Normal Reflex Research Articles

Virtual reality: a game-changer in the diagnosis and surgical planning of astrocytoma grade III: a case report

BackgroundIn the dynamic realm of modern medicine, the advent of virtual reality technology heralds a transformative era, reshaping the contours of diagnosis and surgical planning with its immersive prowess. This study delves into the groundbreaking application of virtual reality in the intricate dance of neurosurgery, particularly spotlighting its role in the management of astrocytoma grade III—a cerebral challenge of significant complexity.Case presentationA 30-year-old Middle Eastern man from Syria grappled with the invisible tendrils of pain, manifesting as persistent headaches and a numbing sensation that crept into his neck and extremities. For two relentless months, the morning sun brought not hope but an intensification of his agony, rendering him unable to partake in the daily dance of life. The usual sentinels of relief, analgesic drugs, stood defeated, offering no respite. The neurological examination was normal, there were no pathological findings on sensory and motor examination, and he exhibited normal reflexes and neither meningeal nor cerebellar signs. He showed a family history of breast cancer. The initial foray into the enigmatic depths of his brain via computed tomography and magnetic resonance imaging imaging unveiled a finding in the right temporal lobe, a lesion that suggested something more sinister. Previous medical interventions included analgesic medications prescribed for persistent headaches, but they offered no relief. No other therapeutic interventions were administered prior to the current diagnosis. It was here that virtual reality technology emerged not as a mere tool but as a beacon of precision, casting a three-dimensional light on the shadowy intruder. This technological marvel allowed for meticulous measurement 21.8 × 14.5 mm and localization within the temporal theater, setting the stage for what was to come. With the path laid clear, the patient embarked on a surgical odyssey, a quest to excise the unwelcome guest. The operation was a triumph, a testament to human ingenuity and the symbiotic relationship between flesh and machine. The postoperative verdict was delivered through the lens of histopathology, confirming the presence of an astrocytoma grade III, a cerebral interloper known for its rapid proliferation. The battle, however, was far from over. Complementary radiotherapy and chemotherapy were enlisted as allies in this ongoing war, their potent forces working in concert to stave off the cellular insurgence. The patient’s journey through the healing arts was charted by periodic clinical and neurological examinations, with laboratory tests and the vigilant gaze of brain magnetic resonance imaging ensuring a watchful eye was kept on any potential resurgence.ConclusionsIn this narrative of resilience and technological prowess, we witness the harmonious fusion of human touch and digital precision, a partnership that redefines the boundaries of medicine and the art of healing, by use of virtual reality technology in the diagnosis of astrocytoma and enhancing the accuracy, effectiveness, and safety of neurosurgical procedures, which can ultimately benefit patients with brain tumors.

Analysis of Urinary Incontinence in the Neurogenic Bladder and Its Relationship with the Satisfaction and Lifestyle of People with SCI.

One of the most common complications of neurogenic bladder secondary to spinal cord injury (SCI) is urinary incontinence, which is possibly related to bladder-emptying methods and changes in quality of life. This study aimed to identify the occurrence of this complication in adults with SCI and analyze its relationship with bladder-emptying methods, satisfaction, and lifestyle. This is a quantitative, exploratory, and cross-sectional study. The variables were collected using the Bowel and Bladder Treatment Index during a telephone interview with 290 participants from February to November 2021. According to the results, 70% of the participants were male and 74.1% performed clean intermediate catheterization (CIC) as the main bladder-emptying method. Moreover, 55.6% were considered incontinent in the last year. Emptying by normal urination and bladder reflex triggering had a statistically significant relationship with urinary incontinence. A statistical association was observed between all the variables of satisfaction and lifestyle with urinary incontinence. Although CIC reduced urine leakage, a considerable number of participants still presented with frequent urine leakage. Urinary incontinence had a negative impact on satisfaction with the bladder-emptying method, effectiveness of bladder management, quality of life, and personal and social relationships.

