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Abstract Background HIV-infected and HIV-exposed, uninfected infants experience a high burden of infectious morbidity and mortality. Hospitalization is an important metric for morbidity and is associated with high mortality, yet, little is known about rates and causes of hospitalization among these infants in the first 12 months of life. Methods Using data from a prevention of mother-to-child transmission (PMTCT) trial (India SWEN), where HIV-exposed breastfed infants were given extended nevirapine, we measured 12-month infant all-cause and cause-specific hospitalization rates and hospitalization risk factors. Results Among 737 HIV-exposed Indian infants, 93 (13%) were HIV-infected, 15 (16%) were on HAART, and 260 (35%) were hospitalized 381 times by 12 months of life. Fifty-six percent of the hospitalizations were attributed to infections; gastroenteritis was most common accounting for 31% of infectious hospitalizations. Gastrointestinal-related hospitalizations steadily increased over time, peaking around 9 months. The 12-month all-cause hospitalization, gastroenteritis-related hospitalization, and in-hospital mortality rates were 906/1000 PY, 229/1000 PY, and 35/1000 PY respectively among HIV-infected infants and 497/1000 PY, 107/1000 PY, and 3/1000 PY respectively among HIV-exposed, uninfected infants. Advanced maternal age, infant HIV infection, gestational age, and male sex were associated with higher all-cause hospitalization risk while shorter duration of breastfeeding and abrupt weaning were associated with gastroenteritis-related hospitalization. Conclusions HIV-exposed Indian infants experience high rates of all-cause and infectious hospitalization (particularly gastroenteritis) and in-hospital mortality. HIV-infected infants are nearly 2-fold more likely to experience hospitalization and 10-fold more likely to die compared to HIV-exposed, uninfected infants. The combination of scaling up HIV PMTCT programs and implementing proven health measures against infections could significantly reduce hospitalization morbidity and mortality among HIV-exposed Indian infants.

Disrupted cytokine networks and autoantibodies play an important role in the pathogenesis of systemic lupus erythematosus. However, conflicting reports and non-reproducibility have hindered progress regarding the translational potential of cytokines in SLE. This study attempts to address the existing knowledge gap using multiplex cytokine assay and machine learning. 67 SLE patients fulfilling SLICC criteria were recruited after informed consent, and circulating cytokines were measured by multiplex cytokine assay kit. We observed a positive association between actual disease activity scores (SLEDAI) and predicted scores from a partial least squares regression (PLSR) analysis of multivariate cytokine response data, with MIP-1α having a strong contribution towards disease activity. Our analysis also highlights increased IL-12 as a potential biomarker in nephritis and elevated MIP-1α as a signature of NPSLE. Using a k-Modes clustering algorithm to stratify patients based on patterns of co-occurrence of circulating autoantibodies, we identified 4 distinct clusters of patients. All 4 clusters had patients with nephritis, but patients in cluster 3 with nephritis were characterised by low levels of housekeeping and homeostatic cytokines and the presence of anti-Ro antibodies, which is a novel observation. Thus, we demonstrate that cytokines can be a surrogate to predict disease activity and organ involvement in SLE. Moreover, we show the utility of unsupervised machine learning algorithms using specific autoantibody signatures to predict renal involvement in SLE., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Conflict of interest: The authors declare that no competing interests exist., (© 2024. The Author(s).)

Abstract: Micropapillary urothelial carcinoma of the renal pelvis is a rare and aggressive variant and poses a diagnostic challenge, especially related to the site and histomorphology of the tumor. A 60-year-old female presented with right pelvic-ureteric junction obstruction and a nonfunctioning right kidney. She underwent a simple right nephrectomy. The microscopy examination revealed a high-grade tumor of the renal pelvis, predominant micropapillary architecture. The tumor infiltrated into the kidney, renal sinus, perinephric fat, adrenal gland, and Gerota's fascia. Extensive lymphovascular and perineural invasions were also noted. On immunohistochemistry, tumor cells were positive for GATA-binding protein 3, cytokeratin 7, and cytokeratin 20, while negative for paired box gene 8, cluster of differentiation 10, mammaglobin, and alpha-methylacyl-CoA racemase. The p63 was positive in the conventional areas and negative in the micropapillary pattern. We reported an additional case of micropapillary urothelial carcinoma of the renal pelvis, literature review, and discussed the differential diagnosis. Immunonegativity of p63 in the micropapillary component was an additional finding., (Copyright © 2023 Indian Journal of Pathology and Microbiology.)

The rippled pattern of basal cell carcinoma (BCC) is a very uncommon variant and poses a diagnostic challenge. A 52-year-old male presented with an ulcerated lesion over the scalp for 8 years. The wedge biopsy of the lesion showed an infiltrating tumour in the upper dermis and mid-dermis with focal attachment with the epidermis. The tumour was arranged in a rippled pattern. The tumour cells were monomorphic with a round to oval nucleus, arranged parallelly with fine chromatin and inconspicuous nucleoli. Brisk mitosis, apoptotic bodies, and necrosis were noted. Immunohistochemically, the tumour cells were positive for p63; focally positive for androgen receptor, Bcl-2, and CD10; and negative for epithelial membrane antigen and CK20. We report this rare case of BCC because of its peculiar pattern, discuss the differential diagnoses, and review the clinicopathological features of reported cases., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Journal of Dermatology.)

