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The present study was undertaken to investigate epidemiological distribution, clinical manifestation, co morbid status, treatment strategy and case fatality index of emerging COVID-19 infection at SMS Medical College Hospital, Jaipur, Rajasthan. It also evaluated efficacy of hydroxychloroquine (HCQ) in treatment of patients and risk of serious adverse outcomes in patients with COVID-19 in relation to their co morbid status.In an attempt to provide extensive information pertaining to epidemiological and clinical characteristics of COVID-19, the present study was undertaken on 522 patients. The patients were COVID-19 confirmed positive by genomic analysis through Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) at SMS Medical College and Attached Hospitals, Jaipur. The indoor admitted patient's information inclusive of demographic profile (age, sex, nationality, residence), date of confirmation for positive COVID-19 case, travel/ exposure history, date of recovery/ death, clinical features, co morbidities and treatment plan was recorded. A serial follow-up of recovered patients to evaluate infective period of the disease was also part of the study.A total of 522 patients of laboratory confirmed COVID-19 test by RT-PCR at SMS Hospitals, Jaipur were assessed. Among the confirmed cases, most of patients were young adult in the age group with mean age of 35.42 years. 22.41% patients were below 20 years of age, majority of patients (58.80%) were in the age range of 21 to 50 years and only 18.79% patient population was in the age range of above 50 years. Females (39.08%) were affected less than males (60.91%) with an average sex ratio of female: male being 0.64. Out of the total analyzed patients, only 24.32% patients were symptomatic, among them fever (55.90%), cough (52.75%), sore throat (49.60%) and shortness of breath (46.45%) were the most common presenting clinical manifestations while a few patients also had symptoms of headache (26.77%), chest pain (6.29%) and other symptoms (7.87%) like pain abdomen, fatigue, joints pain, altered sensorium etc. Most of symptomatic patients belonging to older age group. An average of 40.40% patient population of above 50 years of age, were symptomatic while none of the patients below 10 years of age were symptomatic. 13.98% patients had some or the other underlying co morbid disease. The most prevalent co morbidity was hypertension (42.46%) followed by Diabetes mellitus (39.72%), Old k-chest (20.54%), COPD/ Bronchial Asthma (16.43%), Coronary artery disease (13.69%), Chronic kidney disease (13.69%) and Valvular heart disease (6.84%) distributed in co morbid patients of COVID-19. 60.27% of patient population with underlying co morbid conditions were more prone to develop symptomatology complex as compared to that observed in patients with no co morbidity (18.42%). 116 patients had recovered with effective treatment till the date of data analysis. Time of recovery was counted from the date of positive report to 1st negative report of oropharyngeal sample by RT-PCR for COVID-19 with an average recovery time of 8.15 days. 23.27% patients recovered within 5 days, while 52.58% patients took about 6-10 days, 23.27% patients took 11-15 days and remaining 0.86% took more than 16 days to recover. In the present study 15 patients had died till analysis of data, among the deceased, 73.33% were above 50 year of age with a male preponderance (66.6%). Interestingly, all deceased (100%) had presented with clinical manifestations of COVID-19 and all had underlying multiple co morbid conditions. Majority of patients had early mortality after admission to hospital with two third death account in initial three days. Asymptomatic patients (cases) treated with HCQ recovered early (average recovery time =5.4 days) compared to asymptomatic patients who did not receive any treatment (control group) and had longer recovery time (average recovery time =7.6 days).The varied spectra of COVID-19 mostly affects young adult age group (third to fifth decades of life). Interestingly, early age group was also affected in significant proportion when compared with similar data from other countries. It was observed that male population seemed to be was more prone to getting infected. Majority of COVID-19 positive patients (nearly three-fourth) were asymptomatic (mostly in young age range) at the time of diagnosis, which poses a major challenge for health care workers. Fever, cough, sore throat and shortness of breath were major symptoms that could be detected in such COVID-19 patients. Symptomatic clinical manifestations were more common in old age population. Infectivity was higher in patients that had underlying co morbid disease, especially in patients with multiple co morbid conditions. Symptomatic presentation of COVID-19 was observed to be higher in patients with co morbid disease. Average recovery time from COVID-19 was 8 days with effective treatment. Mortality in COVID-19 was higher in old age population, male gender, symptomatic and co morbid patients as compared to other similarly matched group. Most of mortality was noted within first few days of admission, suggestive of early mortality due to the primary disease process. Treatment with HCQ had early recovery without effectively influencing the overall mortality.