A blend of chitosan-vitamin C and vitamin E nanoparticles robust the immunosuppressed- status in Nile tilapia treated with salt

In aquaculture, fish are exposed to many stressors, such as climate changes and infectious diseases that affect their performance, immunity, and welfare. Freshwater fish subjected to salt bath become exhausted and stressed. In this experiment, Nile tilapia were exposed to a salt bath at a dose of 30 ppt for 30 min a day. Vitamin C and vitamin E are well-known antioxidants that are used in aquaculture. Fish received dietary nanoparticles of chitosan-vitamin C and chitosan-vitamin E (CCE-NPs) for different periods (7 and 14 days) pre- (G2) and post-salt treatment (G3). In the control fish (G1), cortisol 5.44 µg/dL and glucose 91.67 mg/dL were significantly up-regulated post-salt treatment by 1 h and 24 h, respectively, whereas those (G2) fed CCE-NPs diet had significantly lower values of 4.72 and 3.25 µg/dL; 86.3 and 84.3 mg/dL, respectively. A rapid decrease of glucose 68.3 and 66.3 mg/dL was noticed in those (G2) fed CCE-NPs diet compared to the control 84.67 mg/dL at 48 h post-stress. Regardless of the supplementation period, fish (G2) could partially restore normal food reflex at 48 h (post-salt bath) and fully restored at 72 h compared to 7 days in the control (G1). After 48 h, fish that received dietary CCE-NPs (G2 and G3) restored normal mucus lysozyme levels, whereas the control did not restore pre-treatment values till the seventh day. Mucus antibacterial activity, fish received rapid dietary CCE-NPs (G2) and partially restored average values (pre-salt bath) at 96 h. The salt treatment could provoke gene expression of pro-inflammatory cytokines interleukin (IL-1β) and tumor necrosis (TNF)-α in the head kidney of fish at 24 h post-salt bath to 5.9–8.35 fold-change, respectively, with a rapid decline in fish (G2) the gene expression. Post-salt bath (24 h), the gene expression of glutathione peroxidase (GPx), superoxide dismutase (SOD), and catalase (CAT) was higher in fish (G2) than in the control group (G1) regardless of the supplementation period (7 and 14 days). Bacterial infection S. agalactiae (OL471408), a significantly lower MR was recorded in G2 at 40% and 33.3% compared to the control G1 MR (53.3%), with an RPL of 24.95% and 37.5%. In conclusion, Nile tilapia treated with a 30 ppt salt became more vulnerable to S. agalactiae. Adding CCE-NPs to the Nile tilapia diet for 7- and 14-day pre-salt bath could increase immune and antioxidant-related gene expression to counteract S. agalactiae infection.

Cervical percutaneous interferential current stimulation improves citric acid cough tests in patients with Parkinson’s disease on medication

Aspiration pneumonia is the leading cause of death in patients with Parkinson’s disease. The incidence of silent aspiration is high in such patients owing to decreased pharyngeal and laryngeal sensation; thus, interventions for this condition may help prevent pneumonia. In this single-arm, open-label study, we used a cervical percutaneous interferential current stimulation device to activate pharyngeal and laryngeal sensory nerves. We evaluated its effectiveness in patients with Hoehn–Yahr stages 2–4 Parkinson’s disease. The primary endpoint was the proportion of patients with a normal cough reflex after consuming 1% citric acid at the end of the intervention compared with baseline measurements. In total, 25 patients received neck percutaneous interferential current stimulation for 20 min twice weekly for 8 weeks. Afterward, the proportion of patients with a normal cough reflex after 1% citric acid consumption increased significantly (p = 0.001), whereas other indicators, such as tongue pressure, peak expiratory flow, and penetration or aspiration during videofluoroscopic examination, remained unchanged. A longer duration of illness, higher Unified Parkinson’s Disease Rating Scale total scores, and higher levodopa equivalent daily doses were significantly associated with improved cough test outcomes. Hence, cervical percutaneous interferential current stimulation significantly improved cough reflexes and may improve silent aspiration. Trial Registration: Japan Registry of Clinical Trials, jRCTs062220013, first registered 09/05/2022.

