Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review

Objective

Snakebites, a major health concern in developing countries, affect rural farming communities. Venom, primarily neurotoxin, injected during a snake bite disrupts the nervous system, causing symptoms like muscle weakness, paralysis, altered sensation, and coordination issues. This review focuses on evaluating neurological and neuro-ophthalmological manifestations associated with snakebites.

Methods

A database search was conducted in EMBASE and PubMed for studies published from 2000 to 2023. The investigation centered on examining neurological and neuro-ophthalmological symptoms and signs, treatment approaches, treatment outcomes, and long-term complications of snake bites.

Results

Neurological and neuro-ophthalmological symptoms were common in both neurotoxic and hemotoxic snake bites, especially in neurotoxic cases. Ptosis was a prevalent manifestation across various snake bites, along with respiratory paralysis, limb weakness, dysphasia, and visual disturbances in some instances. However, most patients improved without residual neurological symptoms after treatment.

Conclusions

Understanding patterns of neurological manifestations contributes valuable insights for the comprehensive management of snakebite.

Minimally invasive procedure for optic disc pit maculopathy: vitrectomy with scleral plug and analysis on pattern of resolution

Optic disc pit maculopathy (ODP-M) is a rare complication of optic disc pit which can cause irreversible visual impairment. The aim of this study is to evaluate the anatomical and functional outcomes and pattern of resolution of ODP-M following vitrectomy with posterior vitreous detachment (PVD) induction and scleral tissue plug for treatment of ODP-M without ILM peeling, laser or use of long term gas/tamponade or head positioning. This retrospective study included 7 patients with ODP-M, meeting the inclusion criteria. Patients were followed up for 6 months. Complete anatomical success was defined as "Total resolution of all the fluid in retinal compartments". All of the patients had complete resolution of the optic pit maculopathy following surgery. The mean duration for complete resolution was 18.3 weeks. Pattern of resolution of ODP-M was found to be resolution of the subretinal fluid (SRF) followed by disappearance of the retinoschitic lesions (RL) and finally disappearance of macular edema (ME). The proposed minimally invasive procedure (MIP) can produce comparably good and equally reliable results for the treatment of ODP-M.

Multiple myeloma with plasmacytoma of the clivus bone presenting with multiple cranial nerve III, IV, and VI palsy: A diagnostic dilemma

Central nervous system (CNS) manifestation with cranial nerve palsy in multiple myeloma (MM) is a rare manifestation. Plasmacytoma originates from the bones of the skull base in 3% patients with MM but rarely develops from the soft tissues of the nasal cavity and paranasal sinuses. Here, we present a case of 68-year-old male patient with multiple myeloma, clivus bone plasmacytoma, and cavernous sinus syndrome.

Amyotrophic lateral sclerosis and retinal changes in optical coherence tomography: A systematic review and meta-analysis

INTRODUCTION

Increasing evidence suggests Amyotrophic Lateral Sclerosis (ALS) as a widespread pathological process comprising nonmotor features like fatigue, mild sensory symptoms, cognitive decline, and visual impairment. Measurements of retinal nerve fiber layer (RNFL) thickness using Optical Coherence Tomography (OCT) may correlate with the neurodegeneration associated with ALS. In addition to RNFL thickness, other OCT parameters have been explored in the context of diagnosing ALS and predicting disease severity. In this study, we explore the possibility that OCT parameters of patients with ALS may differ significantly from those of healthy controls and thus serve as biomarkers for the disease and its progression.

MATERIALS AND METHODS

Between 2010 and 2021, the PubMed and EMBASE databases were examined for English language literature. ALS severity was assessed using the revised ALS functional rating scale (ALSFRS-R). The pooled mean differences in RNFL thickness between ALS patients and controls were calculated using the Standard Mean Difference (Hedges's g) with a 95% confidence interval (CI) in STATA software version 16.

RESULTS

Eleven studies were reviewed for data collection. RNFL thickness was not statistically significantly different between ALS patients (n = 412) and controls (n = 376) (Hedges's g = -0.22; 95% CI: -0.51 to 0.07, I² = 73.04%, p = .14). However, the thickness of inner nuclear layer was significantly different between ALS patients and controls (Hedges's g = -0.38; 95% CI: -0.61 to 0.14, I² = 14.85%, p = .00).

CONCLUSION

Our meta-analysis found that RNFL thickness as a whole or by individual quadrants was not significantly different between ALS patients and controls while the inner nuclear layer (INL) was substantially thinner.

