Asterixis is a type of negative myoclonus characterized by irregular lapses of posture of various body parts. It is an uncommon but important sign in clinical neurology. Initially described as a "liver flap," its utility encompasses a galaxy of neurological and nonneurological situations. Asterixis has a rich history. Despite being described over 70 years ago, its exact pathogenesis remains unknown. Its significance as a tool for the evaluation and prognosis of encephalopathies has been suggested. This review presents its history, clinical implications and its significance.

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Our patient presented with congenital heart disease (CHD: Tetralogy of Fallot), hypocalcemia, hypoparathyroidism, and facial dysmorphisms. Suspecting DiGeorge syndrome (DGS), a fluorescence in situ hybridization (FISH) analysis for 22q11.2 deletion was made. The child had a hemizygous deletion in the 22q11.2 region, diagnostic of DGS. Unfortunately, the patient succumbed to the heart disease. DGS is the most common microdeletion syndrome, and probably underrecognized due to the varied manifestations. This case stresses the importance of a detailed physical examination and a high index of suspicion for diagnosing this genetic condition. Timely diagnosis can help manage and monitor these patients better and also offer prenatal diagnosis in the next pregnancy.

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Introduction: Warfarin continues to be widely prescribed for a variety of conditions. It has been shown that preinjury warfarin may worsen outcomes in trauma patients. We hypothesized that a substantial proportion of injured patients seen at our institution were receiving preinjury warfarin for inappropriate indications and that a significant number of such patients had subtherapeutic or supratherapeutic international normalized ratios as well as increased mortality. Materials and Methods: A retrospective review of registry data from a Level I trauma center was conducted for the period from January 2004 to July 2013. Included were patients aged ≥22 years (based on the youngest recorded patient on warfarin in this study). Abstracted variables included patient age, Injury Severity Score (ISS), Maximum Abbreviated Injury Score for Head (MAISH), mortality, hospital length of stay (HLOS), indication(s) for anticoagulant therapy, admission Glasgow Coma Scale (GCS), and admission international normalized ratio (INR). Suitability of warfarin indication(s) was determined using the most recent American College of Chest Physicians (ACCP) Guidelines. Inappropriate warfarin administration was defined as use inconsistent with these guidelines. For outcome comparisons, a case-control design with 1:1 ratio was used, matching patients taking preinjury warfarin to a random sample of trauma patients who were not taking warfarin. Severe traumatic brain injury (sTBI) was defined as MAISH ≥4. Results: A total of 700 out of 14,583 patients aged ≥22 years were receiving preinjury warfarin (4.8% incidence, WG). This group was age- and ISS-matched with 700 patients (4.8% total sample) who were not taking warfarin (NWG) in a total case-control sample of 1,400. The two groups were similar in age, gender, ISS, and initial GCS. According to the ACCP guidelines, 115/700 (16.4%) patients in the warfarin group were receiving anticoagulation for inappropriate indications. Nearly 65% of the patients were outside of their intended INR therapeutic window (43.4% subtherapeutic, 21.6% supratherapeutic). Overall, median HLOS was greater among patients taking preinjury warfarin (4 days vs 2 days, P < 0.010). Mortality was higher in the WG (7.4% or 52/700) than in the NWG (1.9% or 13/700, P < 0.010). Patients with sTBI in the WG had significantly greater mortality (12.8% or 34/266) than those with sTBI in the NWG (5.3% or 9/169, P < 0.013). Conclusion: A significant proportion of trauma patients admitted to our institution were noted to take warfarin for inappropriate indications. Moreover, many patients taking warfarin had either subtherapeutic or supratherapeutic INR. Although warfarin use did not independently predict mortality, preinjury warfarin use was associated with greater mortality and HLOS in the subset of patients with sTBI. Safety initiatives directed at better initiation and management of warfarin are needed.

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Background: Adolescent smoking relates to numerous risk factors, of which beliefs and attitudes toward smoking may play a role. The study aimed to investigate the association between beliefs and attitudes and the risk of adolescent smoking. Materials and Methods: In a school-based cross-sectional study, 3,400 students were recruited from 34 intermediate and secondary schools in Madinah City, Al Madinah Region, Saudi Arabia. Data about sociodemographics, smoking-related factors, and beliefs and attitudes toward smoking were collected using a valid and reliable self-administered questionnaire. Prevalence of smoking was estimated and the studied beliefs and attitudes were compared by smoking status and sex using appropriate statistical analyses including multivariate logistic regression. Results: Of the 3,322 respondents, 33.02% (38.9% males and 26.4% females) were current smokers. Beliefs and attitudes toward smoking significantly differed between smokers and nonsmokers in the studied male and female students. The adjusted risk of smoking was significantly increased among female adolescents who believed that male smokers were more attractive [odds ratio (OR) = 2.2; 95% confidence interval (CI) = 1.6-2.9] and among male smokers who believed that female smokers are more attractive (OR = 1.7; 95% CI = 1.2-2.2). The risk was also increased among all adolescents who believed that smoking lent comfort in social gatherings. Belief that smoking is harmful, however, was negatively associated with the risk of smoking, particularly among females (OR = 0.55; 95% CI = 0.35-0.91). Conclusions: The study revealed a considerable high prevalence of smoking among male and female adolescents. Addressing the beliefs and knowledge about smoking during childhood is crucial in any antismoking program.