Tumefactive Multiple Sclerosis: A Mimicker of Intracranial Space-Occupying Lesions

Abstract: A chronic disease of CNS, Multiple sclerosis is characterized by inflammation and demyelination with axonal injury affecting upper motor neurons of brain or spinal cord. Tumefactive multiple sclerosis is a rare form of MS which mimics intracranial tumor-like space-occupying lesions on radiography. A 25-year old gentleman presented 2-month history of gradual onset difficulty in walking, slurring of speech and double vision. The patient had an ataxic gait accentuated by tandem walking with tendency to fall towards right and a negative Romberg’s sign. There was dysarthria and signs of cerebellar lesion present on the right side. Muscle tone was normal in upper limbs but increased (spasticity) in lower limbs bilaterally. Power was normal but deep tendon reflexes were exaggerated in all 4 limbs with bilateral up-going plantar reflex. MRI scan of the brain demonstrated tumour-like tumefactive lesions in the right cerebellum, right pons and the left subcortical region with no post-contrast enhancement of these lesions. MRI of whole spine demonstrated subtle hyperintense signals in the cervical spine. He had a past history of transverse myelitis 2 years ago with full clinical recovery with oral steroids. He was diagnosed with Tumefactive Multiple Sclerosis and started on corticosteroid therapy resulting in dramatic improvement.

Differential Diagnosis of Leukocoria : A Case Report

Introduction : Leukocoria is an abnormal pupillary reflex more clearly seen after mydriasis or photography. It is often the first sign of a range of serious intraocular disorders, including congenital cataracts, Coats disease, retinoblastoma, Familial Exudative Vitreoretinopathy (FEVR).
 Case Illustration : Baby F, 10 months with chief complaint the vision in both eyes appears defocused since birth. A history of trauma to the head is denied, severe pain (-), a history of similar complaints in the family is denied. Pregnancy history: Mother had hypertension. The patient born spontaneusly at 39-40 weeks of gestation, crying immediately, birth weight 2700 grams. Ophtalmology Status ODS: VA Blink reflex(+), Following light (+), Following object (-), Konjungtiva : hiperemis (-), cornea : clear (+), Pupil : leukocoria (+). Funduscopy examination ODS: Vitreus : cloudy (+), papillae: cannot be assessed, blood vessels: visible images of raised blood vessels, retina: detached (+) retinal layers seen, macula: cannot be assessed. USG ODS: cloudy vitreus with hyperreflectivity moderate to high. Patient was diagnosed with Leucocoria ec Retinal Detachment ec Suspect FEVR differential diagnosis Retinoblastoma Bilateral. CT Scan : A mass with a calcified component in the right and left posterior bulbs, consistent with bilateral retinoblastoma
 Discussion : The clinical history of leukocoria, meaning loss of the normal red retinal reflex, is nonspecific. Key findings here are the normal size of the globes and the presence of calcifications, which are more compatible with retinoblastoma, Coats' disease, or FEVR.
 Conclusion Leucocoria in aterm baby has several differential diagnosis such as retinoblastoma that needs further examination.

Vestibular dysfunction in lateral semicircular canal dysplasia.

Lateral semicircular canal (LSCC) dysplasia is the most common inner ear malformation. The severity of dysplasia can appear in various spectrums, from a short and broad LSCC with normal or small-sized central bony island (CBI) to a single fluid-filled cavity confluent with the vestibule without CBI. However, reports on the association between LSCC dysplasia and the loss of vestibular function are still lacking. In this study, the results of vestibular function tests [caloric test and video-head impulse test (vHIT)] in patients with LSCC dysplasia were analyzed and compared between groups with and without CBI. This study retrospectively enrolled 17 patients (23 ears) who had LSCC dysplasia following computed tomography or magnetic resonance imaging and underwent vestibular function tests. LSCC dysplasia was observed unilaterally in 11 patients and bilaterally in six patients. Nine of 23 ears had CBIs, and 14 ears had no CBI. Three of 17 patients experienced dizziness. Abnormal caloric tests were detected in 11 of the 16 patients who underwent the caloric tests (69%); in contrast, 11 of 12 patients who underwent the vHIT (92%) had normal LSCC vestibulo-ocular reflex (VOR) gain on vHIT. A significant correlation was found between the maximum slow-phase velocity of the caloric test and LSCC VOR gain of the vHIT (correlation coefficient 0.792, p = 0.004). The CBI-absent group showed significantly lower SPV and LSCC VOR gains than the CBI-present group (p = 0.001 and 0.004, respectively). LSCC dysplasia impairs VOR function, especially in the absence of CBI.

