Association of recurrent aphthous ulcers with stress among students in an Indian Dental Institution.

Background: Recurrent aphthous ulcers are painful oral lesions with no proven effective treatment. A definitive cause of these ulcerations still remains elusive. It is believed that psychological stress may be a significant contributor. Aim: The aim of the present study was to determine whether there was any significant association of Recurrentaphthous ulcers with episodes of stress by determining the prevalence of ulcers and levels of stress tolerance among dental students. Materials and methods: A cross sectional survey was carried out on 341 students of Manipal College of Dental Sciences, Manipal, India by distributing questionnaires. The questionnaire had two sections, the first part dealt with ulcers and the later part comprised of a perceived stress scale. The data collected was analyzed with Independent sample t test and ANOVA with post hoc Tukey’s test using the SPSS 16 version software. Results: Prevalence of ulcer was found to be 66.9%. Comparison of mean stress scores between the ‘ulcer-experienced’ and ulcer-free groups showed no difference. Assessment of stress among undergraduates, interns and post graduates who had reported ulcer experience revealed that interns were able to handle the stressful situations significantly better than under graduates and post graduates. Conclusion: The present study did not show any association between episodes of ulcers and stressful events.

Lipid storage myopathies with unusual clinical manifestations.

We describe the clinical presentation, course and pathologic findings found in three adult patients with lipid storage myopathy. Excessive lipid storage was found in Type 1 fibers of muscle. Clinical improvement on oral levo-carnitine therapy suggests the possibility of carnitine deficiency as the most likely etiology in two of the patients and one had mitochondrial myopathy confirmed on genetic analysis.

Major histocompatibility complex class I expression can be used as a diagnostic tool to differentiate idiopathic inflammatory myopathies from dystrophies.

Aim: Utility of major histocompatibility complex (MHC) Class I antigen immunostaining was studied to differentiate idiopathic inflammatory myopathies from dystrophies. Materials and Methods: Forty muscle biopsies including seven dermatomyositis (DM), six polymyositis (PM), two sporadic inclusion body myositis (sIBM), 20 dystrophies (one Duchenne, three Becker's, four alpha, one gamma sarcoglycanopathy, nine limb girdle, one myotonic and one fascioscapulohumeral muscular dystrophy) and five controls were stained with antibody for MHC Class I antigen (Novocastra clone W6/32 HL 1:100 dilution). Results: Polymyositis and sIBM showed MHC class I antigen positivity along sarcolemma of single and small groups of muscle fibers. The regenerating fibers in the perifascicular area in DM showed intense cytoplasmic positivity of MHC class I antigen. Muscle fibers in all dystrophies except regenerating fibers and control normal muscle were negative for MHC. Capillaries and lymphocytes were positive controls. There were no false positives in the study. Conclusion: MHC Class I immunostaining can be used as a complementary diagnostic tool for the diagnosis of idiopathic inflammatory myopathies.

Myasthenic crisis: clinical features, complications and mortality.

BACKGROUND AND OBJECTIVE: Myasthenic crisis is a life-threatening complication of myasthenia gravis (MG) and when treated aggressively is associated with good outcome. MATERIALS AND METHODS: Retrospective study of case records of patients with episodes of myasthenic crisis. RESULTS: Twenty-one (22%) of the 95 patients with MG (9 with thymoma), experienced 23 episodes of myasthenic crisis, 3 (33%) in patients with thymoma. The crisis episodes occurred within 2 years of disease onset in 11 (52%) patients. Infection was the most common primary precipitant of the crisis occurring in 65%. The median duration of the crisis episode was 11 days (7-39 days), and the median neurological intensive care unit stay was 15 days (range 9-47 days). Fifteen (65%) episodes were treated with small volume plasma exchange (PE) and 8 (35%) episodes received intravenous immunoglobulin (IVIg). The time taken for disease stabilization, the median number of days for extubation, was 8 days (range 7-12) in the PE group and 10 days (range 7-39) in the IVIg group. Disease stabilization could not be achieved in one patient in the IVIg group. Ventilator-associated pneumonia (VAP) was the commonest complication, seen in 30%. Two (8%) of the 23 episodes of crisis were fatal, one resulting from VAP and septicemia, and the other due to crisis itself. All the 19 patients who survived to discharge had complete resolution of admission symptoms. CONCLUSIONS: In patients with myasthenic crisis, both therapeutic options, PE and IVIg, are equally effective in disease stabilization. To achieve good outcomes all efforts should be directed at decreasing the duration of intubation and also aggressively treating the associated medical complications.

Isolation of Burkholderia pseudomallei from a case of septicaemia--a case report.

Meliodosis, an infectious disease caused by Burkholderia pseudomallei has been recognized as an emerging infectious disease in India. The infection is under diagnosed and underreported, and hence considered a rare disease. Majority of the cases have been documented from the states with heavy rainfall. The present case being reported is a middle-aged woman who had developed a fulminant infection following exposure to stagnant floodwater in the city of Hyderabad. To the best of our knowledge, this is the first case of Melioidosis being reported from this part of the country.

