Bombay Hospital Journal (BHJ) is a peer-reviewed quarterly published Print and Online journal. It is an official Journal of Bombay Hospital institute of medical sciences. The aim of BHJ is to improve medical care by publishing sound scientific articles (both research and practice papers) and focusing on topics that are of great importance to its readership. Editor-in-Chief- Dr Satish Vasant Khadilkar
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Periodic Discharges on Eeg inAn Elderly Female with Vision Loss
Introduction: Rapidly progressive dementia includes a heterogeneous group of disorders. Electroencephalography (EEG) is one of the most important diagnostic tests, especially in the context of disorders such as Creutzfeldt–Jakob disease (CJD), autoimmune encephalitis, metabolic encephalopathy, and non-convulsive status epilepticus. Case Report: A 78-year-old female with no known comorbidities presented with painless, progressive diminution of vision in both eyes over 4 months, followed by abnormal involuntary movements and rapidly progressive cognitive decline. She was referred to our centre after showing no improvement with empirical immunotherapy. On examination, she had altered sensorium, paucity of movements on the right side, and myoclonic jerks. EEG was performed and showed generalized theta slowing with stereotyped periodic sharp wave complexes (PSWCs). Magnetic resonance imaging (MRI) of the brain with diffusion-weighted imaging demonstrated diffuse asymmetric cortical restricted diffusion involving the bilateral cerebral cortices (left more than right), consistent with cortical ribboning. Cerebrospinal fluid (CSF) analysis was positive for the 14-3-3 protein. A diagnosis of sporadic CJD was made. Discussion: The main EEG abnormality in sporadic CJD is the presence of periodic discharges (PSWCs). EEG abnormalities vary depending on stage of the disease. Periodic discharges that mimic CJD can occur in metabolic encephalopathy, autoimmune encephalitis, lithium toxicity, anoxic injury, and sometimes in nonconvulsive status epilepticus; however, these typically lack the highly stereotyped 1-Hz periodicity seen in sporadic CJD, particularly when correlated with the clinical progression. Conclusion: EEG has significant clinical utility. It helps distinguish CJD from autoimmune encephalitis and nonconvulsive status epilepticus, in patients with rapidly progressive dementia when used in conjunction with MRI and CSF prion assays.
Creutzfeldt–Jakob disease; cortical ribboning; EEG; Rapidly progressive dementia
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“Motor Band Sign” Seen in Motor Neuron Disease
Introduction: The “motor band sign” is an emerging magnetic resonance imaging (MRI) feature of upper motor neuron degeneration in motor neuron diseases. It appears as a curvilinear hypointensity along the primary motor cortex on iron-sensitive sequences such as susceptibility-weighted imaging (SWI). Case Report: A 62-year-old male presented with a 3-year history of progressive gait disturbance, trivial falls, and dysarthria, followed by difficulty rising from a chair over six months. Examination revealed spastic dysarthria, upper motor neuron signs, and proximal lower-limb weakness. MRI brain demonstrated symmetric curvilinear hypointensity along the bilateral precentral gyri on SWI and GRE sequences, consistent with the motor band sign. Electrodiagnostic studies did not show lower motor neuron involvement, supporting a diagnosis of primary lateral sclerosis. Discussion: The motor band sign represents abnormal iron deposition within the deep cortical layers of the precentral gyrus due to neurodegeneration and microglial activation. It is best detected using susceptibility-sensitive sequences such as SWI and GRE. Conclusion: Recognition of the motor band sign on MRI may assist in the identification of motor neuron disease, particularly when conventional imaging is otherwise unremarkable.
Amyotrophic lateral sclerosis; Motor band sign; Motor neuron disease; Primary lateral sclerosis; Susceptibility-weighted imaging
What Is New in Peripheral Neuropathy? Recent Advances in Diagnosis and Management
Peripheral neuropathy represents one of the most common neurological disorders encountered in clinical practice and includes a heterogeneous group of conditions affecting sensory, motor, and autonomic nerves. Traditional classification based primarily on etiology often provides limited guidance in the early diagnostic evaluation of patients presenting with neuropathic symptoms. Recent advances in neurophysiology, imaging, molecular diagnostics, and targeted therapeutics have significantly transformed the approach to peripheral neuropathy. A phenotype-based clinical framework emphasizing pattern recognition, fiber type involvement, and biomarker-guided investigations can facilitate more efficient identification of treatable neuropathies. Novel diagnostic modalities such as skin biopsy for quantification of intraepidermal nerve fiber density, corneal confocal microscopy for assessment of small fiber pathology, and next-generation sequencing for hereditary neuropathies have expanded the diagnostic armamentarium. At the same time, the therapeutic landscape has evolved substantially with the development of disease-modifying therapies for hereditary transthyretin amyloidosis, advances in immunotherapy for immune-mediated neuropathies, and emerging neuromodulation strategies for refractory neuropathic pain. Recognition of antibody-mediated nodo-paranodopathies and the development of RNA-based therapies illustrate the growing role of precision medicine in peripheral nerve disorders. This review provides a practical overview of contemporary advances in peripheral neuropathy with emphasis on clinical pattern recognition, modern diagnostic evaluation, and current as well as emerging therapeutic strategies relevant to day-to-day clinical practice.