We analyzed the data of 102 confirmed patients with novel Coronavirus 2 infection (COVID-19) during the early period of nationwide lockdown announced in India after the declaration of pandemic. We analyzed epidemiological, clinical characteristics and outcome of hospitalization in 102 patients with positive results for novel corona virus (SARS-CoV-2) RNA testing which were traced on the basis of history of travel, contact with a confirmed COVID-19 case, resident of hotspot areas or presence of symptoms, thus providing an accurate estimate of the proportion of asymptomatic cases in the initial population. Of 102 patients enrolled in the study, 83.3% (85/102) were asymptomatic and 16.67% (17/102) were symptomatic. Seventy-seven (75.49%) were males and 24.50% (25/102) were females. Eighteen (17.6%) patients had associated comorbidities, the most prevalent of which were diabetes mellitus 10.8% (11/102), hypertension 7.8% (8/102), chronic obstructive pulmonary disease (COPD) in 3.92% (4/102), chronic kidney Disease (CKD) 0.98% (1/102), coronary artery Disease (CAD) 0.98% (1/102) and cerebro-vascular disease (CVD) 0.98% (1/102). The clinical spectrum among symptomatic COVID-19 patients varied from dry cough and fever to respiratory failure and multi-organ failure. Twelve (11.76%) patients were kept in intensive care unit (ICU). Ninety-nine (97.05%) patients recovered while three (2.94%) died during hospital stay. With majority of COVID-19 cases in India being asymptomatic, changes in biochemical and inflammatory profile were small and insignificant in asymptomatic patients when compared to symptomatic patients. Elevated NLR, lymphopenia, age and presence of comorbidities were associated with increased severity and poor outcome.

The resurgence of epidemic of Influenza A (H1N1) pdm 09 was phenomenal in 2015 and has become an annual phenomenon. Antigenic drift and reassortment is the rule rather than exception, conferring survival benefit to the virus. As this disease has high mortality, we compared the clinico-epidemiological profile of patients expired in the year 2015 due to "A/California/7/2009" strain with those of expired in the year 2018 due to "A/Michigan/45/2015" strain.We collected data of all expired patients in our institute in the year 2015 from 1st January to 30th may as well as 2018 in the same time period. The data of 116 patients who expired in 2015 due to "A/California/7/2009" H1N1 strain were compared with similar data of 30 patients expired in 2018 due to "A/Michigan/45/2015" strain of H1N1. Patients of pneumonia, having age18 years, positive for H1N1by real-time reverse-transcriptase-polymerase- chain-reaction (RT-PCR) and died in our hospital were included in this study. Clinical features and laboratory data were obtained from the hospital records of the patients. Data analysis was done using SPSS software.In 2015 total number of hospitalized patients due to "A/California/7/2009" strain were 571 and 116(20.31%) out of them died, in 2018 those due to "A/Michigan/45/2015" total admission were 177 and 30(16.94%) out of them died (p-0.032). Though it was not statistically significant but it is lesser than in 2015 despite the fact that more patients with co morbidities were affected in 2018. Duration in ICU was significantly longer in 2018(MS) group [5(1-7)] compared to 2015 (CS) group [3(1-17)] with p value of 0.017 (i.e.0.05). But both groups were not different in terms of duration on mechanical ventilator. (p-0.257).The 2015 (CS) group had 74.1% with other co-morbidities versus 96.7% of those in 2018 (MS) group (p- 0.015). This implies that the mortality with "A/Michigan/45/2015" infection was mainly seen in the patients who already had one or more co-morbidities unlike "A/California/7/2009" infection.The 2018 (MS) group had significantly higher proportion (60%) of patients with acute kidney injury compared to 34.5% in 2015(CS) (p-0.019). 50% of dead patients in 2018(MS) had anemia compared to 11.2% in 2015(CS) (p0.001). Deranged liver function test was seen in 46.7% patients in 2018(MS) compared to only 15.5% patients in 2014(CS) (p0.001).The only reverse trend was shown in case of diabetes, A/California/7/2009 strain affected 27% diabetics compared with 6.7% affected by A/Michigan/45/2015 strain (p=0.030) (Table 5).The study showed that though "A/Michigan/45/2015" affected higher number of patients with co morbidities compared to "A/California/7/2009" but had slightly lesser mortality.

Background Vertebrobasilar insufficiency resulting from embolism, atherosclerosis, or arterial dissection has long been a challenge for successful management and outcomes. The main treatment options include medical therapy, angioplasty and stenting, and surgical revascularization. Unlike cardiac or peripheral vascular revascularization, large randomized trials with cerebrorevascularization have not revealed favorable outcomes. In patients who have failed maximal medical therapy, and having persistent debilitating symptomology, cerebral revascularization may still be a viable option. Methods We report 3 patients who presented with symptoms of vertebrobasilar ischemia. The diagnosis was verified by computerized tomographic arteriography and digital subtraction angiography. Results These patients subsequently underwent revascularization with a radial artery graft. We also present a comprehensive review of the literature of treatment for vertebrobasilar insufficiency. Conclusions Surgical revascularization should be considered in the posterior circulation in the rare subset of patients with VBI, who remain symptomatic despite having a protracted course of maximal medical therapy with large- and medium-sized vessel occlusions and poor collateral circulation.