Background: Urothelial carcinoma with trophoblastic differentiation is a rare type of urothelial carcinoma that poses a diagnostic challenge., Case Details: A 50-year-old man presented with hematuria for 4 months duration. Ultrasonography examination showed polypoidal lesions along the right lateral wall and near the right vesicoureteric junction of the urinary bladder. The transurethral resection of the bladder tumor (TURBT) specimen showed marked necrosis and urothelial tumor cells arranged in nests, sheets, and papillae, admixed with multinucleated large cells. Deep muscle and extensive lymphovascular invasion were noted. The tumor cells were diffuse immunopositive for GATA3 and focal positive for p63 and SALL4. Large multinucleated tumor cells were immunopositive for β-hCG, GATA3, inhibin-α, and PLAP, focally positive for SALL4 while negative for p63. The patient denied further treatment and succumbed to the disease after 8 months of the TURBT procedure., Conclusion: We report a rare invasive urothelial carcinoma with trophoblastic differentiation and discuss the differential diagnosis and literature review., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: There is limited literature on digital ischemia in systemic Lupus erythematosus (SLE). We report the prevalence, associations and outcome of digital infarcts and gangrene from the Indian SLE inception cohort (INSPIRE)., Methods: From the web-based database of INSPIRE, we extracted information for patients with 'Digital Infarct' and 'Digital gangrene' at enrolment into cohort, together considered as critical peripheral ischemia (CPI); all others were controls. We describe the associations of CPI with SLE clinical phenotype, autoantibodies, and disease activity at enrolment. We also report short term outcomes viz. Digital tissue loss and early mortality up to 6 months and recurrence of digital ischemic events in cases till date., Results: Of 2503 SLE patients enrolled into the INSPIRE cohort, we identified 75 (2.9%) patients with CPI, 72 (96%) women and 6 (8%) children. Of them, 55 (73.3%) had digital gangrene and 21 (28%) patients had digital infarcts. Majority of digital gangrene resulted in amputation distal to terminal phalanx (63.6%). Multivariable analysis showed that pulmonary hypertension AOR [6.34 (1.99, 20.2)], coexistent thrombosis AOR [27.8 (15.7, 48.7)], triple antiphospholipid antibody positivity AOR [5.36 (1.67, 16.9)] and the presence of anti-Scl-70-antibody AOR [5.59 (1.86, 16.7)] were more likely while patients with class 3 or 4 lupus nephritis AOR [0.37 (0.15, 0.95)] and anti-nucleosome antibodies AOR [0.47 (0.23, 0.99)] were less likely to be associated with CPI. SLEDAI and short-term mortality were similar between cases and controls., Conclusions: CPI occurred in a higher proportion (2.9%) of SLE patients in the INSPIRE cohort as compared to earlier reports. Both prothrombotic state and vasculopathy contribute to its occurrence., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Antiphospholipid antibodies (APLA) are present in one-third of systemic lupus erythematosus (SLE) patients, and they are associated with both criteria and non-criteria manifestations. We studied the prevalence, clinical associations, and impact on mortality of APLA in SLE patients from India. Among the Indian SLE inception cohort (INSPIRE), patients who had data on all five routinely performed APLAs [lupus anticoagulant (LA), IgG and IgM anticardiolipin antibody (aCL) and anti-β2-glycoprotein I(β2GPI)] at enrolment were selected. Patients were divided into four categories based on the presence/absence of APLA associated manifestations and presence/absence of the APLA viz SLE-APS, SLE-APLA, SLE: events but no APLA, and SLE: no events, no APLA (reference group). 1035 SLE patients at least 1 APLA antibody was detected in 372 (35.9%). LA was present in 206 (19.9%), aCL in 126 (12.2%) and β2-GPI in 178 (17.2%). There were 88 thrombotic events in 83 patients (8.0%); 73 (82.9%) being arterial; APLA positivity was present in 37 (44.6%) [AOR 1.70 (1.054, 2.76)]. SLE-APS patients were younger and had higher mortality [AOR 4.11 (1.51, 11.3)], neuropsychiatric and hematologic disease. SLE-APLA also had a higher mortality rate [AOR 2.94 (1.06, 8.22)] than the reference group. The mortality was highest in the subset of patients with thrombotic events in the presence of APLA [AOR 7.67 (1.25, 46.9)]. The mere presence of APLA also conferred higher mortality even in the absence of thrombotic events [AOR 3.51 (1.43, 8.63)]. Hematologic manifestations (36.1%) were the most common non-criteria-manifestation. One-third of SLE patients have APLA and its presence is associated with non-criteria hematologic manifestations, arterial thrombosis and higher mortality rate., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background We present the experience of telerheumatology consultation services carried out in an eastern state of India. Methods We did this prospective, observational study of patients with rheumatological disorders and followed through telemedicine between December 2015 and May 2019. Results During the study period, we provided teleconsultation to 3583 patients with the help of 11 201 telemedicine visits. Patients resided at a median distance of 248 (13 to 510) km from the telemedicine hub. The cumulative savings of the patients as a result of this service were ₹2.4 crore (24 million). The median travel time saved was 7 hours (30 minutes to 12 hours) per patient per visit and a median of ₹6700 was saved per visit per patient. Conclusion Sustained efforts over a long period can lead to the delivery of essential rheumatology services via telemedicine to an under-priviledged population, reduce the financial burden of the poor, and help women to access healthcare services in remote parts of low- and middle-income countries (LMICs).