Peripheral neuropathy; Small fiber neuropathy; Precision medicine
Non-Immune Causes of Longitudinally Extensive TransverseMyelitis: Lessons Learnt from A Tertiary Care Cohort
Background: Longitudinally extensive transverse myelitis (LETM) is often presumed to be immune‑mediated. However, a substantial proportion of LETM arises from non‑immune causes that closely mimic inflammatory myelitis, leading to diagnostic delays and inappropriate immunotherapy. Objectives: The aim of the present study was to describe the clinical and radiological characteristics of LETM due to non-immune causes and highlight red flag features that differentiate these conditions from immune‑mediated LETM. Methods: We retrospectively reviewed LETM cases who presented to our tertiary care centre over a period of 6 years (2019–2025) and analysed cases due to non-immune causes. Results: Out of a total 43 LETM cases, 27 cases with a non-immune cause were included in the present study. These included various etiological categories: infectious (n=11), vascular (n=5), nutritional (n=4), neoplastic/paraneoplastic (n=4) and compressive (n=3). The diagnostic delay in cases with vascular etiologies was more compared to other causes. 55% (5/27) of cases received immunotherapy before final diagnosis was established. Clinical and radiological diagnostic clues differentiating various etiologies were strikingly different compared to the immune mediated group. Conclusion: Non-immune causes constitute a significant proportion of LETM in endemic regions. Recognizing red flag features is essential to avoid misclassification as immune-mediated LETM. Early identification of reversible etiologies such as vitamin B12 deficiency and spinal dural arterio-venous fistula significantly alters outcomes. Bottom of Form
LETM; spinal infarct; subacute combined degeneration; spinal dural AV fistula; transverse myelitis
Beyond Patterns: Diagnostic Precision and theChallenge of Neurological Mimics
Neurology remains a discipline defined by pattern recognition; yet, equally, it requires a constant vigilance against the overinterpretation of patterns. As diagnostic technologies evolve, the risk of premature diagnostic closure has increased. This issue of the Bombay Hospital Journal brings into focus a central challenge in contemporary neurology—the differentiation of disease from its mimics—and reinforces the importance of integrative clinical reasoning.
Editorial Leprosy: A Neurologist's Perspective
Leprosy (Hansen’s disease) is a chronic infectious disease caused by Mycobacterium leprae that primarily affects the skin and peripheral nerves. Despite availability of effective treatment, leprosy continues to be an important public health problem, particularly in Southeast Asia. India accounts for a significant proportion of the global disease burden. Transmission typically occurs through prolonged close contact with infected individuals, most commonly via respiratory droplets. The bacillus demonstrates a predilection for cooler areas of the body and preferentially infects Schwann cells, leading to progressive peripheral nerve damage through both direct bacterial invasion and immune-mediated mechanisms. Clinically, leprosy presents across a spectrum ranging from tuberculoid to lepromatous disease, depending on the host’s cell-mediated immune response. Classical manifestations include hypopigmented hypoesthetic skin lesions, thickened peripheral nerves, sensory loss, and painless ulcers. Peripheral neuropathy is a hallmark of the disease and may manifest as mononeuritis multiplex, pure neuritic leprosy, or generalized polyneuropathy. Early involvement of small sensory fibers results in loss of temperature sensation, often preceding impairment of other sensory modalities. Diagnosis is primarily clinical and is supported by slit-skin smear examination for acid-fast bacilli, electrophysiological studies, imaging, and histopathological evaluation. Early recognition is essential to prevent irreversible nerve injury, deformities, and disability. Management involves multidrug therapy with dapsone, rifampicin, and clofazimine as recommended by the World Health Organization. Additional management includes treatment of lepra reactions, control of neuropathic pain, rehabilitation, and preventive strategies such as chemoprophylaxis and vaccination. A multidisciplinary approach and early diagnosis are crucial for reducing long-term complications and social stigma associated with the disease.