Head and Eye Movements Reveal Compensatory Strategies for Acute Binaural Deficits During Sound Localization.

The present study aimed to define use of head and eye movements during sound localization in children and adults to: (1) assess effects of stationary versus moving sound and (2) define effects of binaural cues degraded through acute monaural ear plugging. Thirty-three youth (MAge = 12.9 years) and seventeen adults (MAge = 24.6 years) with typical hearing were recruited and asked to localize white noise anywhere within a horizontal arc from -60° (left) to +60° (right) azimuth in two conditions (typical binaural and right ear plugged). In each trial, sound was presented at an initial stationary position (L1) and then while moving at ∼4°/s until reaching a second position (L2). Sound moved in five conditions (±40°, ±20°, or 0°). Participants adjusted a laser pointer to indicate L1 and L2 positions. Unrestricted head and eye movements were collected with gyroscopic sensors on the head and eye-tracking glasses, respectively. Results confirmed that accurate sound localization of both stationary and moving sound is disrupted by acute monaural ear plugging. Eye movements preceded head movements for sound localization in normal binaural listening and head movements were larger than eye movements during monaural plugging. Head movements favored the unplugged left ear when stationary sounds were presented in the right hemifield and during sound motion in both hemifields regardless of the movement direction. Disrupted binaural cues have greater effects on localization of moving than stationary sound. Head movements reveal preferential use of the better-hearing ear and relatively stable eye positions likely reflect normal vestibular-ocular reflexes.

Rheumatoid Arthritis: A Disease That Bites Joints but Can Also Lick Hearing

Background: Rheumatoid arthritis (RA), a multisystem disorder of unknown etiology, is a chronic polyarthritic condition. Hearing loss (HL) among RA patients is a common finding (prevalence of 60%–62%) with conductive HL (CHL) being more common than sensorineural HL (SNHL). Objectives: The present study was conducted in this context as an attempt (i) to find the prevalence of HL among RA patients, (ii) to assess the type of HL in RA patients, and (iii) to find any correlation between duration of illness, gender, and age of patients. Materials and Methods: This was a case–control study which included 25 RA patients and 25 normal controls. All subjects underwent complete clinical examination and audiological evaluation which included pure-tone audiometry (PTA), tympanometry, and acoustic reflex. Results: Out of 25 cases, 66% had HL (CHL - 50% and SNHL - 16%) while 34% had normal hearing. On tympanometry, 9 out of 25 cases showed as type of curve while the remaining 16 had A type on the right side. On the left side, 7 out of 25 cases showed as type of curve and 18 had A type. Acoustic reflex was absent in 15, delayed in 3, and present in 7 on the right side. On the left, it was absent in 12, delayed in 4, and present in 8. All the controls had normal hearing threshold (<25 dB), A-type tympanogram, and acoustic reflex present in both ears. Conclusion: This study indicates that a large number of RA patients are destined to have ear involvement. Hence, auditory screening using PTA should be done routinely in RA patients and early diagnosis of these patients can help in better rehabilitation.

Chapter 12 - Meralgia paresthetica

Meralgia paresthetica is a common but probably underrecognized syndrome caused by dysfunction of the lateral femoral cutaneous nerve. The diagnosis is based on the patient's description of sensory disturbance, often painful, on the anterolateral aspect of the thigh, with normal strength and reflexes. Sensory nerve conduction studies and somatosensory evoked potentials may be used to support the diagnosis, but both have technical limitations, with low specificity and sensitivity. Risk factors for meralgia paresthetica include obesity, tight clothing, and diabetes mellitus. Some cases are complications of hip or lumbar spine surgery. Most cases are self-limited, but a small proportion of patients remain with refractory and disabling symptoms. Treatment options include medications for neuropathic pain, neurolysis, neurectomy, and radioablation, but controlled trials to compare efficacy are lacking.

Updated NICE Cardiotocograph (CTG) Guideline: Is it Suspicious or Pathological?

