Rama Hospital & Research Centre

Pseudobulbar affect (PBA) is a disabling neuropsychiatric condition characterized by sudden, involuntary episodes of crying or laughing incongruent with mood. It occurs in several neurological disorders, including amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), stroke, and traumatic brain injury (TBI). Dextromethorphan/quinidine (DM/Q) is the only Food and Drug Administration (FDA)-approved therapy for PBA, but optimal dosing and safety profiles remain uncertain. To evaluate the efficacy and safety of different DM/Q dosing regimens for treating PBA through a systematic review and network meta-analysis. A comprehensive search of PubMed, Embase, Cochrane Library, and ClinicalTrials.gov was conducted through March 2025. Randomized controlled trials reporting outcomes on the Center for Neurologic Study-Lability Scale (CNS-LS), Visual Analog Scale-Quality of Life (VAS-QOL), Visual Analog Scale-Quality of Recovery (VAS-QOR), and adverse events were included. Analyses were performed using R (netmeta package), and bias was assessed with the Cochrane RoB 2.0 tool. Five randomized controlled trials comprising 605 participants were analyzed. DM/Q 20/10mg and 30/10mg significantly improved CNS-LS scores (mean difference [MD] - 2.52 and - 2.45, respectively), while DM/Q 30/30mg produced greater gains in VAS-QOL (MD 17.20) and VAS-QOR (MD 14.90). Dizziness was the only statistically significant, dose-related adverse event. DM/Q combination therapy provides effective symptom control for PBA, with favorable tolerability. Both 20/10mg and 30/10mg doses improve emotional lability, while 30/30mg yields additional quality-of-life benefits. Further studies should assess long-term safety and disorder-specific dosing optimization.

Introduction:The goal of this study was to find out how SGLT2 inhibitors and GLP-1 receptor agonists help persons with Type 2 Diabetes Mellitus (T2DM) keep their blood sugar levels stable.Methodology:There were 120 people in the trial. They were randomly given either empagliflozin, Canagliflozin, Dapagliflozin, Ertugliflozin, Bexagliflozin, Sotagliflozin (an SGLT2 inhibitor) or liraglutide, Sitagliptin, Saxagliptin, Linagliptin, Alogliptin, Vildagliptin (n GLP-1 receptor agonist) to consume for 24 weeks. The major goal was to lower the levels of HbA1c. Some of the secondary outcomes included losing weight, markers of heart health, and adverse events.Results:Both treatments brought down HbA1c levels a lot, although GLP-1 agonists brought them down a little bit more. Both groups’ systolic blood pressure and LDL cholesterol levels improved, but the group that took GLP-1 agonists lost more weight. People who took SGLT2 inhibitors didn’t have as many stomach problems, whereas people who took GLP-1 agonists got nauseated and threw up.Conclusion:The study showed that both types of medicines do a decent job of keeping blood sugar levels steady. But GLP-1 agonists are better at helping people lose weight and keep their hearts healthy, so they are also a fantastic choice for people who have these problems. It’s crucial to consider what each patient needs and what could go wrong while establishing treatment plans for them.

IntroductionGiant cell tumours (GCT) of the distal tibia are uncommon, locally aggressive lesions that are frequently difficult to manage due to the anatomical and functional intricacies of the region. This case study seeks to elucidate the clinical presentation, surgical procedures, and results in three individuals with distal tibial giant cell tumours, highlighting management and reconstructive techniques in this uncommon location with higher risk of morbidity compared to other locations and to achieve pain free ambulation.Materials and methodsThree cases presenting with localised pain and swelling with painful weight-bearing in the distal tibia, were included in the study. Two patients had primary GCT whereas one had recurrence of the tumour after being managed elsewhere. All patients had biopsy and radiologically proven GCT with differing degrees of local aggressiveness. The management strategy involved wide-margin tumour resection followed by reconstruction techniques including contralateral fibular strut grafting and ankle arthrodesis with cementation and bone graft to restore structural integrity and functionality.ResultsAll three patients underwent successful tumour resection and reconstruction without major intra-operative complications. Radiological assessments confirmed adequate union of grafts and no signs of recurrence during follow-up.ConclusionThis series highlights the efficacy of various modalities for the treatment of GCT of distal tibia. While these methods demonstrate promising results in terms of stability and patient satisfaction, vigilance for recurrence and long-term complications remains critical.