Leprosy; Mycobacterium leprae; multidrug therapy; peripheral neuropathy; pure neuritic leprosy
Prospective Observational Study of Post-Operative Port-Site Pain After Gall Bladder Retrieval from Umbilicalvs Epigastric in Laparoscopic Cholecystectomy
Background: Laparoscopic cholecystectomy is the standard surgical treatment for benign gallbladder disease. Although minimally invasive, postoperative port-site pain remains a common concern and may influence patient recovery. Gallbladder retrieval is a critical terminal step of the procedure and can be performed through either the umbilical or epigastric port; however, the optimal retrieval site with respect to postoperative pain remains controversial. Objectives: To compare postoperative port-site pain following gallbladder retrieval through the umbilical versus epigastric port in patients undergoing elective four-port laparoscopic cholecystectomy, and to evaluate secondary outcomes including retrieval time, surgical site infection, and length of hospital stay. Methods: This prospective observational study was conducted over 18 months at a tertiary care center. Eighty adult patients undergoing elective laparoscopic cholecystectomy were enrolled and divided into two groups based on the port used for gallbladder extraction: umbilical port (n = 40) and epigastric port (n = 40). Postoperative pain was assessed using the visual analogue scale at 1, 6, 12, 24, and 36 hours after surgery. Demographic variables, gallbladder extraction time, surgical site infection, and duration of hospital stay were also recorded and analyzed. Results: Baseline demographic and operative characteristics were comparable between the two groups. Patients in the umbilical port group demonstrated significantly lower postoperative pain scores at all assessed time intervals compared to the epigastric port group (p < 0.05). No statistically significant difference was observed between the groups in gallbladder extraction time, incidence of surgical site infection, or length of hospital stay. Conclusion: Gallbladder retrieval through the umbilical port is associated with significantly reduced postoperative port-site pain without increasing operative time, infection rates, or hospital stay. The umbilical port may therefore be preferred for gallbladder extraction during elective laparoscopic cholecystectomy to improve postoperative patient comfort.
Laparoscopic cholecystectomy; gallbladder retrieval; port-site pain; umbilical port; epigastric port; visual analogue scale.
Background: Neuroendocrine tumours (NETs) of the ileocaecal junction are uncommon neoplasms and are frequently diagnosed incidentally. Most gastrointestinal NETs are detected on histopathological examination following surgery for presumed benign conditions such as appendicitis. Surgical resection remains the cornerstone of management, with the extent of surgery determined by tumour size, location, and pathological features. Case Presentation: We report the case of a 46-year-old male who presented with recurrent abdominal pain, vomiting, and significant weight loss. Radiological evaluation revealed an ileocaecal mass causing luminal narrowing and features of subacute intestinal obstruction. A CT-guided biopsy suggested a low-grade neuroendocrine tumour. The patient underwent a radical right hemicolectomy. Histopathological and immunohistochemical evaluation confirmed a well-differentiated Grade 1 neuroendocrine tumour involving the ileocaecal junction, terminal ileum, and appendix, with regional lymph node metastasis. Conclusion: This case highlights the diagnostic challenge posed by ileocaecal neuroendocrine tumours due to their nonspecific presentation. Routine histopathological examination of appendectomy and right hemicolectomy specimens is essential, as clinically occult malignancies and NETs may otherwise be missed.
Ileocaecal tumour; Neuroendocrine tumour; Appendiceal neoplasm; Right hemicolectomy
Reclaiming Fitness: Ethics, Simplicity and Scientific Responsibility in Modern Fitness Training
Regular exercise; ideally practiced 5-6 days of the week; alongside a balanced, wholesome home cooked diet and adequate sleep represents the most accessible and inclusive model of fitness. This is a simple and sustainable approach; which can be universal. In this context, fitness trainers occupy a role of profound importance, comparable in many ways to that of medical professionals demanding a high degree of knowledge, ethical integrity and accountability.
Unraveling Emphysematous Gastritis: A Radiological Saga
Objective: Emphysematous gastritis is an uncommon but severe condition marked by the presence of intramural gas within the gastric wall, typically resulting from gas-forming bacterial infections. This study aims to analyse the radiological presentations and outcomes of three distinct cases to enhance diagnostic accuracy and guide management strategies. Methods: We performed a retrospective analysis of three patients diagnosed with emphysematous gastritis. Each case was evaluated using various imaging techniques including plain abdominal X-ray, and computed tomography (CT). The radiological findings were correlated with clinical outcomes and treatment approaches. Results: Radiological evaluations revealed distinctive patterns: (1) Plain X-rays in two patients demonstrated diffuse gas within the gastric wall. (2) CT scans provided detailed insights into the extent of intramural gas, identified associated complications such as pneumoperitoneum, and assessed the involvement of adjacent organs. Clinical management varied; one patient responded well to conservative treatment with antibiotics and supportive care, while the other two required surgical intervention due to complications including perforation and systemic infection. Conclusion: The imaging features of emphysematous gastritis are critical for early diagnosis and effective management. This case series highlights the utility of imaging modalities in evaluating the severity and extent of the disease, which can significantly influence treatment outcomes. Prompt and accurate radiological assessment is essential for optimizing patient care in this challenging condition.