Cardiotocograph (CTG) trace was introduced into clinical practice in 1960s as a tool to record the changes in the fetal heart rate (cardio) in response to ongoing uterine contractions (toco). The intention was to timely recognise the features of fetal decompensation so that immediate action could be taken to avoid hypoxic ischaemic encephalopathy (HIE) and/ or intrapartum hypoxia-related perinatal deaths, without increasing unnecessary operative interventions to the mother. However, very unfortunately, unlike other tools in clinical medicine, CTG was introduced into clinical practice without any randomised controlled trials or robust scientific studies not only to confirm its effectiveness, but to determine the CTG features which actually reflected fetal central organ oxygenation. This chasm of deficiency of knowledge of fetal physiology created a vacuum of understanding regarding what features were reflecting fetal compromise. Regrettably, this vacuum was soon filled by prominent obstetricians from national societies who were presumed to have the knowledge, but they began the arduous journey of classifying decelerations which are normal fetal cardioprotective reflexes, and they misclassified them as signs of “fetal distress”. Classification of these decelerations based on the observed morphology into “reassuring” and “nonreasoning” categories has resulted in disastrous consequences for women and babies. In the UK, since the publication of the first CTG guideline in 2001, due to continuing lack of knowledge and confusion, these guidelines were repetitively revised in 2007, 2014, 2017 and 2022. Despite the international consensus guidelines of physiological interpretation of CTG produced by 44 CTG experts from 14 countries which recommended classification of CTG traces based on the type of fetal hypoxia and fetal response to stress, the latest revised guideline produced by the National Institute of Health and Care Excellence (NICE), had continued the illogical approach of grouping arbitrary features into different categories and then randomly combining them to classify the CTG traces into “Normal, Suspicious and Pathological”. Therefore, all practising clinicians who are focussed on protecting their patients from harm have a responsibility to ask the question whether the revised NICE CTG Guideline itself is suspicious or pathological from a patient safety perspective.

Case report: Acute audiovestibular presentation following hemi-pontine infarction

Posterior circulation stroke is an uncommon cause of sudden-onset sensorineural hearing loss (SSNHL). Anterior inferior cerebellar artery occlusion results in ipsilateral peripheral audiovestibular dysfunction. Few reports describe posterior circulation stroke presenting with contralateral SSNHL and acute vestibular and focal neurological signs. We present a case of contralateral SSNHL and isolated acute central vestibular dysfunction in the absence of other central focal neurological deficits. To the best of our knowledge, this has not been described to date. The patient was identified to have asymmetrical SSNHL, subtle skew deviation with left head tilt, and significant refixation saccades on video head impulse test despite bilaterally normal vestibulo-ocular reflex gains. Left pontine infarct was suspected and confirmed on magnetic resonance imaging. The patient was treated with an appropriate antiplatelet regimen. We highlight the importance of a thorough clinical diagnostic work-up as posterior circulation strokes with isolated audiovestibular deficits can be easily missed if other significant neurological deficits are absent.

EFFECTIVENESS OF PHYSICAL THERAPY AND REHABILITATION IN IMPROVING MOTOR SKILLS AND MENTAL FUNCTION IN CHILDREN WITH CEREBRAL PALSY