Cancer-related pain (CRP) is a complex, multidimensional challenge in oncology that undermines quality of life, psychological well-being, and treatment adherence. This narrative, mechanism-informed review synthesizes pathophysiology, classification systems, and multidisciplinary management strategies to provide clinical insights and research priorities. It connects nociceptive, neuropathic, and mixed pain mechanisms to practical interventions, emphasizing peripheral and central sensitization in chronicity. Major frameworks, including the WHO analgesic ladder, International Classification of Diseases, 11th Revision, Edmonton Classification System for Cancer Pain, and European Pain Federation standards, are appraised alongside assessment tools such as the Visual Analogue Scale, Brief Pain Inventory, and Hospital Anxiety and Depression Scale, with examples of their clinical application. Management is framed within a flexible, mechanism-based, multimodal model that integrates pharmacologic, adjuvant, interventional, and psychosocial approaches, delivered through coordinated, multidisciplinary teams. Evidence for complementary modalities, such as acupuncture and mindfulness-based stress reduction, remains preliminary and heterogeneous, requiring further high-quality trials, whereas opioid-based pharmacologic approaches and structured psychosocial interventions such as cognitive behavioral therapy are supported by more robust, established evidence. Similarly, innovations like AI-driven monitoring and pharmacogenomics hold promise but are still in the early validation phase, underscoring the need to distinguish between evolving and well-established domains of cancer pain management. The principal actionable priorities are to adopt mechanism-based classification, embed multidisciplinary collaboration, expand multimodal access in low-resource settings, and rigorously validate emerging pharmacogenomic and digital health innovations before widespread clinical integration.

Combined filac and lift procedure for complex fistula in-ano: A case report and review of technique - JSAS- Print ISSN No: - Online ISSN No:- 2582-6387 Article DOI No:- 10.18231/j.jsas.2025.004, IP Journal of Surgery and Allied Sciences-IP J Surg Allied Sci

Zinner Syndrome is a rare congenital anomaly involving unilateral renal agenesis, ipsilateral seminal vesicle cyst, and ejaculatory duct obstruction. We report a symptomatic case managed conservatively. A 19-year-old male presented with 6 months of intermittent pelvic pain, dysuria, and ejaculatory discomfort. Examination was unremarkable. Ultrasonography showed right renal agenesis and a pelvic cyst. MRI confirmed a 2.8 cm cystic dilatation of the right seminal vesicle with vas deferens dilatation and absent right kidney. No ectopic renal tissue was seen. Semen analysis revealed oligospermia. Given mild symptoms and fertility concerns, he was treated conservatively with NSAIDs and antibiotics, resulting in symptom improvement within 4 weeks. Surveillance was planned. Zinner Syndrome should be considered in young males with unexplained pelvic or ejaculatory symptoms. MRI is essential for accurate diagnosis. Conservative treatment is suitable for mild cases, reserving surgery for progressive symptoms or fertility issues.

To assess the presence and quantity of CD34+ hematopoietic stem cells in patients with Alzheimer's disease (AD) through a meta-analysis. A systematic search of the databases identified the observational and interventional studies reporting baseline CD34+ cell counts in AD patients. The data on mean counts and the measures of variation were extracted. Standardized mean differences (SMDs) were calculated using common and random effects models to compare the CD34+ cell counts between the AD patients and controls. Heterogeneity among the studies was evaluated using tau2, tau, and I2 statistics. The risk of bias was assessed using the Newcastle-Ottawa Scale and the ROBINS-I tool. Five studies were included, comprising four observational studies and one open-label trial, with a total of 271 participants (139 AD patients and 132 controls). The meta-analysis indicated an increase in CD34+ cell counts of the AD patients when compared to the controls. The common effects model showed a moderate SMD of 0.2964 (95% CI:0.0490-0.5437). However, the random effects model yielded a non-significant SMD of 0.2326 (95% CI: -0.4832-0.9484). Significant heterogeneity was observed among the studies (I2 = 87.1%, p < 0.0001). AD patients may exhibit higher circulating CD34+ cell counts than the controls, but substantial heterogeneity and potential biases limit definitive conclusions.