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Background: Despite lack of evidence supporting the use of fecal occult blood test (FOBT) in the acute hospital setting, FOBT is commonly used in the inpatient setting for reasons other than colorectal cancer (CRC) screening. Aims: To evaluate practice trends in utilizing FOBT on inpatients and its impact on affecting clinical management and outcomes. Materials and Methods: A cross-sectional study of consecutive adult patients undergoing FOBT from January 1, 2011 to December 31, 2011 during an acute medical admission at a large urban safety net hospital was performed. Indications for FOBT, and the impact of FOBT results on endoscopic procedures performed and clinical outcomes were assessed. The number of inpatient endoscopic procedures before and after discontinuing inpatient FOBT was also assessed. Results: A total of 207 inpatient FOBTs were performed in 2011. The most common reason cited for FOBT was anemia (36%, n = 74) followed by gastrointestinal (GI) bleeding (27%, n = 55). Interestingly, 23% (n = 47) of the patients undergoing inpatient FOBT had overt GI bleeding. As expected, patients with positive FOBT were significantly more likely to undergo endoscopic examinations (P < 0.01). After discontinuing the availability of inpatient FOBT, patients were less likely to undergo endoscopic examinations [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.75-0.85]. Conclusion: Inappropriate utilization of FOBT in the inpatient setting is common, even when the indication does not support its use. Setting limitations on inpatient FOBT may reduce the inappropriate utilization of inpatient FOBT. Quality improvement initiatives are needed to educate clinicians on the appropriate use of FOBT, which is primarily for average risk CRC screening.

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Background: Suicide is a psychiatric emergency. Stressors in life and social variables (like marital status, family, and social support) are among the determinants of suicide. Hopelessness and suicidal intent are among the psychological variables that have shown promise in the prediction of suicide. Aims and Objectives: To assess stressful life events, hopelessness, suicidal intent, and sociodemographic variables in patients of attempted suicide. Materials and Methods: Fifty consecutive patients admitted with attempted suicide were interviewed. Presumptive Stressful Life Event Scale, Beck Hopelessness Scale, and Beck Suicidal Intent Scale were used along with a semistructured pro forma for interview. Data were analyzed with statistical tests. Results: Sixty-six percent of the participants were females, 72% were less than 30 years of age. Sixty-six percent of the patients had stressful life event score between 101 and 200 with the mean score of 127. The stressful life event score in those who considered they are in need of psychiatric help was significantly high. Most of the patients had mild (34%) and moderate (40%) degrees of hopelessness, and the mean score was 9.64. The mean suicidal intent in the participants was 25.14, when correlated with hopelessness score significant positive correlation was found. Conclusion: Lethality of the attempt increases with the increase in hopelessness.

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Background: Elevation of the neutrophil to lymphocyte ratio (NLR) has been shown to be an indicator of poor prognosis in many malignancies including recurrent glioblastoma multiforme. Objectives: This study was aimed at assessing if the NLR and other leukocyte counts and indices were deranged in treatment-naïve patients with primary brain tumors when compared with an age-matched healthy control group. Materials and Methods: This was a prospective comparative clinical observational study by design. A healthy control population was compared with treatment-naïve patients diagnosed with intra- and extraaxial brain tumors. Leukocyte counts (neutrophil, lymphocyte, monocyte, eosinophil, and basophil counts) as well as leukocyte ratios such as the NLR and the monocyte to lymphocyte ratio (MLR) were calculated. We also evaluated if the counts and indices were related to the tumor volume. Results: In all patients with tumors, the platelet and neutrophil counts were elevated when compared to the controls. In contrast, monocyte counts and the MLR were found to be decreased in patients with tumors when compared to the controls. The subset of patients with glioblastoma showed a significant increase in NLR when compared to the controls. Conclusions: Significant changes in the neutrophil, monocyte, and platelet counts as well as NLR and MLR were observed. Prospective longitudinal studies are required to determine the prognostic and therapeutic implications of these findings.