Congenital Unilateral Choanal Atresia with Adenoid Hypertrophy: A Case Report
Congenital choanal atresia is a rare developmental anomaly characterized by failure of communication between the nasal cavity and nasopharynx. Bilateral choanal atresia usually presents in the neonatal period with respiratory distress, whereas unilateral choanal atresia often presents late because of subtle symptoms. We report the case of a 6-year-old female child presenting with unilateral nasal discharge since birth. Diagnostic nasal endoscopy and computed tomography (CT) of the paranasal sinuses confirmed left-sided congenital choanal atresia associated with adenoid hypertrophy and pan-sinusitis. The patient underwent endoscopic repair of choanal atresia using a posterior septal flap along with coblator-assisted adenoidectomy. Postoperative recovery was uneventful, and the patient is on regular follow-up.
A Rare Case of Triple Pathogen Co-Infection with Rickettsia, Varicella Zoster Virus, and Plasmodium vivax Confirmed by PCR in an Immunocompetent Adult
A 33-year-old immunocompetent male presented with high-grade fever, generalized maculopapular rash, myalgia, and headache after returning from rural Southeast Asia. Investigation by PCR based Tropical Fever Panel confirmed co-infection with Varicella-Zoster Virus, Rickettsia spp., and Plasmodium malariae. Patient was treated for all three infection concurrently and showed improvement in his symptoms after which he was discharged. This case highlights the importance of considering multiple concurrent tropical infections in endemic regions even in patients with no comorbidities.
Curious Case of Non-Healing A bdominal Wound
ABSTRACT Port-site complications following laparoscopic surgery are uncommon but can present diagnostic and therapeutic challenges. Among these, a persistent port-site sinus is a rare occurrence, often resulting from chronic infection, retained foreign material, or atypical organisms. Early recognition and appropriate management are essential to prevent prolonged morbidity. We report the case of a 33 year-old female who developed a chronic discharging sinus at the left lower port site following a laparoscopic myomectomy performed 1 year earlier. The patient presented with intermittent seropurulent discharge, local tenderness, and non-healing despite multiple courses of antibiotics. MRI imaging suggested Three sinus tracts are seen in the subcutaneous plane of the lower anterior abdominal wall on the left side in relation to the skin defects and in association with the cellulitis. Surgical exploration revealed three sinus tracts in left side of anterior abdominal wall is s/c plane. Histopathology showed chronic pyogenic sinus and NTM culture report confirms presence of NON TUBERCULOUS MYCOBACTERIA . The patient recovered uneventfully with complete healing at follow-up
Nontuberculous mycobacteria (NTM), Port-site infection, Laparoscopic surgery complications, Chronic discharging sinus, Non-healing abdominal wound
Contemporary Advances in Acute Stroke Management: A FullyIntegrated Review
Background: Acute stroke care has evolved in a substantial manner over the past three decades. Advances in imaging-guided reperfusion, expansion of mechanical thrombectomy indications, refinement of thrombolytic agents, and structured post-reperfusion and in-hospital care have contributed to improved outcomes in both ischemic as well as hemorrhagic stroke. Objective: To bring together contemporary developments in acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) and to integrate global evidence with practical considerations relevant to Indian clinical settings. Methods: Narrative review of landmark trials from 1995-2026, major guideline updates with emphasis on applicability to routine clinical practice. Results: Stroke therapeutics have progressed from early intravenous alteplase within narrow time windows (2,3) to late-window reperfusion enabled by tissue-based imaging (4-6). Tenecteplase has emerged as a practical alternative to alteplase due to ease of administration and growing evidence supporting its safety and efficacy (15,16). Mechanical thrombectomy now benefits patients across early and late windows (18,24,25), including those with large- core infarction (12-14) and posterior-circulation stroke (26,27). Post-reperfusion care—including blood pressure optimisation, neurological monitoring, and prevention of secondary complications—plays a critical role in determining outcomes (31). ICH management has advanced with emphasis on controlled blood pressure reduction (45,46), targeted anticoagulation reversal (53-55), and minimally invasive surgical approaches (50- 52). Conclusion: Modern stroke care integrates tissue-based reperfusion strategies, evidence-based antithrombotic therapy, and structured supportive care. Adaptation to Indian health-care systems remains essential for equitable implementation. Timely intervention remains essential to prevent irreversible brain injury.
Stroke; Ischemic Stroke; Thrombolytic Therapy; Mechanical Thrombectomy; Intracerebral Hemorrhage
Scrolling away our intelligence - The smartphone generation’s cognitive challenge
As elders, it is the responsibility of educators to optimize screen exposure in schools and to takes steps to maximize the cognitive capacity and long-term flourishing of Gen Z and the generations beyond.