The cytological features of the hobnail variant of papillary thyroid carcinoma may be subtle. It is important to recognize this variant because it may influence the corresponding surgical treatment and follow-up due to its aggressive nature. The hobnail subtype of papillary thyroid carcinoma is a rare entity with aggressive features. It presents extrathyroidal extension or lymph nodal metastasis in a high percentage of the cases., (© 2023 John Wiley & Sons Ltd.)

Case Presentation: A 37-year-old man presented to the ED with symptoms of productive cough, self-reported fever, and shortness of breath for the past 15 days. He was placed on noninvasive mechanical ventilation for respiratory distress. IV piperacillin-tazobactam and inhaled bronchodilators were promptly administered, and he was subsequently transferred to the respiratory ICU for further care. He had no history of bowel and bladder disturbance, altered sensorium, swelling of feet, or abdominal distention. He never used tobacco and denied a history of TB. Medical history was notable for recurrent hospitalizations and administration of multiple courses of antibiotics in the past for similar complaints. He often used inhaled bronchodilators/corticosteroids when clinically stable to relieve symptoms., Competing Interests: Financial/Nonfinancial Disclosures None declared., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: SLE is associated with significant mortality, and data from South Asia is limited. Thus, we analysed the causes and predictors of mortality and hierarchical cluster-based survival in the Indian SLE Inception cohort for Research (INSPIRE)., Methods: Data for patients with SLE was extracted from the INSPIRE database. Univariate analyses of associations between mortality and a number of disease variables were conducted. Agglomerative unsupervised hierarchical cluster analysis was undertaken using 25 variables defining the SLE phenotype. Survival rates across clusters were assessed using non-adjusted and adjusted Cox proportional-hazards models., Results: Among 2072 patients (with a median follow-up of 18 months), there were 170 deaths (49.2 deaths per 1000 patient-years) of which cause could be determined in 155 patients. 47.1% occurred in the first 6 months. Most of the mortality (n = 87) were due to SLE disease activity followed by coexisting disease activity and infection (n = 24), infections (n = 23), and 21 to other causes. Among the deaths in which infection played a role, 24 had pneumonia. Clustering identified four clusters, and the mean survival estimates were 39.26, 39.78, 37.69 and 35.86 months in clusters 1, 2, 3 and 4, respectively (P < 0.001). The adjusted hazard ratios (HRs) (95% CI) were significant for cluster 4 [2.19 (1.44, 3.31)], low socio-economic-status [1.69 (1.22, 2.35)], number of BILAG-A [1.5 (1.29, 1.73)] and BILAG-B [1.15 (1.01, 1.3)], and need for haemodialysis [4.63 (1.87,11.48)]., Conclusion: SLE in India has high early mortality, and the majority of deaths occur outside the health-care setting. Clustering using the clinically relevant variables at baseline may help identify individuals at high risk of mortality in SLE, even after adjusting for high disease activity., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Hepatic involvement in sarcoidosis, though common, is usually asymptomatic. Hepatomegaly and deranged liver function tests are the usual manifestations. However, unexplained hepatomegaly in sarcoidosis not responding to immunosuppressive therapy could indicate an alternative pathology. Haemophagocytic lymphohistiocytosis (HLH), although seldom reported in sarcoidosis, can cause hepatosplenomegaly and cytopenias. HLH occurring concomitantly with hepatic sarcoidosis is extremely rare. We report a patient of systemic sarcoidosis who presented with fever, hepatosplenomegaly and jaundice despite being on steroid therapy. He was subsequently diagnosed with HLH. The clinical response to treatment with pulse steroid and oral cyclosporine was dramatic.

Competing Interests: Competing interests: None declared.

The present manuscript describes the synthesis and the photophysical properties of a pair of novel flavin-pyrene dyads where the donor and the acceptor entities are separated via variable spacer. The dyads were well characterized using standard techniques and investigated for their photophysical and electrochemical nature. The observed absorption spectra of the dyads mainly display peaks corresponding to the individual pyrene and flavin units, with some contribution from the flavin entity in the pyrene region. While, strong emission quenching was observed for both the dyads if compared to its individual constituents. However, a careful analysis of the emission spectra and the solvent dependent studies reveals subtle difference between the two dyads. While no significant difference could be observed when excited in the flavin region; excitation at the pyrene region displays a weak and broad emission band in case of closely connected dyad. Further, the electrochemical properties were investigated by cyclic voltammetry and the reduction ability was observed to follow the trend as FlPy2 < FlPy1 < Fl., (© 2022 John Wiley & Sons Ltd.)

Competing Interests: There are no conflicts of interest.