Subtypes of Ischemic Stroke in a Metropolitan City of South India (One year data from a hospital based stroke registry).

Limited data exists on the subtypes of ischemic stroke from the Indian subcontinent. The present study was aimed to investigate the frequency, spectrum and risk factors of various subtypes of ischemic stroke in a south Indian referral center. The study was conducted on consecutive patients of ischemic stroke, fully investigated to determine the underlying mechanism and enrolled in the stroke registry of Nizam's Institute of Medical Sciences between Ist February 2000 to 31st January 2001. There were 282 men and 110 women (mean age 54 years; range 2-97 years). Of all ischemic stroke patients, 41%, 18%, 10%, 4%, and 27% were classified as large-artery atherosclerosis, lacunae, cardioembolism, other determined etiology and undetermined etiology respectively. The most notable difference of this registry from western registries was the predominance of intracranial rather than extracranial location of the large artery atherosclerosis. Hypertension, diabetes and smoking were the common risk factors among all the subtypes. Coronary artery disease and rheumatic heart disease were responsible for most of the cardioembolic strokes.

Decompressive craniectomy for stroke : indications and results.

The role of decompressive hemicraniectomy in stroke victims is gaining popularity among neuroscientists as it is found to be beneficial in malignant infarction of middle cerebral artery (MCA) territory which results in massive edema and brain swelling. Recent articles have showed that this procedure not only reduces mortality but also improves the functional outcome. We report our experience of 32 patients, who underwent this procedure. We found a good outcome in patients in whom the procedure was done early and whose pre operative Glasgow coma scale (GCS) score was 8 and above. It offered no benefit in patients whose pre operative GCS was below 5.

Critical care management of acute stroke.

Treatment of acute stroke in an intensive care unit improves the outcome by reducing the mortality and morbidity. In addition to the primary neurological condition that affects the outcome, the secondary complications and associated co-morbid conditions also influence the outcome. It is essential to monitor and maintain the general physiological conditions in the neurologically sick patients. Maintenance of a clear airway is important to prevent hypoxic insult to the brain in stroke patients whose airway is compromised. Mean arterial blood pressure should be maintained > 110mm of Hg. The choice of antihypertensive is labetolol. Drugs causing raised intracranial pressure (ICP) should be generally avoided. Cardiac arrhythmias should be monitored and treated. Treatment of ICP by osmotic agents is the usual practice. Hyperventilation is reserved for patients who are coning and is only a temporizing measure prior to surgery. Hemicraniectomy in malignant middle cerebral artery territory infarcts reduces the mortality significantly. Insulin therapy may be required to maintain a normoglycemic state for preserving the functionally impaired neurons. Infections should be treated by appropriate antibiotics. Care should be taken to prevent aspiration, and deep vein thrombosis. Intravenous thrombolysis for the eligible candidates and Aspirin for the rest is the recommended therapy for acute ischemic stroke.

Cognitive rehabilitation in stroke : therapy and techniques.

Cognitive deficits following stroke are common and interfere with recovery. Cognitive rehabilitation incorporates principles of restorative neurology and neuropsychology and has now become an integral component of stroke rehabilitation strategy. The process of cognitive rehabilitation involves assessment of cognitive functions, identification of specific areas of impairment, goal setting and institution of appropriate rehabilitation techniques. Currently, there is enough evidence supporting the effectiveness of cognitive rehabilitation of neglect and aphasia in stroke. Apraxia, inattention and executive dysfunction may also improve with specific intervention. Compensatory strategies are the mainstay of managing patients with memory disturbances. In addition to specific cognitive deficits, physical and emotional disturbances as well as social support affect functional recovery. Comprehensive and holistic cognitive rehabilitation programs are necessary to improve daily life function in stroke patients.

Primary cutaneous nocardiosis with epidural abscess caused by Nocardia brasiliensis: a case report.

Dissemination of primary cutaneous nocardiosis is a rare event. An interesting case of a 20 year old female labourer with progressive weakness in both the lower limbs and large multiple subcutaneous abscesses over the back, since 4 years, is presented. MRI showed an epidural abscess compressing the cord. Histopathology of skin lesions suggested a chronic suppurative lesion. Microbiological tests on the aspirate from the skin lesion identified the causative organism as Nocardia brasiliensis.

Severity-of-illness scoring systems and models: neurological and neurosurgical intensive care units.