Aneurysmal subarachnoid hemorrhage (SAH) remains an important health issue in the United States. Despite recent improvements in the diagnosis and treatment of cerebral aneurysms, the mortality rate following aneurysm rupture. In those patients who survive, up to 50% are left severely disabled. The goal of preventing the hemorrhage or re-hemorrhage can only be achieved by successfully excluding the aneurysm from the circulation. This article is a comprehensive review by contemporary vascular neurosurgeons and interventional neuroradiolgists on the modern management of cerebral aneurysms.

BACKGROUND The management of basilar apex (BX) aneurysms remains problematic. OBJECTIVE We quantified the surgical exposure of the BX through the opticocarotid window (OCW) and the carotid-oculomotor window (COW), before and after mobilization of the internal carotid artery and division of the posterior communicating artery (PCoA). METHODS Eleven silicone-injected cadaveric heads were dissected bilaterally. The surgical dissection was divided into 4 major steps: (1) supraorbital modified orbitozygomatic craniotomy, (2) mobilization of the internal carotid artery after drilling out the anterior clinoid process intradurally and cutting the distal dural ring, (3) drilling out the posterior clinoid process and dorsum sellae, and (4) dividing the PCoA from the posterior third portion of the vessel. A frameless navigation system was used to quantify the surgical exposure area of the BX through the OCW and COW. RESULTS The total surgical area increased significantly from steps 1 to 4 (P < .001) in both OCW and COW groups. Overall, there was a larger total surgical area obtained in the COW compared with the OCW (P = .010). ICA mobilization increased the surgical area for temporary (P < .001) and permanent (P < .003) clip application in both windows. The division of PCoA significantly increased the overall surgical area for permanent clip application (P < .003). Compared with the OCW, the COW had a significantly increased change in the area for permanent clip application in the low-lying group (P = .03). CONCLUSION When approaching the BX via the pterion route, the appropriate surgical step and window should be selected according to characteristics of the PCoA and height of the BX.

We quantified the effects on anatomical cadaver dissection of a balloon-inflation tumor model positioned in the parasellar region and approached through an orbitozygomatic (OZ) craniotomy. A modified supraorbital OZ was performed bilaterally on 5 silicon-injected cadaver heads. Ten predetermined anatomical points assigned using a frameless stereotactic device were used to measure the working area of exposure, degree of surgical freedom, and horizontal and vertical angles of attack to specific target points before and after inflation of a balloon catheter mimicking a parasellar tumor. Balloon inflation displaced the central anatomical structures (pituitary stalk, lamina terminalis, anterior chiasm, and internal carotid artery [ICA]-posterior communicating artery and ICA-A1 junctions) by 14-51% (p ≤ .05). With tumor simulation, the vertical angle of attack increased by 67% (p .01), while the area of exposure increased by 83% (p .01) and surgical freedom increased by 58% (p .01). This tumor model also significantly displaced central anatomical sella-associated structures. Compared to a normal anatomical configuration, the tumor simulation (balloon) opened surgical corridors (especially vertical) and acted as a natural retractor, widening the angle of access to the infundibular apex-hypothalamic junction. Although this model cannot exactly mimic a tumor mass in a patient, the effects of tumor compression and sequential displacement of important structures can be combined into and then assessed in a cadaveric neurosurgical anatomical scenario for training and research.

Progressive Disseminated Histoplasmosis (PDH) is mainly described in immuno-compromised individuals and rare in immuno-competent subjects. Here we report a case of progressive disseminated histoplasmosis with Comb's positive hemolytic anemia, which is infrequently reported from a country like India where histoplasmosis is not an endemic mycosis.

Gout, the most common of the crystal arthritides is a result of disturbed uric acid metabolism and precipitation of urate crystals in extra cellular space of joints, periarticular tissue, bones and other organs. In the West, gout affects around 1% of adult men over 45 years of age. The estimated incidence being 0.6 to 2.1 per 1000 per year, with a prevalence of 9.5 to 13.5 per 1000 persons of all ages.1 The incidence of gout has been on rise globally; potentially attributable to recent shifts in diet, lifestyle, medical care, and increased longevity.2 Gout is three to four times more common in males than in pre-menopausal females; incidence in women increases after menopause and after the age of 60, approaches that in men.3 This update aims to highlight recent developments in understanding pathogenesis of gout along with current management strategies.