Syringomyelia is an important etiology of Charcot arthropathy of the elbow. We present five interesting patients, along with a systematic literature review summarizing the clinical profile and management of syringomyelia-induced Charcot arthropathy of the elbow. PUBMED, SCOPUS, EMBASE, and Science Direct databases were screened for English articles published between 1980 and 2022 using the search query: "Syringomyelia" AND "elbow" AND ("arthropathy" OR "neuropathic" OR "Charcot"). Articles without full text and/or lack of conclusive evidence of elbow arthropathy due to syringomyelia were excluded. The reference lists of the selected articles were reviewed to identify additional articles describing syringomyelia-induced Charcot arthropathy of the elbow. All five patients in the current series had elbow arthritis with variable motor weakness and dissociated sensory loss. The literature review included 31 reports (45 patients) and five patients from our center (n = 50). The median age at presentation was 45 (13-77) years. The median duration of arthropathy was 24 (0.5-180) months. Thirty-three patients had isolated elbow arthropathies. The other joints affected included the shoulder (n = 13), wrist (n = 7), metacarpophalangeal joints (n = 3), and interphalangeal joints (n = 1). Chiari malformations were present in 33 (66%) patients. Sensory deficits, motor deficits, and ulnar neuropathies were described in 36 (72%), 31 (62%), and 14 (28%) patients, respectively. Surgical decompression for syringomyelia was performed in 13 (26%) patients. The presence of dissociated sensory loss, with or without motor weakness, is key to the suspicion of syringomyelia-induced Charcot arthropathy of elbow. Chiari malformation and ulnar neuropathy are frequently associated with this condition. Key Points • Charcot arthropathy of elbow is not so uncommon as believed • Syringomyelia is an important etiology of Charcot arthropathy of elbow • Therefore, all patients with elbow arthropathy of unknown etiology must be evaluated for dissociative sensory loss • Chiari malformation and ulnar neuropathy are commonly associated with syringomyelia-induced Charcot arthropathy of elbow joint., (© 2022. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Background : Patients with Systemic Lupus Erythematous (SLE) are at an increased risk of infection and it is often difficult to differentiate between infection and disease activity in a febrile patient with SLE. Methods : Patients with SLE (SLICC criteria) presenting with fever between December 2018 and August 2021 were included. Neutrophil to lymphocyte ratio (NLR), NEUT-x, -y, -z indices, Erythrocyte sedimentation rate (ESR), C-reactive protein(CRP), C3, C4, anti-dsDNA antibodies, and procalcitonin(PCT) were tested in addition to investigations as per the treating physician's discretion. Based on the clinical assessment and laboratory data, the febrile episode was classified into infection, disease flare, or both. Statistical analysis was done using GraphPad prism v8.4.2. A novel composite score was devised and validated with a calculator incorporated is a spreadsheet. The performance of a previously proposed model of duration of fever, CRP, and dsDNA (Beca et al) was evaluated and other models using PCT and NEUT-Z were explored . Results : Among 168 febrile episodes in 166 patients with SLE (25 (19-32) years), 46 were due to infection, 77 due to flare, 43 due to both, and two due to other causes. High SLEDAI 2K (0.001), anti-dsDNA ( p = 0.004), and low complements(C3, p = 0.001 and C4, p = 0.001) were characteristic of disease flare, whereas high total leukocyte count (TLC) ( p = 0.008), NLR ( p = 0.008), NEUT-x ( p = 0.001), -y ( p = 0.03), -z ( p = 0.002), CRP ( p = 0.001), and PCT ( p = 0.03) were observed with infection. A model using age, TLC, and CRP was devised using 80% of the cohort with an AUC of 0.88 (0.78-0.97) which was validated in the remaining 20% to have an AUC of 0.83(0.60-1.0). The model devised by Beca et al yielded an AUC of 0.74. Use of PCT did not improve the discrimination between flare and infection. A Model of C4 and NEUT-z analyzed in a subset performed well and needs further exploration. Conclusion : A composite score of low cost and routinely available parameters like age, TLC, and CRP gives a good discrimination between infection and flare in a febrile patient with SLE.

Background: Systemic lupus erythematosus (SLE) is an autoimmune disorder affecting various organ systems with unknown etiology. Interleukin-6 (IL-6) and interferon-alpha (IFN-α) have been shown to have a major role in disease pathogenesis, and they correlate with SLE disease activity, but reports in the literature are conflicting. The present study aims to investigate the significance of IL-6 and IFN-α levels in SLE pathogenesis in an eastern Indian cohort., Material and Methods: 70 SLE patients fulfilled SLICC 2012 criteria, and 40 age- and gender-matched healthy controls (HC) were enrolled. Baseline characteristics along with disease activity were recorded for all patients. Levels of IL-6 and IFN-α were measured by using ELISA. For the meta-analysis, published articles were searched through different databases. Two independent researchers extracted data, and the meta-analysis was performed with CMA v3.1., Results: The plasma levels of IL-6 and IFN-α in SLE patients were significantly elevated compared to HC (IL-6: p < .0001, IFN-α: p = 0.01). SLEDAI score correlated positively with plasma IL-6 ( p < .0001, r = 0.46) and IFN-α levels ( p < .0001; r = 0.47). Meta-analysis of previous reports, including our case-control data, revealed higher IL-6 ( p < .0001) and IFN-α ( p = .005) in SLE patients compared to HC. Furthermore, IL-6 ( p < .0001, r = 0.526) and IFN-α ( p < .0001; r = 0.371) levels positively correlated with the disease activity., Conclusion: IL-6 and IFN-α levels are elevated in SLE and they correlate with disease activity. Further studies with a larger sample size in different populations are required to validate our findings.