We read the recent article by Imaoka et al., which investigates the prognostic efficacy of the liver immune status index (LISI) in predicting postoperative outcomes in hepatocellular carcinoma (HCC) patients.1 This multi-institutional retrospective study provides valuable insights into LISI as a prognostic tool, yet certain aspects warrant further discussion. The study comprehensively evaluates LISI, combining BMI, serum albumin levels, and the FIB-4 index to predict HCC prognosis. LISI outperformed existing models, especially in HCC with vascular invasion, correlating strongly with overall survival (OS) and recurrence rates (RR). However, relying on the FIB-4 index, originally developed for HIV/HCV coinfected patients,2 raises questions about its applicability in HCC. While the authors briefly address this limitation, they do not explore whether other fibrosis markers could enhance LISI's predictive power. Considering alternative markers such as the AST to platelet ratio index (APRI) or FibroTest might improve LISI's predictive accuracy.3 The reported AUROC values for LISI in predicting 2-year OS and RR (0.67 and 0.59, respectively) indicate moderate predictive accuracy. Although LISI showed superiority in the early postoperative period, its performance diminishes beyond 2 years. This raises concerns about its long-term reliability and suggests the need for a dynamic model. The introduction of the HISCO-HCC score, incorporating LISI, tumor burden score (TBS), and alpha-fetoprotein (AFP) levels, enhances predictive power. However, comparing the HISCO-HCC score with established models like the Barcelona Clinic Liver Cancer (BCLC) staging system or the Cancer of the Liver Italian Program (CLIP) score would clarify its efficacy. The study uses a large sample of 1337 patients, ensuring statistical robustness. The authors should elaborate on the selection criteria for defining the LISI cutoff points (low, moderate, high) and their biological rationale. These cutoff points are derived from a single prior study, limiting their generalizability. Sensitivity analyses or validating these cutoffs in an independent cohort would enhance their applicability. A notable omission is the consideration of potential confounding factors such as liver cirrhosis severity, comorbidities, or the impact of different HCC treatments. Variables like the model for end-stage liver disease (MELD) score, presence of diabetes or cardiovascular disease, and prior treatments like transarterial chemoembolization (TACE) can significantly influence OS and RR.4, 5 Including these factors in the multivariate analysis would provide a more nuanced understanding of LISI's prognostic efficacy. Lastly, while the study emphasizes the importance of natural killer (NK) cell-mediated antitumor activity, the biological mechanisms underlying LISI's predictive capacity remain speculative. Prospective studies measuring NK cell cytotoxicity or TRAIL expression levels alongside LISI scores could substantiate the biological basis of LISI's prognostic capacity. Validating the direct correlation between LISI scores and NK cell activity would reinforce its biological plausibility as a prognostic tool. In conclusion, Imaoka et al. provide a compelling exploration of LISI as a prognostic index for HCC, particularly in predicting early recurrence and OS. However, its moderate predictive accuracy, lack of consideration for confounding factors, and need for long-term validation suggest that LISI should be part of a broader prognostic framework rather than a standalone tool. Future studies addressing these limitations would be invaluable in confirming LISI's utility in clinical practice. Ganesh Bushi: Conceptualization, literature review, writing – original draft. Muhammed Shabil: Data analysis, writing – review and editing. Amogh Verma: Supervision, project administration and correspondence. We thank the authors for their valuable contribution to the field of hepatocellular carcinoma research and for stimulating further discussion on prognostic tools. The authors declare that they have not received any funding for this current study. The authors declare to have no financial and non-financial interests relevant to this study to disclose.