To study clinical and electrophysiological properties of peripheral neuropathy (PN) in systemic lupus erythematosus (SLE) and their association with disease activity parameters.A hospital-based observational study done among 50 SLE patients after informed consent. History and clinical examination including a detailed neurological examination was carried out. Blood and urine investigation were done and modified SLE disease activity index (SLEDAI)-2000 score was calculated.PN was found in 18 out of 50 (36%) SLE cases as defined electrophysiologically, nine had clinical and nine had subclinical neuropathy. On nerve conduction studies (NCS) 17 patients had axonal pattern. There were significant difference for mean ESR in patients with neuropathy (64.17 ± 42.43 mm/1st hour) and without neuropathy (42.34 ± 27.68 mm/1st hour) (P 0.033) and for mean modified SLEDAI-2000 of patients with neuropathy (15.61 ± 10.09) and without neuropathy (6.84 ± 6.16) (P0.05).The study suggests significant association of peripheral neuropathy in SLE patients with ESR, modified SLEDAI-2000, pyuria, pleurisy and leucopenia.

The purpose of the study is to examine the effect of subliminal priming in terms of the perception of images influenced by words with positive, negative, and neutral emotional content, through electroencephalograms (EEGs). Participants were instructed to rate how much they like the stimuli images, on a 7-point Likert scale, after being subliminally exposed to masked lexical prime words that exhibit positive, negative, and neutral connotations with respect to the images. Simultaneously, the EEGs were recorded. Statistical tests such as repeated measures ANOVAs and two-tailed paired-samples t-tests were performed to measure significant differences in the likability ratings among the three prime affect types; the results showed a strong shift in the likeness judgment for the images in the positively primed condition compared to the other two. The acquired EEGs were examined to assess the difference in brain activity associated with the three different conditions. The consistent results obtained confirmed the overall priming effect on participants’ explicit ratings. In addition, machine learning algorithms such as support vector machines (SVMs), and AdaBoost classifiers were applied to infer the prime affect type from the ERPs. The highest classification rates of 95.0% and 70.0% obtained respectively for average-trial binary classifier and average-trial multi-class further emphasize that the ERPs encode information about the different kinds of primes.

Background: The proximal superior cerebellar artery (pSCA) is often considered a perforator-free area. Precise anatomical knowledge of this region clarifies the pathophysiology underlying posterior fossa ischemic syndromes and helps avoid treatment-related complications. Objective: To anatomically evaluate perforating branches arising from the pSCA and the upper basilar artery (BA). Methods: Forty-four SCAs from 20 cadaveric heads were examined to determine patterns of the pSCA; its morphometry for medial and lateral branches; and frequency, number, diameter, distribution, and vascular territory of perforators arising from the pSCA and rostral BA. Results: SCA arose as a single trunk in 36 sides (90%): mean diameter at origin was 1.38 mm; mean length was 14.± 6 7.9 mm. Ninety-nine pSCA perforator branches were present in 82% of specimens (mean, 2.3 ± 1.6; range, 0-7 perforators/side). Of these, 59% were direct, belonging to the interpeduncular group in 85% of cases; 28% were short circumflex, belonging to lateral and medial pontine group; and 13% were long circumflex, reaching the medullary perforation zone (basal cerebellar group). Median distance to the first perforator was 2.0 mm (range, 0.1–15 mm). There were 132 perforator branches in the last centimeter of the BA. Conclusion: The pSCA should not be regarded as a perforator-free area. Although the pSCA territories likely overlap with the posterior cerebral artery, BA, and anterior inferior cerebellar artery, the pSCA segment cannot be surgically manipulated with impunity.