Management of unusual missed diagnosis of a Intra-orbital wooden foreign body: A case report and review of literature

Introduction

Although intra-orbital foreign bodies (IOrFBs) are commonly seen in daily ophthalmology practice, rarely, they can have very unusual clinical presentations, especially nonmetallic FBs.

Presentation of case

A 33-year-old male presented with sudden onset right lower lid swelling and tearing. He was initially tolerating the symptoms, however, it got progressively worse, so he came two weeks after the initiation of symptoms. His eye vitals were within normal limit, including the visual acuity of 6/6 OU. Additionally, slit lamp and fundus examinations were benign. Concern was for infectious etiology with unclear source. After a lengthy conversation, he recalled falling on the ground with face down about 16 months ago. However, he stated that he had remained asymptomatic and never went for treatment after the incident. Non-contrast CT of head and orbit showed hyperdense tract in medial aspect of right eye adjacent to the globe, piercing across the bilateral ethmoidal sinuses. Thus, a diagnosis of retained IOrbFB was made. He underwent surgery where a 5cm rotten wood was extracted. Post-surgical course was uncomplicated. Not all penetrating intra-orbital foreign bodies present immediately after the incident. In our case the patient remained asymptomatic for 16 months.

Conclusion

Therefore, when dealing with an ocular infection of unclear source, clinicians should ask about distant histories of ocular or facial injuries to assess intraocular foreign bodies.

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Recognizing retained orbital foreign bodies secondary to trauma can be a challenge.

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Organic IOrbFB following a penetrating injury can remain asymptomatic for a significant period, resulting in delayed diagnosis and treatment.

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When dealing with an ocular infection of unclear source, clinicians should ask about distant histories of ocular or facial injuries to assess intraocular foreign bodies.

Coronavirus disease 2019 (COVID 19) induced acute necrotizing pancreatitis in a female child: A case report

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Although Coronovirus disease 2019 mainly affects respiratory symptoms, the involvement of gastrointestinal system is also quite common.

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The precise mechanism by which the virus causes pancreatitis is not well understood.

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Coronavirus disease should be ruled out in cases of pancreatitis when the etiology is not found out.

Tuberous sclerosis complex-associated neuropsychiatric disorder (TAND) in a low-resource setting - From seizure to psychosis: A case report

Introduction

Tuberous sclerosis complex (TSC) patients commonly present with neuropsychiatric symptoms – grouped as TSC-associated neuropsychiatric disorder (TAND) - incorporating Autism Spectrum Disorder (ASD) symptoms, intellectual and learning disabilities, psychiatric and behavioral problems. A structured symptomatic assessment known as the TAND-checklist can be useful in reviewing these symptoms systematically and comprehensively.

Case summary

A 21-year-old woman presented with delusions of reference, auditory hallucinations, irritability, restlessness, aggressive behavior, new-onset tremors and rigidity in both upper limbs, and refusal of food and medication intake for 1 week. She has a history of several seizure episodes since 3 years of age which was controlled on oral sodium valproate, carbamazepine, and clobazam. MRI revealed tubers in frontal and insular cortex.Ultrasound of the abdomen showed bilateral renal angiomyolipomas. She was diagnosed with TSC with psychotic symptoms.

Discussion

TSC2 mutations usually present early with epileptic spasms (ES), complex epilepsies, intellectual and cognitive deficits, cardiac rhabdomyomas, and sub-ependymal giant-cell astrocytomas (SEGAs) with high tuber-to-brain proportions (TBP). There is also a remarkable symptom overlap between autism spectrum disorder (ASD) and TSC with behavioral/psychiatric disorders. Social and behavioral problems seen in our patient may be a manifestation of either TSC, ASD, or both. Cost-effectiveness and pragmatism must be considered for TAND-patients in low-resource settings. While it may be theoretically valid to seek genetic testing, TBP-measurement, and mTOR-inhibitor therapy to address TAND-symptoms, they are impractical when compared to TAND-checklist during follow-up.

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Tuberous sclerosis complex (TSC) patients commonly present with neuropsychiatric symptoms – grouped as TSC-associated neuropsychiatric disorder (TAND) - incorporating Autism Spectrum Disorder (ASD) symptoms, intellectual and learning disabilities, psychiatric and behavioral problems.

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Cost-effectiveness and pragmatism must be considered for TAND-patients in low-resource settings. TAND-checklist can be useful in reviewing TAND symptoms systematically and comprehensively.

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Tuber-to-brain proportion (TBP) from imaging studies also help predict cognitive and neuropsychiatric disorders better than only radiologically summing up the number of tubers at a certain age; and TBP is inversely related to age at seizure onset, and cognitive index.