Background: Ectopic pregnancy (EP) defined as extrauterine implantation of the embryo can be managed medically or surgically. Medical management entails systemic administration of the antineoplastic drug methotrexate (MTX) which, if not successful, surgical management is resorted to. However, we carried out this study wherein the failed medical management cases were given intra-gestational sac MTX instead of surgery., Aim: The aim of this study was to assess the efficacy of intra-gestational MTX administration as a treatment modality for failed medical management of ectopic pregnancies., Study Setting and Design: It was a prospective interventional study carried out at the Reproductive Medicine Centre of a tertiary care hospital., Materials and Methods: It was a prospective interventional study wherein 12 patients of EP with failed medical management (as per established criteria) were administered intra-gestational MTX with follicle aspiration needle under transvaginal sonography guidance., Statistical Analysis Used: Data were collected in Microsoft Excel. Numerical continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as count/percentage., Results: All the patients responded to the local administration of MTX, with none requiring rescue surgery. In addition, no one had any complication of the local instillation. However, one patient required an additional dose of MTX., Conclusion: Intra-gestational MTX administration is a viable non-surgical modality for treatment of ectopic pregnancies even in cases of failed medical management with an added benefit of tubal preservation., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Human Reproductive Sciences.)

Introduction: The ongoing pandemic of COVID-19 has led to severe disruption of healthcare services worldwide. We conducted this study to assess the impact of COVID-19 pandemic on the management of Systemic Lupus Erythematosus (SLE) patients who were enrolled in the nation-wide inception cohort., Methods: A questionnaire was administered to the SLE patients enrolled in the inception cohort. Questions related to the effect on disease activity, preventive measures adopted against COVID-19, the incidence of COVID-19, hardships faced in getting access to health care professionals and availability of medicines, adherence, fear of COVID-19 and the potential benefits of being part of the registry., Results: A total of 1040 (90% females) patients completed the questionnaire. The mean age was 27.5 ± 19.1 years and the mean disease duration was 1.25 years. Twenty-Four (2.3%) patients had developed fever (>1 day) during this period, including one patient with additional symptoms of diarrhoea and anosmia, however, none of the patients developed COVID-19 infection. 262 patients (25.2%) reported financial difficulty during this period and patients reported an average excess expenditure of at least 2255.45 INR ($30) per month. 378 patients (36%) reported problems in getting their prescribed medicines due to lockdown. Of these, 167 (40%) patients needed to change their medication schedule due to this non-availability. Almost 54% of patients missed their scheduled follow up visits during the lockdown period and 37% of patients were unable to get their investigations done due to closure of laboratories and hospitals. 266 patients (25.5%) reported worsening of various symptoms of SLE during this period. Almost 61% patients felt confident that being associated with the inception cohort had helped them in managing their disease better during this period of lockdown as they received help in the form of timely and frequent telephonic consults, assistance in making the medicines available, and regular counselling resulting in abetment of their fears and anxieties., Conclusion: The current COVID-19 pandemic has made a huge impact on our SLE patients. Patients faced difficulty in the availability of medicines, missed the doses of medicines, had financial constraints, and spent more money on health during the pandemic.

Severe fatigue, pain, deformity, and disability, are the major concerns for rheumatoid arthritis (RA). The extreme pain experienced by the patients often force them to experiment with various indigenous substances including animals and animal products. However, there is little evidence on the use of animals or animal products as traditional medicine in RA. Hence, this study was aimed to explore the experience and perception of patients toward the use of animals and animal products for the treatment of RA. A qualitative, explorative study was conducted at the out-patient-department of Rheumatology of a tertiary care medical college and hospital at Cuttack, Odisha, India. Out of 113 patients with RA, 18 patients gave history of use of animal and/or animal products and were selected for in-depth interviews. The content analysis methods were used for data analysis. Four major categories emerged: (1) prevailing patterns of traditional treatment of RA using animals, (2) beliefs and values behind the traditional treatment of RA, (3) sources and traditional learning pathway of indigenous practices on RA, and (4) ethical aspects of the indigenous practice of using animals and/or animal products in the treatment of RA. This study revealed the practice of eating dead animals to get relief from RA. However, there was hardly any perceived positive outcome of the practice; which indicates the lack of awareness of rational, scientific, treatment, and prevalence of irrational and unethical practices for the treatment of RA. Hence, community awareness, social mobilization, and newer screening tools are necessary to improve the timely detection and prevention of irrational treatment practices among RA patients., (Copyright © 2020 Samal, Sahoo, Pati, Tripathy, Parida and Das.)