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Background: Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are life-threatening dermatologic conditions. Although, the incidence of SJS/TEN in Thailand is high, information on cost of care for SJS/TEN is limited. This study aims to estimate healthcare resource utilization and cost of SJS/TEN in Thailand, using hospital perspective. Methods: A retrospective study using an electronic health database from a university-affiliated hospital in Thailand was undertaken. Patients admitted with SJS/TEN from 2002 to 2007 were included. Direct medical cost was estimated by the cost-to-charge ratio. Cost was converted to 2013 value by consumer price index, and converted to $US using 31 Baht/ 1 $US. The healthcare resource utilization was also estimated. Results: A total of 157 patients were included with average age of 45.3±23.0 years. About 146 patients (93.0%) were diagnosed as SJS and the remaining (7.0%) were diagnosed as TEN. Most of the patients (83.4%) were treated with systemic corticosteroids. Overall, mortality rate was 8.3%, while the average length of stay (LOS) was 10.1±13.2 days. The average cost of managing SJS/TEN for all patients was $1,064±$2,558. The average cost for SJS patients was $1,019±$2,601 while that for TEN patients was $1,660±$1,887. Conclusions: Healthcare resource utilization and cost of care for SJS/TEN in Thailand were tremendous. The findings are important for policy makers to allocate healthcare resources and develop strategies to prevent SJS/TEN which could decrease length of stay and cost of care.

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Borderline ovarian tumors represent 10-20% of epithelial ovarian neoplasms that typically have an excellent prognosis. Both the oncological behavior of this group of tumors and also the diagnostic histological criteria are intermediate between the specific criteria of benign and malignant. They usually occur in the third to fourth decade of women's lives and are limited to the ovary in 80% of cases. Atypical proliferative or borderline ovarian tumors constitute a group of epithelial tumors with an excellent prognosis due to the low aggressiveness, microscopic examination is mandatory in order to establish an accurate histological diagnosis in all cases of borderline ovarian tumors and to differentiate from well differentiated adenocarcinoma. We report a case of a 45 year old female who presented with irregular bleeding per vaginum and underwent hysterectomy with bilateral salpingo-oophorectomy. Atypical proliferative endometrioid tumor of the left ovary was an incidental finding, which is a very rare occurrence.

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Background: Free radicals such as reactive oxygen species (ROS), which induce oxidative stress, are the main contributors to head and neck carcinogenesis (HNC). The present study was conducted with the aim to assess the oxidant/antioxidant status and DNA damage analysis in head and neck cancer/control patients. Materials and Methods: This prospective study was conducted on 60 patients with biopsy-proven HNC and 17 patients of head and neck disease (HND). The total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) were determined by novel automatic colorimetric methods from tissue homogenate. DNA damage analysis was determined by single cell gel electrophoresis (SCGE). Results: The mean age of the study cohort was 46.65 ± 14.84 years for HNC patients, while it was 49.41 ± 13.00 years for HND patients. There were no significant differences found between the two groups with respect to demographic presentation except tobacco addiction. The association between oxidative stress parameters and DNA damage analysis with study group revealed the following. (A) DNA damage - tissue homogenate TOS and OSI were significantly higher in HNC subjects than in HND (16.06 ± 1.78 AU vs 7.86 ± 5.97 AU, P < 0.001; 53.00 ± 40.61 vs 19.67 ± 21.90, P < 0.01; 7.221 ± 5.80 vs 2.40 ± 2.54, P < 0.01, respectively), while TAS was significantly decreased. (B) Aggressive histological features were identified, more commonly with higher TOS and lower TAS [probability (P) = 0.002, relative risk (RR) = 11.838, 95% confidence interval CI = 2.514-55.730 and P = 0.043, RR = 0.271, 95% CI = 0.077-0.960, respectively]. Conclusion: The increase in free radicals may be the event that led to the reduction of antioxidant status in HNC, thus explaining the oxidative damage of DNA and the severity of disease. Increased OSI represents a general mechanism in its pathogenesis.

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Context: Rabies poses a serious public health concern in developing countries such as India. Aims: The study focuses on molecular diagnosis of street rabies virus (RABV) from human clinical specimens received from Maharashtra, India. Materials and Methods: Nucleoprotein gene from eight (of total 20 suspected samples) rabies cases that tested positive for rabies antigen using reverse transcriptase-polymerase chain reaction (RT-PCR) were sequenced. Results: Sequence analysis using basic local alignment search tool (BLAST) and multiple sequence alignment (MSA) and phylogenetic analysis showed similarity to previously reported sequences from India and those of Arctic lineages. Conclusions: The circulating RABV strains in Maharashtra, India show genetic relatedness to RABV strains reported from Indo-Arctic lineages and India-South and Japan.

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We present a case of polyarticular synovitis following alendronate treatment for osteoporosis. The patient had no evidence of rheumatoid arthritis, pyrophosphate arthropathy, or seronegative/seropositive arthritis. Our main aim in this study is to highlight the potential adverse effects of alendronate and to warn orthopedic surgeons about the possibility of such a side effect that might lead orthopedic surgeons to administer wrong and unnecessary treatments like arthrocentesis. The withdrawal of alendronate is found to be the treatment of choice. Alendronate should be considered as a possible cause of synovitis or polyarthritis in patients treated with this agent in the absence of any other pathology. An association between alendronate and synovitis has rarely been described in the literature. We present a patient who developed polyarticular synovitis after treatment with alendronate and responded to its withdrawal.

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