BACKGROUND The transciliary supraorbital approach (TCSO) provides an anterior view for visualizing sellar, parasellar, and suprasellar structures. Whether an orbital osteotomy adds to this exposure has not been quantified. OBJECTIVE We quantitatively evaluated the TCSO and benefits of an additional orbital osteotomy for exposing common sites of anterior circulation aneurysms. METHODS Under image guidance, TCSO and orbital osteotomy were performed on 10 sides of 5 cadaver heads to quantify exposures of 4 surgical targets: (1) the junction of the anterior cerebral and anterior communicating arteries (ACoA); (2) the internal carotid artery (ICA) at the level of the posterior communicating artery (PCoA); (3) the bifurcation of the ICA; and (4) the middle cerebral artery (MCA) bifurcation. Horizontal and vertical angles of attack and surgical freedom for instrument manipulation were measured before and after the orbital rim and roof were removed. RESULTS An orbital osteotomy significantly increased surgical freedom to the ACoA (from 471.15 +/- 182.14 mm2 to 683.35 +/- 283.78 mm2, P = .021); PCoA (from 746.58 +/- 242.78 mm2 to 966.23 +/- 360.22 mm2, P = .007); ICA bifurcation (from 616.08 +/- 310.95 mm2 to 922.38 +/- 374.88 mm2, P = .002); and MCA bifurcation (from 1160.77 +/- 412.03 mm2 to 1597.71 +/- 733.18 mm2, P = .004). There were no significant differences in horizontal angles of attack. The vertical angles of attack were significantly greater after orbital osteotomy, principally with the ACoA and ICA bifurcation as targets. CONCLUSION TCSO combined with orbital osteotomy improves exposure. Removing the orbital rim and roof increases the area for instrument use and improves the vertical angle of attack to common sites in the anterior circulation involving aneurysms.

To detect level of serum vitamin D in patients of Rheumatoid arthritis (RA) and to establish relationship between serum vitamin D level and disease activity in RA.Eighty patients of RA fulfilling 1987 revised criteria of the American College of Rheumatology (ACR) of RA classification and eighty healthy controls were included in the study. 25 (OH) vitamin D levels were measured. Disease activity was assessed by DAS-28 score.Ninety percent of RA patients were either vitamin D deficient or insufficient while only seventy percent of healthy controls were either vitamin D deficient or insufficient(p=0.007). Mean serum vitamin D levels of RA patients was significantly low compared to healthy controls (p=0.009). Thirty-one patients had high disease activity (DAS-28 score5.1, group A), 32 patients had moderate disease activity (DAS 28 score 3.2-5.1, group B) and 17 patients had low disease activity (DAS-28 score3.2, group C). Vitamin D levels in high disease activity group was significantly low compared to vitamin D level in patients with low and moderate disease activity (p.001) and vitamin D level had significant negative correlation with DAS28 score (r=-0.604, p0.001).Serum vitamin D levels were significantly low in RA patients than in healthy controls. Vitamin D deficiency was seen in significantly higher numbers of patients and vitamin D had negative correlation with disease activity in RA.

Methaemoglobinaemia due to nitrite poisoning is rare. Awareness of this condition in the cyanosed patient not responding to oxygenation and timely administration of methylene blue may be life saving. We report a case of methaemoglobinaemia as a result of sodium nitrite poisoning.

To describe the clinical and epidemiological factors of influenza A (H1N1)pdm09-infected patients who were pregnant or in the puerperal period during a recent influenza outbreak in Rajasthan, India.A retrospective, observational study was performed using hospital records of individuals with confirmed influenza A (H1N1)pdm09 infection admitted to a large tertiary care center in Rajasthan, India, between January 1 and March 15, 2015.The study cohort included 44 patients who were pregnant or in the puerperal period. The mean age was significantly lower in the study cohort than in other female patients treated for influenza A (H1N1)pdm09 infection at the hospital during the study period (25.45±3.45years vs 40.46±13.99 years; P0.001). Mortality was significantly higher in the study cohort than in the comparison female patients (36% vs 17%; P=0.003). Factors found to be associated with mortality were delayed initiation of oseltamivir, poor oxygen saturation at admission, and more than 50% lung involvement under radiographic examination. None of the patients in the study cohort had received a vaccination against seasonal influenza.Influenza A (H1N1)pdm09 infection during pregnancy causes more severe illness. Early recognition and timely administration of antiviral therapy can improve outcomes. The role of influenza vaccination in this high-risk population cannot be overemphasized.

The research presented in this article investigates the influence of subliminal prime words on peoples' judgment about images, through electroencephalograms (EEGs). In this cross domain priming paradigm, the participants are asked to rate how much they like the stimulus images, on a 7-point Likert scale, after being subliminally exposed to masked lexical prime words, with EEG recorded simultaneously. Statistical analysis tools are used to analyze the effect of priming on behavior, and machine learning techniques to infer the primes from EEGs. The experiment reveals strong effects of subliminal priming on the participants' explicit rating of images. The subjective judgment affected by the priming makes visible change in event-related potentials (ERPs); results show larger ERP amplitude for the negative primes compared with positive and neutral primes. In addition, Support Vector Machine (SVM) based classifiers are proposed to infer the prime types from the average ERPs, which yields a classification rate of 70%.