Floating thrombus- basilar artery occlusion
Aim The treatment of Basilar artery occlusion (BAO) with low NIHSS score requires to be individualized to each patient Background Basilar artery occlusion represents a small proportion of strokes worldwide but can have catastrophic presentations. Recent trials for BAO have studied the benefits of endovascular treatment (EVT) over intravenous thrombolysis (IVT) and have concluded that EVT has better mortality and morbidity outcomes. However, the management of BAO with lower NIHSS scores may become risky as the complications of the said treatment may outweigh the benefits. Case description We present a 54-year-old lady who presented with dizziness and hemiplegia which resolved within 1 hour. She had hypertension, mild left facial weakness and NIHSS score of 1 on presentation. MRI Brain revealed an acute focal left lateral medullary infarct, and angiogram showed a basilar artery thrombosis with distal basilar artery flow. She was started on dual antiplatelet therapy, low molecular weight heparin and statin. Cerebral DSA revealed a floating thrombus within the basilar artery and left vertebral artery V4 segment stenosis with normal flow in the distal basilar artery. As the patient had mild symptoms, she was discharged on oral anticoagulant and single antiplatelet therapy. She underwent stenting of the Vertebral artery V4 segment, 2 months later as she had recurrent posterior circulation transient ischemic attacks. Conclusion All basilar artery occlusions need not require immediate endovascular thrombectomy and may be managed conservatively initially with anti-coagulation and antiplatelet therapy.
Basilar artery occlusion, thrombus, Thrombectomy
Not All That Looks Like ALS Is ALS: Spectrum of Amyotrophic Lateral Sclerosis Mimics at a Tertiary Neuromuscular Center
Abstract Background: Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disorder diagnosed clinically in the absence of a definitive biomarker. Several neuromuscular and structural disorders can closely mimic ALS, leading to diagnostic errors with significant prognostic and therapeutic implications. Objective: To analyze the spectrum, clinical characteristics, and key predictors of ALS mimic disorders among patients referred with suspected ALS at a tertiary neuromuscular center. Methods: This retrospective observational study reviewed approximately 500 patients referred with a provisional diagnosis of ALS between January 2021 and December 2025. Clinical data, electrophysiology, neuroimaging, and relevant laboratory investigations were analyzed. Fifty-one patients with confirmed ALS mimic diagnoses and complete clinical data were included. Comparative analyses with published ALS epidemiologic parameters were performed using Student’s t-test and chi-square/Fisher’s exact tests. Multivariate logistic regression was used to identify predictors of ALS mimic diagnosis. Results: The most frequent ALS mimics were Hirayama disease (29.4%), post-polio syndrome (23.5%), and adult-onset spinal muscular atrophy (23.5%). Patients with ALS mimics were significantly younger at symptom onset than reported ALS cohorts (19.1 ± 3.6 vs 58.7 ± 11.3 years; p <0.001). Bulbar onset was absent in the mimic cohort (p <0.001). Conduction block on electrophysiology and structural spinal abnormalities on MRI were significantly associated with mimic diagnoses. Multivariate analysis identified age <40 years, absence of bulbar onset, conduction block, and MRI structural abnormalities as independent predictors of ALS mimic disorders. Conclusion: ALS mimics represent a substantial proportion of patients referred with suspected motor neuron disease. Recognition of clinical red flags, careful electrophysiological interpretation, and routine spinal imaging are essential to avoid misdiagnosis and identify treatable conditions.
Amyotrophic lateral sclerosis, ALS mimics, misdiagnosis, motor neuron disease
Antibody-Negative but Not Immune-Negative: Seronegative Autoimmune Encephalitis Presenting as NORSE
Abstract Background: New-onset refractory status epilepticus (NORSE) is a rare neurological emergency characterized by prolonged seizures without prior epilepsy or clear acute structural cause. Autoimmune encephalitis is increasingly recognized as an important etiology. Case Presentation: We report a 28-year-old previously healthy male who presented with acute febrile illness followed by focal seizures rapidly progressing to refractory status epilepticus. Neuroimaging revealed bilateral basal ganglia and mesial temporal involvement. Extensive infectious and autoimmune workup was negative. Despite escalation of antiseizure medications and anaesthetic agents, seizures remained refractory, necessitating immunotherapy with intravenous immunoglobulin and rituximab, following which gradual neurological recovery was observed. Conclusion: This case highlights the importance of early recognition of NORSE and prompt initiation of immunomodulatory therapy in suspected autoimmune encephalitis, even in seronegative cases.
NORSE, refractory status epilepticus, autoimmune encephalitis, seronegative, immunotherapy
Seronegative Autoimmune Encephalitis , NORSE ,Immunotherapy
Incidentally detected aortic coarctation during evaluation of newly diagnosed hypertension in a young adult
Coarctation of the aorta is a congenital condition that may remain clinically silent until adulthood. We report the case of a 20-year-old male who presented with headache and was found to have newly diagnosed hypertension on routine examination. Further evaluation for secondary causes of hypertension incidentally revealed a previously undiagnosed aortic coarctation. This case highlights the importance of systematic evaluation of young patients with hypertension and reinforces the need to consider congenital cardiovascular anomalies even in the absence of classical clinical signs.