Introduction: Ten to 15% of patients with sarcoidosis have associated arthritis. Chronic arthritis is fairly uncommon. There is a paucity of data on articular manifestations of the disease from India., Methods: Case records of adult patients with sarcoidosis presenting to 11 rheumatology centers from 2005 to 2017 were retrospectively reviewed. Joint involvement was assessed clinically, classified as acute or chronic depending on duration of symptoms less or greater than 6 months, respectively., Results: A total of 117 patients with sarcoid arthritis were reviewed. Forty-five patients were classified as having Lofgren's syndrome. The pattern of joint involvement revealed the ankle to be most commonly affected in both the groups. Shoulder, wrist, metacarpophalangeal, proximal interphalangeal joints of hands and knee joint involvement were significantly more common in chronic sarcoid arthritis. Peripheral lymphadenopathy and uveitis were significantly more frequent in chronic sarcoid arthritis. Forty out of 49 patients with acute arthritis followed up over a median of 1.8 years had achieved complete remission. Twelve out of 16 chronic sarcoid arthritis (median follow up 2.5 years) had achieved complete remission with 15, 12 and five patients on steroids, methotrexate and hydroxychloroquine, respectively. One patient with acute sarcoid arthritis with concomitant interstitial lung disease had died due to lung infection., Conclusion: Acute oligoarthritis was the commonest presentation with the ankle being the most commonly affected joint. Upper limb joint (predominantly distal) and knee involvement were more common as reported in our largest series worldwide of chronic sarcoid arthritis in adults. Hilar adenopathy and erythema nodosum were common extra-articular features in both acute and chronic sarcoid arthritis. A limitation of the study was the retrospective nature of the analysis., (© 2018 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Postural Instability (PI) is a major reason for fall in geriatric population as well as for people with diseases or disorders like Parkinson's, stroke etc. Conventional stability indicators like Berg Balance Scale (BBS) require clinical settings with skilled personnel's interventions to detect PI and finally classify the person into low, mid or high fall risk categories. Moreover these tests demand a number of functional tasks to be performed by the patient for proper assessment. In this paper a machine learning based approach is developed to determine fall risk with minimal human intervention using only Single Limb Stance exercise. The analysis is done based on the spatiotemporal dynamics of skeleton joint positions obtained from Kinect sensor. A novel posture modeling method has been applied for feature extraction along with some traditional time domain and metadata features to successfully predict the fall risk category. The proposed unobstrusive, affordable system is tested over 224 subjects and is able to achieve 75% mean accuracy on the geriatric and patient population.

Eye tracking is one of the most widely used technique for assessment, screening and human-machine interaction related applications. There are certain issues which limit the usage of eye trackers in practical scenarios, viz., i) need to perform multiple calibrations and ii) presence of inherent noise in the recorded data. To address these issues, we have proposed a protocol for one-time calibration against the "regular" or the "multiple" calibration phases. It is seen that though it is always desirable to perform multiple calibration, the one-time calibration also produces comparable results and might be better for individuals who are not able to perform multiple calibrations. In that case, "One-time calibration" can also be done by a participant and the calibration results are used for the rest of the participants, provided the chin rest and the eye tracker positions are unaltered. The second major issue is the presence of the inherent noise in the raw gaze data, leading to systematic and variable errors. We have proposed a signal processing chain to remove these two types of errors. Two different psychological stimuli-based tasks, namely, recall-recognition test and number gazing task are used as a case study for the same. It is seen that the proposed approach gives satisfactory results even with one-time calibration. The study is also extended to test the effect of long duration task on the performance of the proposed algorithm and the results confirm that the proposed methods work well in such scenarios too., Competing Interests: Tata Consultancy Services Ltd. (TCS) provided support in the form of salaries for all the authors and provided infrastructural support and subjects for data collection, decision to publish and preparation of the manuscript. The clearance on ethical issues for handling and analysis of the data collected has been acquired from Institutional Review Board of Tata Consultancy Services Ltd. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Eye movement analysis finds tremendous usefulness in various medical screening applications and rehabilitation. Infrared sensor based eye trackers are becoming popular but these are expensive and need repeated calibration. Moreover, with multiple calibration also, there persists some noises called, variable and systematic, resulting in inaccurate gaze tracking. This study aims to build an one time calibration module to avoid the overhead of multiple calibration and to design an algorithm to remove both the types of errors effectively. The proposed approach is used for correcting the gaze tracking data for Digit Gazing task and standard recall-recognition test, where an accuracy of 90% and 82% are achieved respectively for detecting the gaze positions against the raw eye gaze data. Results also show that it is possible to perform accurate gaze tracking with one-time calibration method provided the experimental setup is not altered.

Balance plays an important role for human bipedal locomotion. Degeneration of balance control is prominent in stroke patients, elderly adults and even for majority of obese people. Design of personalized balance training program, in order to strengthen muscles, requires the analysis of muscle activation during an activity. In this paper we have proposed an affordable and portable approach to analyze the relationship between the static balance strategy and activation of various lower extremity muscles. To do that we have considered Microsoft Kinect XBox 360 as a motion sensing device and Wii balance board for measuring external force information. For analyzing the muscle activation pattern related to static balance, participants are asked to do the single limb stance (SLS) exercise on the balance board and in front of the Kinect. Static optimization to minimize the overall muscle activation pattern is carried out using OpenSim, which is an open-source musculoskeletal simulation software. The study is done on ten normal and ten obese people, grouped according to body mass index (BMI). Results suggest that the lower extremity muscles like biceps femoris, psoas major, sartorius, iliacus play the major role for both maintaining the balance using one limb as well as maintaining the flexion of the other limb during SLS. Further investigations reveal that the higher muscle activations of the flexed leg for normal group demonstrate higher strength. Moreover, the lower muscle activation of the standing leg for normal group demonstrate more headroom for the biceps femoris-short-head and psoas major to withstand the load and hence have better static balance control.

