%males and 34% females. Mean age of thepatients was 47.95± 6 years. Hypertension was seen as etiologyin 36%, Diabetes in 27%, chronic glomerulonephritis in 22%,Analgesic nephropathy in 4%, Obstructive nephropathy in 3%and in 4% cases no obvious cause for CKD could be found.Among the complications pain was seen in 11%, pericatheterleak in 5%, bleeding 7%, intestinal perforation in 2%, herniain 5%, total obstruction in 4%, exit site infection in 7%,tunnel infection in 2% and total 111 episodes of peritonitis.Technique survival at 1 year and 2 years was 97%and 94%respectively. Patient survival at one and two years was 90%and 78% respectivelyConclusion: CAPD presents a viable form of renalreplacement therapy. There has been sustained decrease incomplication rates and improvement in technique and patientsurvival with advancement in catheter implantation andcomplication management
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ABSTRACT While the developed world is focusing on laying guidelines for selecting out cases of Asymptomatic primary hyperparathyroidism (PHPT) for surgical intervention and promoting minimal access surgery, the developing world is observing a change in disease spectrum from advanced symptomatic to lesser degree of symptomatic disease and not many with associated Vitamin D deficiency. Few studies from the developing countries of the world have focused on the changing clinical spectrum of PHPT. Objective of this study is to review the changing profile of PHPT in developing world. A systematic literature search was done in December 2017 focussing on publications from the developing world. All studies pertaining to the epidemiology of PHPT published after 1st January 2000 and published in English language were included for analysis. Most of the studies published from developing countries report a predominance of symptomatic disease (79.6% of all included patients) with musculoskeletal disease present in the majority of patients (52.9%). The combined mean serum total calcium (11.9 ± 1.4 mg/dL), serum PTH (668.6 ± 539 pg/mL), serum alkaline phoshpatase (619 ± 826.9 IU/L) and weight of excised parathyroid glands (4.4 ± 3.8 grams) are much higher than those reported from the western studies. Despite this, we found that there is a distinct trend towards a milder form of disease presentation and biochemical profile noticeable in more recent times. Although there is a striking difference in all aspects of PHPT disease epidemiology, clinical presentation and biochemical profile of developing and developed countries, there is a distinct trend towards a milder form of disease presentation and biochemical profile in more recent times.
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Humans , Hyperparathyroidism, Primary/complications , Hyperparathyroidism, Primary/blood , Hyperparathyroidism, Primary/epidemiology , Severity of Illness Index , Developing CountriesABSTRACT
Pulse oximetry is an important screening technique to intensify timely diagnosis of critical cyanotic congenital heart disease in neonates which is a noninvasive, safe and an easy method. It is a highly specific test having low false positive rates. This screening test was conducted in Department of Pediatrics, Darbhanga Medical College & Hospital, Laheriasarai, Darbhanga, Bihar, between 24 hours and 36 hours after birth, with use of the right hand of infants and either foot to diminish false positive results.METHODSData for study has been collected from birth records from Darbhanga Medical College & Hospital, Bihar, and included- 1. saturation level from either feet and right hand for the primary and further recurrence of screening. 2. outcomes of the echocardiographic test findings. 3. important non-cardiac illness diagnosed at the hospitalization for infants which failed screening for cyanotic CHD. For the correction of errors related to data of the study, we satisfied autonomous investigations of pulse oximetry requiring AAP CCHD screening algorithm to identify infants to pass with a saturation ≥95% in hand or either foot and a ≤3% difference and those falling after finishing 3 transitional screening tests. After three consecutive measurements, there is difference of SpO2 of more than 3% between pre-ductal and post-ductal SpO2.RESULTSThe combination of pulse oximetry and physical examination improved the sensitivity to up to 57.14% with a specificity of 99.73%. The overall mortality rate of CCHD was 36.8% [7 out of 19]. The mortality rate of early detection were 37.5% [6 out of 16]. Late detection of CCHD has mortality rate of 33.3% [1 out of 3]. 123 [13.1%] and 70 [7.4%] newborns have either foot or right hand SpO2 level < 95% among 941 study newborns at the time of the initial screening. The mean SpO2 level of either feet and right arm of study newborns were 95.8% [SD 2.3] and 96.0% [SD 2.2] respectively. Either feet and right arm level of SpO2 <95% and either feet to right arm level of SpO2 difference of >3% among 142 [15.1%] study newborns.CONCLUSIONSPulse oximetry screening for primary diagnosis of critical cyanotic CHD is an easy, economical and non-invasive test which covers the essential criteria in addition to worldwide newborn screening panel. Extensive approval and implementation can considerably reduce the morbidity in newborns infants and is likely to be an additional important tool in low resource settings where most of newborn infants are born without prenatal diagnosis. Although, this study showed reduced sensitivity of pulse oximetry for critical cyanotic CHD nearly <50%.
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Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a fatal illness manifested by fever, morbilliform rash, multi systemic involvement and eosinophilic leucocytosis with about 10% mortality. Authors report DRESS syndrome in an adolescent girl due to anti-depressant and anti-psychotic which improved dramatically after withdrawal of offending drugs and starting of steroids
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Psychiatric symptoms attributable to vitamin B12 deficiency have been described for decades. Vitamin B12 deficiency is common in developing countries and its prevalence ranges up to 67% among Indian population.1 The earlier reports are for the most part in accordance with more recent ones, despite being diagnostically less specific in psychiatric and haematological terms. These symptoms seem to fall into several clinically separate categories like slow cerebration, confusion, memory changes, delirium, with or without hallucinations and/or delusions, depression, acute psychotic states, and (more rarely) reversible manic and schizophreniform states.2 Apart from these conditions, some cases of dementia, violent behaviour and fatigue have also been documented to be caused by vitamin B12 deficiency.3 Reports of patients initially presenting to psychiatric facilities without associated haematological manifestations are rare. There are a few case reports of acute psychosis attributed to vitamin B12 deficiency, but more evidence is required to substantiate and establish this association.4 We describe three patients who developed acute psychosis accompanied by features suggestive of organic aetiology. They were found to have cobalamin deficiency in the absence of typical neurological or haematological abnormalities.