A CASE REPORT BEYOND THE SCAR: DIAGNOSTIC COMPLEXITY IN A CASE OF POST-HYSTERECTOMY VAULT ENDOMETRIOSIS: A CASE REPORT
ABSTRACT Background: Vault endometriosis is a rare cause of post-hysterectomy vaginal bleeding and often presents years after surgery, posing a diagnostic challenge. Case Presentation: A 50-year-old woman with a history of total laparoscopic hysterectomy with bilateral salpingectomy (TLH+BS) presented with brownish per vaginum spotting. Ultrasonography revealed a small vascular lesion at the vaginal vault. Laparoscopic excision of the vault nodule was performed. Histopathology confirmed vault endometriosis. Postoperatively, the patient was treated with a gonadotropin-releasing hormone (GnRH) agonist, with complete resolution of symptoms. Conclusion: Vault endometriosis, though rare, should be considered in women presenting with post-hysterectomy vaginal bleeding. Laparoscopic excision with adjunctive hormonal therapy provides excellent outcomes. Keywords: Vault endometriosis, Post-hysterectomy bleeding, Vaginal vault, Laparoscopy, GnRH agonist
case report Echoes of the Present : Experiential and Autonomic Auras in Temporal Lobe Epilepsy
Experiential auras such as déjà vu and jamais vu are distinctive manifestations of temporal lobe epilepsy. We report a young adult presenting with recurrent episodes of altered familiarity perception associated with unilateral piloerection. This case highlights the neurobiological basis of novelty–familiarity circuits and their disruption in focal epilepsy, and underscores the diagnostic value of experiential and autonomic auras.
Retrospective Analysis of Ureteric Injury During Ureteroscopy (URS) Versus Retrograde Intrarenal Surgery (RIRS) Over a Three-Year Period
Background Ureteroscopy (URS) and retrograde intrarenal surgery (RIRS) are widely used minimally invasive procedures for urolithiasis. Ureteric injury remains a significant complication with potential long-term morbidity. Objective To compare the incidence and severity of ureteric injury during URS and RIRS over a three-year period. Materials and Methods A retrospective analysis of 400 patients undergoing endourological stone surgery was performed. Two hundred patients each underwent URS and RIRS. Ureteric injuries were graded intraoperatively and postoperatively as: Grade 1—superficial mucosal abrasion; Grade 2—mucosal injury; Grade 3—partial disruption; Grade 4—total avulsion. Statistical analysis was performed using the Chi-square test. Results Ureteric injury occurred in 30 patients (15%) in the URS group and 10 patients (5%) in the RIRS group (p = 0.0015). Low-grade injuries (Grade 1–2) constituted the majority in both groups. Severe injuries (Grade 3–4) were significantly more common in the URS group (26.7% vs 10%). No Grade 4 injury was observed in the RIRS group. Conclusion URS is associated with a significantly higher incidence and severity of ureteric injury compared to RIRS. RIRS appears to be a safer modality with respect to ureteric integrity. Keywords: Endourology, RIRS, ureteroscopy, ureteric injury
Case Report Manubriosternal Osteomyelitis – Rare Cause of Acute Onset Chest Pain
The aim of this case report is to establish the role of radiology in diagnosing manubriosternal osteomyelitis – a rare cause of acute onset chest pain that is difficult to diagnose clinically and, most of the time, misdiagnosed as angina. Early diagnosis and timely management are clinically important to avoid fatal complications in the later stages of the disease.