Background: Subacute subdural hematoma (SASDH) is an entity which is yet to capture the popular imagination among the neurosurgeons. Its management is often equated clinically to that of the chronic subdural hematoma (CSDH). However, their neurological deterioration is usually rapid, which seems to align them with acute subdural hematoma (ASDH). We proceed for their epidemiological evaluation. The advantages of a novel "double barrel technique (DbT)" over the conventional burrhole drainage are also presented., Methods: This retrospective study was conducted on all the patients having clinical and radiological evidence of SASDH, admitted to a tertiary care referral institute, during the period August 2013 to December 2015. Postoperatively, patients were followed-up for 3-24 months., Results: 46.87% of the patients belonged to the 35-54 year age group with a male predominance (3.6:1); 68.7% had a history of alcohol abuse, whereas aspirin users were 25%. 87.5% cases were unilateral, 18.75% were hemispheric, and 46.87% were present on the left side. Altered consciousness (100%) followed by headache (37.5%) were the most common presenting clinical features., Conclusion: SASDH is an uncommon neurosurgical entity (0.89% of traumatic brain injury cases in our study) and mimics both CSDH as well as ASDH. The true incidence of SASDH may have been underestimated due to its clinical imitation with CSDH. This study in a South Asian nation also provides the epidemiological data of this rare neurosurgical entity. Outcome of surgery is good; our retrospective study confirms that "DbT" is an adequate and safe treatment. However, a better designed, randomized control trial will be needed to reinforce our findings.

Background: Intramedullary spinal cord metastases (IMSCM) are typically drop lesions from intracranial metastases and are a rare manifestation of systemic malignancy (8.5% of central nervous system metastases). They arise from primaries such as the lungs, breast, kidney, melanoma, or lymphoma. On the other hand, they arise very rarely from papillary thyroid carcinoma (PTC), even though it is the most common type of primary thyroid malignancy., Case Description: A 54-year-old male presented with pain in the lower back along with tingling, numbness, and weakness in the bilateral lower limbs. This was associated with urine incontinence for 1½ months. In the previous month, he developed a left-sided solitary thyroid nodule. Fine needle aspiration cytology and ultrasonography were suggestive of metastasis. Furthermore, the thoracolumbar magnetic resonance imaging showed T1-hypo and T2-hyper-intense D11-D12 level intramedullary lesion, with intense enhancement, which was consistent with an intramedullary lesion involving the conus. At surgery, a firm, brownish yellow, friable, vascular tumour was removed en toto. Upon discharge, the patient was neurologically intact except for residual bladder incontinence., Conclusion: In an extensive literature review (pubmed), IMSCM metastasis from PTC primary is confirmed as a rarity and this may be the fourth documented case. Moreover, this may be the first report of a case of PTC metastatic neurological deterioration "even before the treatment of the primary was undertaken." Early diagnosis and microsurgical resection can result in improvement of neurological deficits and in the quality of life of patients with IMSCM.

Background: Isolated orbital neurofibroma unassociated with systemic neurofibromatosis is relatively rare and may be difficult to clinically differentiate from other orbital tumors. Sensory branches of the trigeminal nerve-namely lacrimal, nasociliary, and frontal-are the most common nerves of origin for intraorbital neurofibroma, but we discovered a neurofibroma arising out of the right trochlear nerve, in absence of clinical stigmata of neurofibromatosis type 1, which is rare., Case Description: A 41-year-old adult presented with painless progressive proptosis of the right eye for 10 years without history of visual problems or diplopia. The right eye had axial proptosis with periorbital swelling. On magnetic resonance imaging (MRI), a right orbital extraconal, expansile, lobulated, cystic space-occupying lesion was seen with an enhancing component, pushing the lateral rectus with T1 isointensity and T2 hyperintensity, suggesting a preoperative working diagnosis of pseudotumor or lymphoproliferative tumor. Intraoperatively, a rudimentary slender, white, elongated structure was passing through the length of the tumor. The elongated tumor engulfing the trochlear nerve was traced up to the lateral part of the superior orbital fissure. The tumor was excised completely and was found to be a neurofibroma., Conclusion: Isolated trochlear nerve neurofibromas, in the absence of clinical stigmata of NF1, are rare. Multiplicity, multilobulation, ring-configured contrast enhancement, and heterogenous MRI signal intensities help in the accurate preoperative imaging diagnosis. A possible cure is thus achievable with complete excision without damaging important adjacent neurovasculo-musculotendinous structures in the orbit. To the best of our knowledge, this is the fourth reported case of isolated trochlear nerve neurofibroma., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Though, traumatic brain injury (TBI) has been documented as the single most common cause of morbidity and mortality in infancy and childhood, the exact incidence is unavailable in India. Moreover, modes of injury, mechanisms of damage, and management differ significantly from that of an adult., Aims and Objectives: To analyze the epidemiological factors, the spectrum of TBI, modes of injury, types of injury, and the outcome in the children <15 years with TBI., Materials and Methods: This is a retrospective study from August 2012 to May 2013 at Department of Neurosurgery, S.C.B. Medical College, Cuttack, Odisha, India. All the pertinent details from case records of hundred and forty-seven children <15 years with TBI were analyzed. Follow-up was done for 6 months at outpatients department., Results: Age wise, incidence and severity of TBI is more common in 10-15 years. Males outnumber females with a male: female ratio 2.19:1. Overall, road traffic accident (RTA) is the commonest mode of injury. Assault is not uncommon (7.48% cases). Falls is common in <5 years while RTA is common in 5-15 years. The extradural hematoma was the most common injury pattern; however, surgical consideration was maximal for fracture skull. Overall mortality was 7.48%. Diffuse axonal injury has the maximum individual potential for mortality. We noticed excellent recovery in 68.7%, disabilities in 17.68%, and persistent vegetative state in 5.45% cases., Conclusion: TBI in children carries good outcome, if resuscitated and referred early to a neurotrauma center, and managed subsequently on an individualized basis with a well-organized team approach. Severe TBI in children has a poor outcome.