Cerebral palsy was first described by William John Little in 1846. There are many definitions of cerebral palsy that vary from author to author. However, we can say that cerebral palsy (CP) is a chronic non-progressive brain damage, postural and body motility disorder. Apart from sensorimotor abnormalities, some cases are accompanied by mental disorders as well as disorders of cognitive functions. It can occur during pregnancy, at birth or during the postnatal period, ie. prenatal, perinatal and postnatal - equally in both sexes. There are different classifications of cerebral palsy: according to changes in muscle tone, according to topographic features and according to the severity of the clinical picture.According to changes in muscle tone, they are divided into: Spastic form, Athetoid form, Ataxic form, Hypotonic form and Mixed form. According to the topography they are classified as: Diplegia, Quadriplegia, Hemiplegia, Triplegia and Monoplegia Physical therapy program is determined based on the clinical form of the disease. When determining a rehabilitation program, the principle of an individual approach is followed. Rehabilitation includes: physical medicine, kinesitherapy, reflex exercises according to Vojta, manual massage, thermotherapy, education of parents for rehabilitation at home; orthopedic aids; special education techniques. The aim of this study is to determine the role and impact of Physical Medicine and Rehabilitation in the treatment of children with Cerebral Palsy in early childhood. The research was conducted at the University of Southeast Europe - (Stul University) at the Faculty of Health Sciences in the Department of Physical Therapy and Rehabilitation, over a period of 6 months, from the beginning of April to the end of September 2023. 61 patients with cerebral palsy are included in the research, of which 28 are male, and the remaining 33 patients are female. The patients included in the research are classified into groups according to: gender, age and clinical form of cerebral palsy. The treatment of Cerebral Palsy (CP) has a complex character and includes medical, pedagogical and social rehabilitation. The individual tasks of the rehabilitation are determined after a functional examination of the motor abilities, where the main role is played by muscle tone, normal and pathological reflex motor activity, in the period up to 1 year of age. The goal of treatment with Physical Therapy and Rehabilitation is to achieve correct and timely development of movements and correction of pathological movement stereotypes (models), which occurred as a result of brain tissue damage. As for the motor deficit, kinesitherapy plays a major role. Established modern methods for kinesitherapy are the specialized methods for neuromuscular re-education of Vojta and Bobath. The Rood and Rabat methods werw also be used to facilitate the required movements and train coordination. Physical therapy and rehabilitation combined with kinesitherapy have an exceptional positive effect in: prevention of pathological primitive reflexes;creation and automation of normal active movements;saving irregular positions of the limbs and the whole body;establishment of balance and correct pattern of movement; fight against spasticity, secondary contractures and deformities; improvement of coordination and awareness of the body in relation to the environment.

Acute disseminated encephalomyelitis following the COVID-19 Vaccine Sinopharm in low- and middle-income country: a case report

Introduction and importance: Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and various vaccines against it have been developed. Acute disseminated encephalomyelitis (ADEM) is a disease of the central nervous system that cause inflammation and demyelination and manifests as a multi-symptom acute neurological condition. Although infections are usually the cause of ADEM, vaccines may cause 5–10% of cases. Case presentation: A 40-year-old woman had received a second dose of the Sinopharm COVID-19 vaccine 4 months before her visit and experienced sudden gait imbalance and vertigo a day after her vaccination, which lasted for more than a month. On examination, no signs of skin bruising or bleeding were observed, and her vital signs were within the normal range. On neurological assessment, the patient had a Glasgow Coma Scale score of 14/15 (E4V5M5), had normal pupil size and light reaction, normal fundus, normal deep tendon reflexes and bilateral extensor plantar response. Meningeal symptoms were absent, and SARS-CoV-2 RNA tests using NAAT (Nucleic Acid Amplification Test) were negative. Development of central nervous system (CNS) manifestations during the recovery phase of fever, along with typical MRI findings; the diagnosis of para-infectious ADEM with COVID-19 vaccination was made. After the treatment with methylprednisolone sodium succinate injection, the patient showed improvement. Clinical discussion: ADEM associated with post-vaccinations is a rare condition. There has been growing evidence that shared epitopes between neuronal proteins and SARS-CoV-2 antigens may trigger autoimmune reactions against the CNS through molecular mimicry as its pathogenesis. Conclusion: We suggest the need for a strict vaccine safety monitoring system and post-vaccine monitoring and surveillance.

Autoimmune hepatitis and myositis as presenting manifestation of mixed connective tissue disease – A case report

In the course of mixed connective tissue disease (MCTD), hepatitis is very rare. Most commonly liver steatosis or elevated liver enzymes are reported and only a few cases of MCTD associated with autoimmune hepatitis were described previously. We report a case of 30-year-old female, who initially presented with autoimmune hepatitis and was treated with oral Prednisolone. Few weeks later, she presented with lower motor neuron weakness of all four limbs with normal reflexes and sensory findings. Clinically, the pattern of weakness was suggestive of a myopathic process which was confirmed with a high creatine phosphokinase levels and electromyography. She had history of Raynaud’s phenomenon with minimal skin thickening involving the extremities and face. Thus, a diagnosis of overlap syndrome/MCTD was kept. MCTD has been confirmed on high titers positive anti U-1 ribonucleoprotein antibodies. Autoimmune hepatitis and myositis as the presenting manifestation are very rare. Here, we highlight a patient of MCTD with initial symptoms of autoimmune hepatitis and myositis.

Superior Cluneal Nerve Entrapment Syndrome: Thought to Be Spondylolysis.