Cryptococcal spinal arachnoiditis occurs in patients with meningitis and usually when they are immunocompromised. Spinal symptoms in cryptococcosis are rare and a very exceptional entity in the immunocompetent population. We present a young immunocompetent male who developed progressively increasing paraparesis due to primary cryptococcal arachnoiditis, who showed significant improvement after antifungal therapy. Although extremely rare, spinal arachnoiditis in an immunocompetent individual can be caused due to cryptococcus, as in our case. This case illustrates and emphasizes the necessity for an exhaustive and complete investigation, with a high index of suspicion for fungal etiology in patients presenting with spinal arachnoiditis or other disabling, progressive spinal cord syndromes of unknown etiology. Awareness of this presentation is necessary to avoid delay in diagnosis and management of this potentially curable condition.

A newborn female baby presented to us with horizontally oval swelling involving posterior lamella of both upper eyelids and is limited by lid margin. The swelling was bright red, nontender, firm in consistency, nonreducible, blanches on pressure, and fixed to underlying structures with no rise in temperature. The size of the swelling was 2.8 cm × 1.1 cm × 1 cm in the right upper eyelid and 2.8 cm × 1.3 cm × 1 cm in the left upper eyelid. There was total occlusion of the visual axis [Fig. 1]. Magnetic resonance imaging of both orbit shows diffusely bulky and heterogeneous altered signal intensity lesions involving the posterior lamella of upper eyelid on both sides [Fig. 2]. Figure 1 Bilateral infantile hemangioma of upper eyelid Figure 2 Infantile hemangioma involving posterior lamella of upper eyelid on magnetic resonance imaging scan The patient was prescribed oral propranolol 2 mg/kg in two divided doses under the supervision of a pediatrician and responded well to the treatment within a week of the initiation of the treatment [Fig. 3] and reduce further in size within 12 weeks of the treatment with the clearing of the visual axis [Fig. 4]. Figure 3 Response of the lesion 1 week postmedication Figure 4 Response of the lesion 12 weeks postmedication

To compare the utility of anti-nucleosome antibodies and anti-dsDNA antibodies in diagnosis of Systemic Lupus Erythematosus (SLE) and as a marker of disease activity.This is a hospital based observational study among 40 (37 females and 3 males) selected cases of SLE (or = 4 ACR criteria) and 80 control. 40 cases of other systemic autoimmune disease (SAD) [e g. 29 cases of Rheumatoid arthritis, 4 cases of Systemic sclerosis/scleroderma, 4 cases of Sjögren syndrome, 3 cases of MCTD and 40 Healthy blood were taken as control. From each patient venous blood samples were collected and submitted for anti-nucleosome and anti-dsDNA antibodies assay by enzyme linked immunosorbent assay (ELISA).Anti-nucleosome antibodies were positive in 19 (47.5%) SLE, 02 (05%) other SAD and none of the healthy persons. Anti dsDNA antibodies were positive in 15 (37.5%) SLE patients, 07 (17.5%) other SAD and 01(2.5%) healthy persons. For diagnosis of SLE, sensitivity of anti-ds DNA and anti-nucleosome antibody was found to be 37.5% and 47.50% respectively. The specificity of anti-nucleosome was 100% and that of anti-dsDNA was 97.50%. So, anti-nucleosome antibody test is more specific and more sensitive for diagnosis of SLE than anti-dsDNA. When SLE cases were compared with SAD, sensitivity of anti-dsDNA and anti-nucleosome antibody, for diagnosis of SLE, found to be 37.50% and 47.50% respectively but the specificity of anti-nucleosome was 95% and that of anti-dsDNA was 82.50%. Both antibodies show positive correlation with SLEDAI score .The correlation coefficient was stronger for anti-dsDNA antibodies (r = +0.550, P =.001) than anti-nucleosome antibodies (r = +0.332, P =.05) CONCLUSIONS: Anti-nucleosome antibodies show higher positivity than anti-dsDNA antibodies among SLE than other SAD and healthy population. Anti-nucleosome antibodies are more sensitive and specific for the diagnosis of SLE than anti-dsDNA antibodies. Anti-nucleosome and anti-dsDNA both show positive correlation with SLEDAI. But anti-dsDNA antibodies show stronger correlation with SLEDAI than anti-nucleosome. So, anti-nucleosome antibodies can be used as an additional marker for diagnosis of SLE and SLE disease activity.