Background: Cerebral aspergillosis, often encountered in immunocompromised patients, is almost always fatal despite radical surgical and medical management and frequently is a finding at autopsy. Attempts at fungal isolation often are unsuccessful, and a high index of radiologic suspicion is necessary., Case Description: A premature, 5-month-old female infant, born via normal vaginal delivery, presented with a progressive increase in head size since birth, delayed developmental milestones, and intermittent vomiting for 1 month. There was no history of trauma and no evidence of diabetes mellitus or hypertension, family history of tuberculosis, gestational diabetes, jaundice, or febrile eruptions. Neonatal jaundice was present after day 1, remained for 2 days, and was treated with phototherapy. Findings of the general and systemic examinations were unremarkable. Findings of a neurologic examination revealed a hypoactive infant with papilledema and extensor plantar bilaterally. Computed tomography scan of brain showed hydrocephalus attributable to aqueductal stenosis. On endoscopic third ventriculostomy, dense, friable, whitish yellow, nonvascular masses were encountered in the third ventricle, obstructing it. Her endoscopic third ventriculostomy success score was 10 + 0 + 10 = 20%. Histopathologic examination and culture revealed Aspergillus flavus. A week later, a medium-pressure ventriculoperitoneal shunt was done, and voriconazole was added., Results: At discharge on the 7th postoperative day, 4 weeks and 12 weeks later (ie, first and second follow-up) the child was active, playful, and feeding normally. The first reported case of an aqueductal stenosis due to aspergillosis was in 2000 by van Landeghem FK et al. (Clin Neuropathol 19:26-29, 2000). To the best of our knowledge, this may only be the second reported case of hydrocephalus attributable to aqueductal stenosis caused by Aspergillosis. In conclusion, aspergillosis should not be ruled out as a differential diagnosis in aqueductal stenosis, even when the patient seems to be immunocompetent., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Spinal epidermoid cyst, congenital or acquired, is mainly congenital associated with spinal dysraphism, rarely in isolation. Intramedullary epidermoid cysts (IECs) are rare with less than 60 cases reported so far; isolated variety (i.e., without spinal dysraphism) is still rarer. Complete microsurgical excision is the dictum of surgical treatment. A 14-year-old boy presented with 4-month history of upper backache accompanied with progressive descending paresthesia with paraparesis with early bladder and bowel involvement. His condition deteriorated rapidly making him bedridden. Neurological examination revealed upper thoracic myeloradiculopathy probably of neoplastic origin with sensory localization to D5 spinal level. Digital X-ray revealed no feature suggestive of spinal dysraphism. Contrast magnetic resonance imaging (MRI) characteristics clinched the presumptive diagnosis. Near-total microsurgical excision was done leaving behind a small part of the calcified capsule densely adhered to cord. Histopathological features were confirmative of an epidermoid cyst. Postoperatively, he improved significantly with a gain of motor power sufficient to walk without support within a span of 6 months. Spinal IECs, without any specific clinical presentation, are often diagnosed based upon intraoperative and histopathological findings, however early diagnosis is possible on complete MRI valuation. Complete microsurgical excision, resulting in cessation of clinical progression and remission of symptoms, has to be limited to sub-total or near-total excision if cyst is adherent to cord or its confines.

Background: Spinal cord compression can be due to various causes but spinal intramedullary tuberculoma is a rare cause. We report a case that had an intramedullary spinal cord tuberculomas in which the diagnosis was made histologically, without evidence of symptoms of systemic tuberculosis. This lesion, located in the thoracic region, mimicked as an intramedullary tumor radiologically., Case Description: The patient was a 25-year-old male who presented with a history of progressive paraparesis. Initial diagnosis was made as an intramedullary tumor by magnetic resonance imaging (MRI). The treatment of the patient involved is complete surgical excision of intramedullary lesion followed by appropriate antituberculous therapy. Postoperatively, his neurological symptoms were dramatically improved. With combination of both surgical and medical treatments, excellent clinical outcome was obtained., Conclusion: This case illustrates the risk of misdiagnosis and the importance of histological confirmation of a pathological lesion as spinal cord tuberculoma prior to surgical therapy, which should be kept in mind as a differential diagnosis of the intramedullary spinal cord tumors.