Retrograde signaling by a mtDNA-encoded non-coding RNA preserves mitochondrial bioenergetics

Alveolar epithelial type II (AETII) cells are important for lung epithelium maintenance and function. We demonstrate that AETII cells from mouse lungs exposed to cigarette smoke (CS) increase the levels of the mitochondria-encoded non-coding RNA, mito-RNA-805, generated by the control region of the mitochondrial genome. The protective effects of mito-ncR-805 are associated with positive regulation of mitochondrial energy metabolism, and respiration. Levels of mito-ncR-805 do not relate to steady-state transcription or replication of the mitochondrial genome. Instead, CS-exposure causes the redistribution of mito-ncR-805 from mitochondria to the nucleus, which correlated with the increased expression of nuclear-encoded genes involved in mitochondrial function. These studies reveal an unrecognized mitochondria stress associated retrograde signaling, and put forward the idea that mito-ncRNA-805 represents a subtype of small non coding RNAs that are regulated in a tissue- or cell-type specific manner to protect cells under physiological stress.

Substrate Supporting Disc Method for Confirmed Detection of Total Coliforms and E. coli in all Foods: Collaborative Study

The Coli Complete® substrate supporting disc (SSD) method for simultaneous confirmed total coliform count and Escherichia coli determination in all foods was compared with AOAC most probable number (MPN) methods, 966.23 and 966.24. Twenty-nine laboratories participated in this collaborative study in which 6 food types were analyzed. Four food types, raw ground beef, pork sausage, raw liquid milk, and nut meats, were naturally contaminated with coliform bacteria. Two foods, dry egg and fresh frozen vegetables, were seeded with coliforms. Three food types, ground beef, raw liquid milk, and pork sausage, were naturally contaminated with E. coli. Although pork sausage was naturally contaminated, the level was very low (<10/50 g); therefore, additional E. coli were inoculated into 1 lot of this food type. Three food types, nut meats, dry egg, and fresh frozen vegetables, were inoculated with E. coli. For naturally contaminated samples, duplicate determinations were made on 3 separate lots for each food type. For inoculated samples, low, medium, and high contamination levels plus uninoculated control samples were examined in duplicate. Data were analyzed separately for total coliform bacteria and for E. coli. Mean log MPN counts were determined by the SSD method and the appropriate AOAC MPN method. Results were then analyzed for repeatability, reproducibility, and mean log MPN statistical equivalence. Results were statistically equivalent for all total coliform levels in all food types except frozen vegetable and raw nut meat uninoculated control samples and 1 lot of pork sausage where the SSD method produced statistically significant greater numbers. For the E. coli determinations, results were statistically equivalent across all samples and all levels for each food type. The SSD method has been adopted first action by AOAC International for confirmed detection of total coliforms and E. coli in all foods.

Round Block Technique in Management of Breast Lesions

The basic tenets of oncoplastic surgery essentially includes volume displacement and volume replacement. The round block technique, so-called donut mastopexy or Benelli mastopexy, is frequently used as a volume displacement technique in breast conserving surgery for benign multicentric fibroadenomas and early breast cancers. Such techniques are still underused in Nepal. In this article we present on four cases managed with original round block technique and followed prospectively with their outcome.

Anorectal tuberculosis as a chronic rectal mass mimicking rectal prolapse in a child-a case report

Tuberculosis of the colon commonly involves the ascending,transverse, or sigmoid colon while rectal involvement in tuberculosis is uncommon and poorly characterized. We report a six-year-old male from Nepal who presented with abdominal pain and difficulty passing stool for two years. On per rectal examination, palpation revealed a circumferential rectal mass. On further evaluation, CT scan showed mural thickening and luminal narrowing in the ano-rectum. Colonoscopy with biopsy showed caseating granuloma and positive acid fast bacilli culture consistent with tuberculosis. After starting anti-tubercular therapy, the patient's abdominal pain resolved and the patient was able to pass stool normally within two weeks. Colonoscopy three months after starting treatment showed complete resolution of the mass. Gastrointestinal tuberculosis should be considered in cases of children from endemic areas who present with a rectal mass.

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Anorectal tuberculosis is a rare entity which can present as a chronic rectal mass.

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A high index of suspicion for tuberculosis is necessary in all pediatric patients from TB endemic areas with nonspecific abdominal signs and symptoms.

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When diagnosed early, with 6–12 months of therapy ano-rectal tuberculosis shows very good prognosis.

Acute renal infarction and cardioembolic stroke in a patient with atrial fibrillation and hyperthyroid-induced cardiomyopathy: a case report

BACKGROUND

Acute renal infarction is a rare entity with varied misleading manifestations resulting in diagnostic delay, misdiagnosis, and treatment leading to renal damage.