Angina, Manubriosternal osteomyelitis, Steroids
REVIEW OF LITERATURE Comprehensive Physical and Systemic Examination in Neurological Disorders
Introduction: A comprehensive general physical and systemic examination is fundamental in evaluating patients with neurological disorders. It helps not only in localizing neurological dysfunction but also in identifying systemic conditions, such as diabetes, hypertension, and infections, that may contribute to or mimic neurological symptoms. A thorough examination is crucial for accurate diagnosis and effective management. Key components of the physical examination: This includes an assessment of the patient’s general appearance, vital signs, head and neck, cardiovascular, respiratory, musculoskeletal, gastrointestinal and dermatological systems. Each of these aspects can reveal significant clinical findings, ranging from facial expressions and posture indicative of specific neurological disorders to skin manifestations and cardiovascular irregularities that provide clues for underlying conditions. The systemic examination’s depth depends on the patient’s history, yet a complete assessment is crucial for uncovering unexpected findings and ensuring accurate diagnosis and management of neurological conditions. Conclusion: By incorporating both targeted neurological and broader systemic assessments, this approach facilitates the holistic evaluation of patients helping in optimizing treatment strategies for neurological disorders
Amyotrophic lateral sclerosis, Mucopolysaccharidosis, Transient ischemic attack, Arteriovenous malformation
Original Article Exploring the Efficacy of Telmisartan and Cilnidipine Combination Therapy in Hypertension: A Cross-sectional Analysis
Introduction: Hypertension is a common non-communicable disease and is of major public health concern accounting for 19% of all deaths globally. The lack of awareness about hypertension is a major contributory factor for the delayed diagnosis of asymptomatic cases, thus being labeled as a “silent killer disease.” Effective control of blood pressure is a must and for achieving it, a long-acting antihypertensive agent is required. Telmisartan is one of the angiotensin II receptor blockers whereas cilnidipine is a novel calcium antagonist. Cilnidipine has shown prolonged and desirable antihypertensive effects. The present questionnaire-based study conducted on various clinicians across different parts of the country analyses the pattern of patients with hypertension and other comorbidities in their clinical practice along with the trend in the prescription of antihypertensives either mono and/or combination therapy. Materials and Methods: The present study is a questionnairebased cross-sectional study consisting of 25 validated structured questions. The study was approved by the Institutional Ethical Committee. All the completed forms were included in the study whereas incomplete form was excluded from the study. Observation and Results: The survey reflects that 87% of the patients have diabetes mellitus as one of the most common comorbid conditions associated with hypertension. About 86.5% of the clinicians (86.5%) are of the opinion that more than 30% of the patients required combination therapy of telmisartan and cilnidipine with the addition of diuretics in uncontrolled hypertension. The combination also offers many other benefits such as its anti-atherosclerotic properties and endorgan protection. Conclusion: The study highlights that combination therapy is very effective in treating hypertension even if associated with other comorbid conditions such as diabetes and chronic kidney disease.
Cilnidipine, Combination therapy, Diuretics, Hypertension, Telmisartan
Surviving Twin In A Bicornuate Uterus with Horn Specific IUFD and Transfusion incompatibility : A Case Report
Abstract Twin pregnancy in a bicornuate uterus is rare and associated with significant obstetric risk. We report a 25-year-old G2A1 woman with a DCDA twin pregnancy complicated by pregnancy-induced hypertension, prior cervical cerclage, and horn-specific intrauterine fetal demise at 34+6 weeks. The demised twin was located in the smaller uterine horn, while the surviving twin occupied the dominant horn. Management was further complicated by transfusion incompatibility due to a prior blood transfusion. Emergency caesarean section resulted in delivery of a healthy neonate. This case highlights the importance of anatomy-driven decision-making and anticipation of transfusion challenges in complex twin pregnancies. Introduction Congenital uterine anomalies result from abnormal Müllerian duct development and are associated with adverse reproductive outcomes. A bicornuate uterus, characterized by incomplete fusion of the Müllerian ducts, accounts for a small proportion of these anomalies and is associated with miscarriage, preterm birth, malpresentation, and placental abnormalities. Twin pregnancy in a bicornuate uterus is rare, and implantation of each twin in a separate horn further complicates management. The occurrence of horn-specific intrauterine fetal demise (IUFD) poses additional maternal and fetal risks, particularly in the third trimester. Management is further challenged when transfusion incompatibility is encountered due to red cell alloimmunization. There are no standardized guidelines for such scenarios, and clinical decisions must be individualized. We present a rare case highlighting anatomy-driven management and multidisciplinary preparedness. Case Presentation A 25-year-old woman, gravida 2 abortion 1, presented at 34+6 weeks of gestation with complaints of lower abdominal pain for 24 hours. She had a known bicornuate uterus and a spontaneously conceived DCDA twin pregnancy. Her obstetric history was significant for a first-trimester spontaneous abortion. In the current pregnancy, a cervical cerclage had been placed at six months of gestation in view of cervical insufficiency. She was diagnosed with pregnancy-induced hypertension two weeks prior to presentation and was on oral labetalol. She also had a history of hypothyroidism for seven years, well controlled on levothyroxine. Notably, she had received a blood transfusion four years earlier for an unrelated indication. Ultrasonography at presentation revealed intrauterine fetal demise of Twin B at 32weeks of gestational age, located in the smaller horn of the bicornuate