Previously considered the domain of the otolaryngologists, the endoscopy is now a common part of the armamentarium of a neurosurgeon. Neuroendoscopy or endoscope-assisted microsurgery is now being used in almost all routine procedures performed in the neurosurgical operating room. Hands-on training has become essential to learn the basics of neuroendoscopy, even for neurosurgeons well accustomed to the use of microscopes. To decrease the slope of the learning curve of residents during their training and reduce complications of procedures, most neurosurgery training programs around the world have incorporated laboratory or dissection programs in their curricula. Preconference workshops held during annual meetings are also an excellent tool to aid in the transition of surgeons from being a resident under the umbrella of an attending neurosurgeon to being a neurosurgeon able to operate independently and with confidence. In this "tech-savvy era," various cadaver or synthetic models are readily available for endoscopy training in a virtually simulated environment. In accord with the results of a surveys conducted by individual groups and societies, the authors firmly believe that incorporation of endoscopy in the neurosurgical curriculum would add a new dimension to the existing protocol. There is an urgent need for dedicated endoscopy training programs similar to postresidency fellowships in addition to translational research and establishment of dedicated societies to formulate guidelines for such research and monitor its progress.

INTRODUCTION Restrictions in elective surgery and large group gatherings as well as changes in faculty and resident schedules during the COVID-19 pandemic has led to rapid evolvement of the training curriculum for neurosurgical trainees While necessary, these changes may have significant impact on the training of neurosurgery residents METHODS A survey assessing changes to resident clinical and educational workload and their sentiment about how these changes may affect their careers was distributed electronically to neurosurgery residents in the United States and Canada RESULTS One hundred ninety-seven resident responses were collected between April 17, 2020 and April 30, 2020 The survey respondents were spread over 29 states and Canada and were evenly spread across all residency levels (P = 619) Nearly 82% reported that the inpatient and outpatient volumes were either greatly (44 0%) or moderately (37 8%) reduced Greater than 91% reported a significant reduction in work hours and a significant increase in resident didactics (P < 001) Nearly all residents surveyed (98 5%) reported that their program had converted to electronic platforms for their didactic lectures, and there was a significant increase in the time residents spent in didactic lectures Residents reported converting the majority of their time outside of neurosurgery clinical responsibilities into watching remote didactic lectures, conducting research, and preparing for board examinations, while nearly 14% of trainees spent at least a portion of that time providing COVID-19 medical care Senior residents were more likely to express concern about their educational experience as well as their future career prospects CONCLUSION Universally, residents have experienced reduced work hours and operative case volumes Programs have adapted by increasing didactic time and using electronic platforms The findings suggest that senior residents may feel the effects more than their junior counterparts This may require more acute attention from faculty with respect to preparing senior residents for moving on to fellowship or ultimate job It is possible that this remarkable time period will prompt a critical re-appraisal of the pre-COVID-19 adequacy of educational content in our training programs, and that enhanced educational efforts driven by this pandemic may be lasting

The transoral (TO) approach to the craniocervical junction provides similar access to the periclival and subaxial spine compared with the extraoral anterolateral prevascular (EAP) approach, but the additional exposure gained by the EAP approach has not been quantified. This study quantitatively compared the two surgical exposures.Ten silicon-injected fixed cadaver heads were used for the TO approach and another 5 heads (10 sides) were dissected for the EAP approach. For the TO approach, mouth opening was standardized to 5.5 cm using a Spetzler-Sonntag retractor, and the soft palate was split 1.5 cm to access the periclival area. A frameless stereotactic device was used to calculate the lengths, angles, and areas of surgical exposure for different anatomic targets.The vertical working length on the dura progressively increased 61% (336 ± 26 mm to 539 ± 16 mm [mean ± standard deviation]; P0.001), and the vertical working angle increased 23% (98 ± 3 degrees to 121 ± 5 degrees; P0.0) using the TO versus the EAP approach. In the TO approach, the bilateral average horizontal working length on the C1 arch was less on the ipsilateral side than for the EAP approach (11 ± 1 mm vs. 17 ± 1 mm, 61%; P0.01). The mean periclival and subaxial exposures were 546 ± 72 mm(2) and 932 ± 70 mm(2) with the TO approach and 874 ± 75 mm(2) and 1644 ± 107 mm(2) with the EAP approach (mean increases 62% and 77%, respectively; both P0.001).Both the TO and EAP approaches improved surgical exposure, but the EAP approach provides more significant and consistent gains to the anterolateral periclival and subaxial areas.