A rare but typically overlooked diagnosis in the orthopaedic surgery community is superior cluneal nerve (SCN) entrapment syndrome. The cluneal nerves function as purely sensory fibers, and the SCNs provide cutaneous innervation to the posterior parasacral, gluteal, and posterolateral thigh regions. When irritated, this syndrome can cause acute and chronic lower back pain and lower extremity symptoms. A 14-year-old adolescent girl presented to the clinic for an evaluation of pain in the right side of her lower back. The patient's physical examination showed tenderness to palpation on the right posterior iliac crest seven centimeters from the midline. Her neurologic examination demonstrated normal deep tendon reflexes, muscle strength, and sensation in the L2-S1 dermatomal distribution. Although imaging showed evidence of a left L5 spondylolysis, she responded positively to a steroid injection over the posterior iliac crest but negatively to one over the L5 pars defect. She later underwent a right SCN decompression surgery. After the procedure, she reported at least 90% improvement in her pain and rated it as a one in severity, on a scale of 0 to 10. Research regarding SCN entrapment syndrome has increased in the past several years. However, most of these studies are limited to the adult population. Therefore, more reports highlighting the potential for this syndrome in adolescents are needed as well.

Relation between Vitamin D Deficiency and Dry Eye

Background Tears are very important to the overall health of the eye and vision. The tear film is mechanically distributed over the ocular surface through a neuronally controlled blinking mechanism. Normal blink reflex, contact between the external ocular surface and the eye lids, and normal corneal epithelium are three factors required for effective resurfacing of the tear film (tear stability). (1) Objective To demonstrate the relation between vitamin D deficiency and dry eye disease searching for finding a correlation between dry eye parameters with vitamin D deficiency. Patients and Methods Cross sectional study. A total 50 patients attending the ophthalmology outpatient clinic of General Ain Shams Hospital, from February 2019 to October 2019 were enrolled in the study after the approval of the research ethical committee in the Faculty of Medicine, Ain Shams University. They were divided randomly into 2 groups. Group 1: consisted of 35 patients who were vitamin D deficient. Group 2: consisted of 15 patients who had normal vitamin D levels (control group). Results The study showed that there was statistically significant increase in symptoms of dry eye in female patients than male patients and there was statistically significant decrease in the level of tear film break up time, Shirmer test and serum 25 (OH) vitamin D in cases with dry eye than those without. It was found that there was statistically significant decrease in vitamin D level in female cases than male cases. Also, there was statistically significant decrease in vitamin D level in cases with symptoms of dry eye and conjunctival hyperemia than cases without. There was also statistically significant positive correlation between serum 25 (OH) vitamin D and tear film break up time and Shirmer test. Conclusion The present study suggests that patients with vitamin D deficiency may suffer from dry eye. Investigations to confirm and quantify a clinical diagnosis of dry eye should include serum 25 (OH) vitamin D when suspecting vitamin D deficiency especially in patients prone to this type of vitamin deficiency.

Impaired Direction Selectivity in the Nucleus of the Optic Tract of Albino Mice.

Human albinos have a low visual acuity. This is partially due to the presence of spontaneous erroneous eye movements called pendular nystagmus. This nystagmus is present in other albino vertebrates and has been hypothesized to be caused by aberrant wiring of retinal ganglion axons to the nucleus of the optic tract (NOT), a part of the accessory optic system involved in the optokinetic response to visual motion. The NOT in pigmented rodents is preferentially responsive to ipsiversive motion (i.e., motion in the contralateral visual field in the temporonasal direction). We compared the response to visual motion in the NOT of albino and pigmented mice to understand if motion coding and preference are impaired in the NOT of albino mice. We recorded neuronal spiking activity with Neuropixels probes in the visual cortex and NOT in C57BL/6JRj mice (pigmented) and DBA/1JRj mice with oculocutaneous albinism (albino). We found that in pigmented mice, NOT is retinotopically organized, and neurons are direction tuned, whereas in albino mice, neuronal tuning is severely impaired. Neurons in the NOT of albino mice do not have a preference for ipsiversive movement. In contrast, neuronal tuning in visual cortex was preserved in albino mice and did not differ significantly from the tuning in pigmented mice. We propose that excessive interhemispheric crossing of retinal projections in albinos may cause the disrupted left/right direction encoding we found in NOT. This, in turn, impairs the normal horizontal optokinetic reflex and leads to pendular albino nystagmus.