CASE PRESENTATION

We report the case of a 28-year-old Dalit Nepalese man who presented with sudden onset occipital headache and later developed severe left flank pain. He was diagnosed with posterior cerebral infarction with hemorrhagic transformation and a subsequent acute renal infarction with atrial fibrillation and hyperthyroid-induced cardiomyopathy. He was managed with oral anticoagulant and antithyroid drug.

CONCLUSION

A high index of suspicion of acute renal infarction is required in patients with risk factors of thrombosis presenting sudden onset flank pain.

Laparoscopic common bile duct exploration using a rigid nephroscope

Background

Patients with cholelithiasis and choledocholithiasis are increasingly managed with laparoscopic bile duct exploration and cholecystectomy. Large impacted bile duct stones continue to defy laparoscopic extraction. This study explored the feasibility of laparoscopic bile duct clearance using a rigid nephroscope, which is suited to extracting large stones.

Method

This prospective study recruited patients with large bile duct stones and a bile duct wider than 8 mm on ultrasonography. In addition to standard ports for laparoscopic cholecystectomy, a custom-made 9-mm port was introduced in the epigastrium for the rigid nephroscope, which was negotiated into the bile duct through a choledochotomy. Rigid graspers and lithotripters were introduced through the nephroscope to fragment and remove the calculi.

Results

Between December 2005 and September 2008, 18 patients had nephroscope-guided bile duct exploration (mean(s.d.) age 49(13·9) years, bile duct diameter 11·3(2·3) mm). Three patients had solitary stones and 15 had multiple calculi. Most of the stones were removed with graspers, but the lithotripter was required in five patients. The mean(s.d.) hospital stay was 6(2·3) days. Two patients required postoperative endoscopic retrograde cholangiopancreaticography for residual stones.

Conclusion

The rigid nephroscope was useful for laparoscopic bile duct exploration, particularly for large impacted stones.

Prevalence of diabetes and impaired fasting glucose in a selected population with special reference to influence of family history and anthropometric measurements--the Kolkata policeman study

AIMS AND OBJECTIVES

The aim of this study was to estimate the prevalence of diabetes as well as IFG in a population of policemen and to evaluate the possible influence of some risk factors.

MATERIAL AND METHODS

It was an epidemiological study on a group of policemen in Kolkata. Diagnosis of diabetes was based on history and fasting plasma glucose. The study population was divided in three categories: normoglycaemic, IFG and diabetes. BMI, waist circumference, WHR and waist-to-height ratio were estimated.

RESULTS

Out of 2160 subjects with a mean age of 36.4 yrs (between 20 and 60 yrs), diabetes was found in 11.5% (10.4% known and 1.1% newly diagnosed) and 6.2% had IFG. Prevalence of diabetes was found to be increasing with age (p < 0.001). There was no statistically significant difference in BMI when compared between groups (normoglycaemic, IFG and diabetes). Waist circumference, waist-to-height ratio and WHR of normoglycaemic group were significantly less than those with IFG and diabetes; however there was no statistically significant difference between the diabetes and IFG groups. Parental history had significant influence on the prevalence of diabetes; a 37.5% prevalence was found in persons with history of biparental diabetes and 20.8% with uniparental diabetes, whereas it was only 9.9% without any family history (p < 0.01 and p < 0.05, respectively.).

CONCLUSION

The prevalence of diabetes in the study population was high and was strongly influenced by family history, age and abdominal adiposity, without having any appreciable impact of BMI.

Correlation of endoscopic interpretation of endometriosis with histological verification

INTRODUCTION

In this study we correlate the laparoscopic findings of endometriosis with the histological confirmation of the disease over a period of two years.

MATERIALS AND METHODS

One hundred and sixty-four laparoscopies performed at the Department of Gynecology & Obstetrics, University of Kiel, over a two-year period were reviewed for laparoscopic findings and histological confirmation of endometriosis.

RESULTS

The majority of patients suspected of endometriosis at laparoscopy were confirmed by histological examination, i.e. 138 out of 164 patients (84.1%).

CONCLUSION

Laparoscopy is the easiest diagnostic tool for the diagnosis of endometriosis which can be confirmed by histological examination.

Unilateral renal agenesis associated with urinary outflow tract obstruction in a diabetic pregnancy

We report a case of diabetic pregnancy where the foetus had enlarged cystic left kidney with agenesis of right kidney. The urinary bladder was dilated and urethra revealed posterior urethral valve an postmortem.