uterus, with features of maceration. Twin A was viable, appropriately grown, and located in the dominant uterine horn, with reassuring fetal heart activity. The placentation was dichorionic diamniotic. Given the gestational age, presence of IUFD, maternal hypertension, and uterine anomaly, the patient was admitted for close monitoring. Preoperative evaluation revealed blood group B positive. Cross-matching with available blood units across multiple blood banks was unsuccessful, likely due to red cell alloimmunization from prior transfusion. In view of the high risk of hemorrhage, arrangements were made for least incompatible blood in consultation with the transfusion services. An emergency lower segment caesarean section was performed. Intraoperatively, a bicornuate uterus with asymmetric horns was confirmed. Twin A, a live male neonate, was delivered by breech extraction from the dominant horn and shifted to the neonatal intensive care unit for observation. Twin B, a macerated female fetus, was delivered from the smaller horn. The postoperative period was uneventful. The neonate was observed in the NICU for 72 hours and subsequently discharged in stable condition. The mother had an uncomplicated recovery and was discharged with appropriate follow-up advice. Discussion Twin pregnancy in a bicornuate uterus is an uncommon occurrence, and implantation in separate uterine horns is even rarer. The reduced distensibility and altered vascularity of the smaller horn may predispose to placental insufficiency and fetal compromise, explaining the horn-specific IUFD observed in this case. In contrast, DCDA placentation likely protected the surviving twin from hemodynamic disturbances, contributing to a favorable neonatal outcome. Management of such cases is challenging due to the lack of standardized guidelines. Decisions must be guided by uterine anatomy, gestational age, fetal condition, and maternal status. In our case, the presence of pregnancy-induced hypertension and prior cervical cerclage further increased maternal risk. An additional complexity was transfusion incompatibility due to suspected alloimmunization following prior blood transfusion. In high-risk obstetric surgery, anticipation of transfusion challenges and early coordination with blood banks are critical. The availability of least incompatible blood serves as a contingency strategy when fully compatible units are unavailable and can be life-saving in emergencies. This case underscores the importance of individualized, anatomy-driven management and preparedness for rare but potentially catastrophic complications. Conclusion Twin pregnancy in a bicornuate uterus represents a high-risk obstetric condition. Horn-specific IUFD further complicates management and necessitates timely intervention. DCDA placentation may confer protection to the surviving twin. Anticipation of transfusion challenges and early surgical decision-making are crucial to optimize maternal and neonatal outcomes. Conflict of Interest The authors declare no conflict of interest.
Case Report The Case of a Melting Face: Parry–Romberg Syndrome
Background: Parry–Romberg syndrome (PRS), or progressive hemifacial atrophy, is a rare acquired disorder characterized by unilateral facial tissue loss of uncertain etiology. It is often associated with neurological, ocular, dental, and autoimmune manifestations. Case Report: We report a 38-year-old woman with 12–13 years of progressive right-sided facial atrophy associated with enophthalmos and hypothyroidism. Clinical examination showed marked hemifacial atrophy involving skin, soft tissue, and jaw with no neurological deficits. Conclusion: This case highlights the classical presentation of PRS with ocular involvement and autoimmune association. Early recognition and multidisciplinary management are essential to optimize functional and cosmetic outcomes. Keywords: Parry–Romberg syndrome, progressive hemifacial atrophy, enophthalmos, hypothyroidism, autoimmune
Editorial Artificial Intelligence in Healthcare: Balancing Technological Innovation with Clinical Judgment
Artificial Intelligence in it's current form is a good tool; but remains, at present only an assistant - the final responsibility always lies with the licensed medical practitioner which is the clinician.
progressive lower limb paraplegia in pregnancy -An vertebral haemangioma - A case report
We present a rare case of spinal cord haemangioma in a pregnancy at 38 weeks of gestation, managed with multidisciplinary approach. The patient presented with back pain and neurological symptoms, diagnosed via MRI. Successful management involve close monitoring, pain control, and planned delivery. This case highlights the importance of prompt diagnosis and collaborative care in ensuring optimal outcome for both mother and baby.
Original article Radial SNAP- Optimal site of stimulation in healthy Indian subjects
Abstract Background: The radial sensory nerve action potential (SNAP) is an important electrodiagnostic study of the upper limbs for a large variety of conditions. Inappropriate distance of stimulation and unavailability of reference data can lead to erroneous conclusions. Objectives: To establish the optimal site of recording the Radial SNAP and obtain reference data for radial SNAP in age-stratified healthy subjects. Materials and Methods: A prospective study was conducted in 181 nerves from healthy subjects aged between 18 years and 86 years, stratified into five groups as per age: a = 18-30 years, b = 31-40 years, c = 41-50 years, d = 51-60 years, e > 61 years. Radial SNAP was recorded antidromically, stimulating at 10 cm from the recording electrode. Mean – 2 standard deviation (SD) of the transformed data was used to generate reference values for amplitudes. Results: The lower limits of amplitude at 10 cm were 28.8, 30.4, 24.4, 23.7 and 16.2 mV for groups a, b, c, d and e, respectively and at 12 cm were 25, 29.2, 18.9, 17.9 and 14.5 mV respectively. A statistically significant difference in amplitudes was noted from the three different sites of stimulation (P < 0.001). A 17% variation in amplitude is explained by age. Height, BMI and wrist girth had minimal effect on the amplitude obtained (r2= 0.05, 0.01, 0.00) Conclusion: This study provides age stratified reference data for antidromic Radial SNAP in Indian population and also gives the optimal site of stimulation of the SNAP.