Cerebral Infarction Due to Polycythemia Vera: A Case Report

Introduction: Changes in blood viscosity can cause thrombosis in the brain, causing a stroke. Polycythemia vera is one of the causes of blood hyperviscosity. This study aimed to present cases of cerebral infarction related to polycythemia vera.
 Case presentation: A 55-year-old woman came to the emergency room with complaints of sudden weakness in the left limbs. One week before admission, the patient complained of headaches accompanied by spinning dizziness. Her left limbs often tingled and became weaker. There was an asymmetric facial deviation to the right, and the patient had difficulty communicating with unclear articulation. Specific examination of neurology shows dysarthria, left-sided motor type facial paralysis, examination of motor strength of the upper and lower extremities on the left 2 and 5 on the right, and the left upper limb often feels tingling. On the left limb, normal physiological biceps reflex was found, positive Chaddock pathological reflex. Morphological examination of peripheral blood showed normocytic normochromic with erythrosis and thrombocytosis and found giant platelets. This patient was diagnosed with an ischemic stroke caused by cerebral infarction, with polycythemia vera etiology, and accompanied by comorbid diseases of diabetes mellitus and uncontrolled hypertension.
 Conclusion: In patients with high-risk criteria for thrombosis, the management of phlebotomy, administration of low-dose aspirin, and cytoreduction in the form of hydroxyurea aims to achieve a hematocrit <45% so as to prevent worsening and recurrence of stroke.

Chiari 1 malformation with Platybasia

Background. The incidence of CM-I is estimated to be 1/1,000 births. In rare cases, CM-I is complicated by associations with other malformations of the craniocervical junction, including mainly Basilar invagination (BI). Chiari malformation (CM) is characterized by a congenital malformation of the posterior cranial fossa with cerebellar tonsils herniation through the foramen magnum, probably due to the underdevelopment of the posterior bony skeleton (exo-occipital and supraoccipital bones). CM may be complicated by a variety of other malformations, including platybasia, basilar invagination and occipitalization, although syringomyelia (SM) is the most commonly observed Case Report. A girl, 14 years old came with a chief complaint of headache, which is exacerbated whenever the patient coughed or sneezed. The patient also complained about neck pain and a tingling sensation in her hand. A history of vomiting or seizure has not been found. A history of muscle weakness was not found. On physical examination, the patient has a GCS score of 15 on admission, with normal muscle tone and normal reflexes. The patient has a sensory deficit, on the level below C4. The patient underwent CT Scan and MRI whole spine, Chiari 1 malformation and platybasia were diagnosed. The patient underwent posterior fossa decompression, and postoperatively symptoms of Chiari and sensory deficit gradually improved. Discussion. As an association with this syndrome, there is also basilar invagination as shown by flat basioccipt (platybasia) and upward odontoid projection. hydrocephalus [3]. Virchow coined the term ‘platybasia’ to describe an abnormal flattening of the skull base, a defect which he attributed to abnormal bone development. In addition to the flattening of the base of the skull, there was upward displacement (impression) of the basilar and condylar portions of the occipital bone, which caused infolding, or impression of the foramen magnum, reduction of the posterior fossa, and consequent protrusion of the upper cervical spine into the anterior brainstem, with neurological signs. The symptomatology presented by CM-1 patients is diverse, and its severity does not correlate with the degree of TH, with some asymptomatic cases presenting with prominent TH. The onset of symptoms generally develops gradually, however, trauma, coughing/sneezing or pregnancy can also precipitate the event. The most common treatment for these patients is surgical PCF decompression (alone or with duraplasty), although cerebellar tonsillectomy, cervical laminectomy, and suboccipital cranioplasty are also applied. The goal of these surgical procedures is to decompress the foramen magnum and increase the subarachnoid space in order to avoid the impaction of the cerebellar tonsils, reestablish the CSF flow and reverse the symptoms Conclusion. This patient was diagnosed with Chiari 1 malformation and platybasia, as suggested in the literature, posterior fossa decompression was done and the patient improved clinically