Disease and dislocation: the impact of refugee movements on the geography of malaria in NWFP, Pakistan

Studies of the health implications of refugee movements have generally focused on the effects of dislocation on the health of refugees and the impacts on health care provision at the destination. A somewhat more neglected aspect of the refugee-health research has been the impact of refugee flows on the geography of disease, i.e., how the spatial patterns of disease prevalence are modified through the influx and settlement of refugee populations. We examine this issue by examining the changing geography of malaria in Pakistan's North West Frontier Province (NWFP) between 1972 and 1997. Until the late 1970s, the highest incidence of malaria in the region was seen in the southern and eastern parts. During the 1980s, however, two and a half million Afghan refugees entered the NWFP and were housed in tented villages along the border and in some interior areas. As the decade progressed, there was a significant shift in the spatial pattern of malaria, with the regions of highest incidence shifting to the west and north, coinciding strongly with refugee concentrations. Our study draws attention to the manner in which refugee influx and settlement can alter the ecology of the disease system, leading to long-term changes in the geography of malaria.

Process evaluation of pulse polio immunisation in Delhi

The aim of the study was to assess the functional aspects and the staffing at Pulse Polio immunisations posts. Interns and medical students conducted the survey in eighty seven pulse polio immunisation posts scattered all over National Capital Territory of Delhi on 18th January 1997. A pre-tested structured format containing information pertaining to dose utilisation and staffing was filled. Number of children given pulse polio was on an average 459.2 per immunisation post (474.7 rural, 516.35 slums and 435.0 urban). Average number of neonates (below one month) per immunisation post given polio drops was 5.1 (1.1%). The break-up for rural area, slums and urban area was 3.0 (0.63%), 6.7 (1.30%) and 4.9 (1.13%) respectively. By 12 pm, 67.8% and by 2 pm 88.7% of the doses had been administered. Staffing at most of the immunisation posts was adequate for all categories of staff except doctors (0.48 per booth).

The spatial dynamics of U.S. fertility, 1970-1990

"The fertility downturn in the U.S. since the baby boom has been accompanied by a growing divergence in regional fertility rates. This paper examines the spatial implications of recent fertility trends. Two interrelated questions are posed. First, how and why have the time trends in fertility varied spatially? Second, how have the regional patterns of fertility changed over time? These questions are investigated using a continuous spatio-temporal model of U.S. fertility built using the Dual Expansion Method. Results indicate that the pace of fertility decline has been the most rapid in the Northeast and the slowest in the West. Further, the traditional North-South distinctions in fertility rates are being replaced by East-West patterns. These changes tentatively suggest that regional ethnic composition is becoming an increasingly important factor in accounting for the spatial variation of U.S. fertility."

Snowbelt-to-Sunbelt migration and the North-South fertility convergence: exploring the theoretical links

"This paper explores the theoretical linkages between the recent fertility convergence in the historically high-fertility South and the historically low-fertility North and the well documented Snowbelt-to-Sunbelt migration [in the United States]. It argues that the large scale migration likely played an important role in reducing the North-South fertility differential by homogenizing regional environments and influencing labor markets. The paper suggests that regional fertility theories need to become more sensitive to the effects of internal migration."

Knowledge of fresh medical graduates about immunization: impact of posting in community medicine

Immunization being the most cost effective health intervention rightly forms an integral part of MCH health activities spectrum. Of late medical colleges in the country are directly involved from the planning to evaluation stages in the immunization programmes in their respective catchment areas. Immunization knowledge of 91 interns during their course of involvement in community work, was tested on the first day and last day of their three months posting in the Community Medicine Department. The study showed positive impact of training in the Department of Community Medicine on the performance levels of interns. This was found mainly attributable to effective interaction of interns with the community in the field and taking independent decisions as per the case requirements.

Prevalence of dental caries and associated teeth cleaning habits among children in four primary schools

A study was conducted in four primary schools of Mehrauli block of rural Delhi. Four hundred and fifty eight primary school children of both sexes in the age group of 5-14+ were medically examined in daylight using a mouth mirror and probe. The children came from low socioeconomic backgrounds. Presence of clinical caries was recorded by naked eye examination. Dental caries prevalence was 33.19% and DMF index was 0.52. Teeth cleaning habits of the school children in terms of regularity and associated caries prevalence was also noted. The 'Regular' teeth cleaning group showed significantly less caries prevalence while 'Not Regular' and 'Never Cleaning' groups had higher caries prevalence. Since childhood is such an impressionable age all students were made aware of the need for proper oral hygiene to minimize the incidence of caries among them.