Background The lower cranial nerves must be identified to avoid iatrogenic injury during skull base and high cervical approaches. Prompt recognition of these structures using basic landmarks could reduce surgical time and morbidity. Methods The anterior triangle of the neck was dissected in 30 cadaveric head sides. The most superficial segments of the glossopharyngeal, vagus and its superior laryngeal nerves, accessory, and hypoglossal nerves were exposed and designated into smaller anatomic triangles. The midpoint of each nerve segment inside the triangles was correlated to the angle of the mandible (AM), mastoid tip (MT), and bifurcation of the common carotid artery. Results A triangle bounded by the styloglossus muscle, external carotid artery, and facial artery housed the glossopharyngeal nerve. This nerve segment was 0.06 ± 0.71 cm posterior to the AM and 2.50 ± 0.59 cm inferior to the MT. The vagus nerve ran inside the carotid sheath posterior to internal carotid artery and common carotid artery bifurcation in 48.3% of specimens. A triangle formed by the posterior belly of digastric muscle, sternocleidomastoid muscle, and internal jugular vein housed the accessory nerve, 1.90 ± 0.60 cm posterior to the AM and 2.30 ± 0.57 cm inferior to the MT. A triangle outlined by the posterior belly of digastric muscle, internal jugular vein, and common facial vein housed the hypoglossal nerve, which was 0.82 ± 0.84 cm posterior to the AM and 3.64 ± 0.70 cm inferior to the MT. Conclusions Comprehensible landmarks can be defined to help expose the lower cranial nerves to avoid injury to this complex region.

AComA aneurysms are most commonly found at the A1-A2 junction on the dominant side. The angle of the arteries at the bifurcation and the direction of blood flow are factors of hemodynamic stress in the apical region where these aneurysms often develop. They exist at the bifurcation of dominant A1, A2 and AComA and usually point in the direction away from the dominant A1. They are more prone to rupture and demonstrate the highest incidence of post-operative morbidity among anterior circulation aneurysms. Consideration of aneurysm morphology may be used to guide approaches in AComA aneurysms. Resection of the gyrus rectus in combination with a pterional approach was popularized by Yasargil and it became the standard for treatment or exposure of AComA aneurysms, although other skull base approaches are also widely used. Clip selection is of extreme importance and the preservation of blood flow to the perforators should be emphasized. Adequate dissection and exposure of the entire "H" complex prior to clipping is the key to a successful outcome. Separating the perforators from the neck or dome of the artery and preserving the parent vessel presents a substantial challenge to the surgeon when the aneurysm is behind the parent artery, making it difficult to achieve a good outcome.

To determine factors that help decide the side of approach for anterior communicating artery (AComA) aneurysms, based on a prospective study.Between January 2004 and January 2006, 93 cases with AComA aneurysms were treated through pterional approach. They were classified as Type I, II (IIa, IIb), III and IV, based on the various projections and size of aneurysm. The principle for the choice of operative side was designed based on the type of aneurysm and the A2 fork orientation (the interrelations between the plane of bilateral A2, AComA, and mid-saggital plane).There were 55 aneurysms of Type I, 10 of Type IIa, 14 of Type IIb, 12 of Type III, and 2 of Type IV. In Types I and IIa, the side posteriorly placed to A2 was chosen for the approach. In Type IIb, the side of the dominant A1 was selected. In Type III, the side anteriorly placed to A2 was chosen. Type IV aneurysms were difficult to handle even if approached from the dominant A1. There were 11 cases treated from the side of non-dominant A1. The overall outcome in the treatment of AComA aneurysms were considered excellent in 90.8% of cases according to the Glasgow Outcome Scale, with complete occlusion of aneurysms and complete patency of parent or perforating arteries.Applying three-dimensional computed tomography and magnetic resonance angiography, we classified AComA aneurysms as four types and undertook surgical clipping from the chosen side of approach, according to the type of aneurysm and the A2 fork orientation. The selective side of approach on the basis of individual decision-making has led to favourable outcomes.

Within a few months of Wilhelm Conrad Röntgen's discovery of x-rays in 1895, Fedor Krause acquired an x-ray apparatus and began to use it in his daily interactions with patients and for diagnosis. He was the first neurosurgeon to use x-rays methodically and systematically. In 1908 Krause published the first volume of text on neurosurgery, Chirurgie des Gehirns und Rückenmarks (Surgery of the Brain and Spinal Cord), which was translated into English in 1909. The second volume followed in 1911. This was the first published multivolume text totally devoted to neurosurgery. Although Krause excelled in and promoted neurosurgery, he believed that surgeons should excel at general surgery. Importantly, Krause was inclined to adopt technology that he believed could be helpful in surgery. His 1908 text was the first neurosurgical text to contain a specific chapter on x-rays (“Radiographie”) that showed roentgenograms of neurosurgical procedures and pathology. After the revolutionary discovery of x-rays by Röntgen, many prominent neurosurgeons seemed pessimistic about the use of x-rays for anything more than trauma or fractures. Krause immediately seized on its use to guide and monitor ventricular drainage and especially for the diagnosis of tumors of the skull base. The x-ray images contained in Krause's “Radiographie” chapter provide a seminal view into the adoption of new technology and the development of neurosurgical technique and are part of neurosurgery's heritage.