Predicting the outcome of critically ill patients admitted to intensive care units (ICU) has undergone considerable evolution over the last two decades. Various general purpose severity-of-illness scoring systems, Acute Physiology and Chronic Health Evaluation score (APACHE II, APACHE III), Mortality Predicting Model (MPM II), and Simplified Acute Physiology Score (SAPS II), have been extensively validated for large groups of critical care patients with mixed diagnoses and found to correlate well with observed outcome in general. The general hypothesis underlying the use of severity-of-illness scoring systems is that clinical variables that can be assessed on ICU admission and subsequent days of stay in the ICU predict survival and other outcomes of critically ill patients. Variables included in severity-of-illness scoring systems measure specific clinical and physiological functions that are major determinants of mortality. These scoring systems may be used alone within a single disease category or any other independently defined patient group to perform relative risk stratification. Variation in death rates by disease reflects the nature of the underlying process. There is a need for using these scoring systems in specialized ICUs like neurological and neurosurgical ICU as they allow, in addition to predicting outcome, evaluation of new therapies, monitoring of resource utilization and quality assessment of intensive care units.

Neurological intensive care in India--disease spectrum and outcome.

In recent years neurological and neurosurgical intensive care (NNICU) has evolved into a well-recognized subspeciality world over. However it is still a novel concept in the developing world. The admission criteria are variable and flexible. The pattern of disease in the NNICU varies according to the admission policy. In the west, cerebrovascular diseases account for a significant proportion of admissions. In a few studies from the developing countries infections of central nervous system are additional causes requiring intensive care. At our center the disease admission pattern was similar to the pattern reported from the developed countries. Predictors of outcome of neurointensive care have not been systematically evaluated. Limited available data concerns patients of neurotrauma. In addition to the disease severity indices, pre-existing chronic illness, adverse events during ICU stay, and the 24-hour presence of a physician also influence patient outcome in the NNICU.

Sleep apnoea syndromes : clinical and polysomnographic study.

Sleep apnoea syndromes have been known since long, and frequently the presenting symptoms are neurological in nature. However, these disorders have not been systematically studied and reported in the Indian literature. Out of 12,000 neurology outpatients seen by authors in 2 years, 60 had primary sleep disturbances. All these 60 patients underwent clinical evaluation and video EEG polysomnography. In 8 out of 60 (13%) patients, sleep apnoea was documented. Five patients had obstructive sleep apnoea, 3 had mixed sleep apnoea and none had pure central sleep apnoea syndrome. Three-fourths of the patients were obese (mean weight 82kg) middle aged males (mean age 46.3 years). The main symptoms encountered were excessive daytime somnolence and snoring. The symptom severity was found to correspond directly with the duration of symptoms as well as obesity. Sleep apnoea syndromes must be seriously considered and documented in all patients complaining of excessive daytime somnolence.

Mycotic aneurysm on posterior cerebral artery: resolution with medical therapy.

Mycotic aneurysms on the branches of vertebro basilar artery are rare. A patient of infective endocarditis with mycotic aneurysm on the posterior cerebral artery is described. The aneurysm resolved with medical therapy. Controversies regarding the management of mycotic aneurysms are discussed.

Cortical sinovenous thrombosis in a child with nephrotic syndrome and iron deficiency anaemia.

Cortical sinovenous thrombosis in a child with nephrotic syndrome and iron deficiency anaemia is described. The most probable mechanism for the hypercoagulable state was thrombocytosis associated with iron deficiency anaemia. The other possible contributing factor might have been the diuretic therapy during the phase of relapse.

Spinal extradural abscess following local steroid injection.

A case of spinal extradural abscess following local steroid injection for back ache, in a 26 years old male is described. The abscess presented as a swelling externally. MRI localised the lesion to L2-S1 segments. Mechanism of such an infection has been discussed.

Frequency, clinical features and risk factors of lacunar infarction (data from a stroke registry in South India).

Analysis of 893 patients of ischaemic stroke in the stroke registry of Nizam's institute of Medical Sciences, Hyderabad is presented. 16% of them had lacunar infarction. The mean age at presentation was 56.9 years and male to female ratio was 3.5:1. The common risk factors included hypertension(62%),diabetes(38%) and smoking(28%). Six percent had an underlying cardiac source of embolism and none had significant (>50%) extracranial carotid atherosclerosis. In 22% of patients, no obvious risk factors could be identified. The frequency of risk factors was similar in patients with lacunar and non- lacunar infarctions. However, patients with lacunar infarction had higher frequency of diabetes and absence of significant (>50%) extracranial carotid artery disease. Pure motor hemiparesis was the presenting syndrome in 45% patients. Ataxic hemiparesis and sensorimotor stroke accounted for 18% each and dysarthria-clumsy hand syndrome for 14%. This study suggests that the frequency, risk factors and clinical profile of lacunar infarction in our stroke registry is similar to most of the western stroke registries.

Pyomyositis - clinical and MRI characteristics report of three cases.

We report three patients with pyomyositis due to Staphylococcus aureus. Magnetic resonance imaging aided in the accurate diagnosis of the infection and of the extent of involvement. Incision, drainage and antibiotic therapy eradicated the infection in all the patients. We suggest clinical or subclinical bacteraemic seeding of the diseased muscle, as the most likely mechanism for pyomyositis.