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1.  Looking at “thunderclap headache” differently? Circa 2016 
The term “thunderclap headache” (TCH) was first coined in 1986 by Day and Raskin to describe headache that was the presenting feature of an underlying unruptured cerebral aneurysm. The term is now well established to describe the abrupt onset headache seen with many other conditions and is also now included in The International Classification of Headache Disorders 3rd edition beta version rubric 4.4. An essential to label an acute headache as “TCH” and differentiate it from other “sudden onset, severe headaches” is the arbitrary time frame of 1 min from onset to peak intensity for “TCH.” What happens in practice, however, is that even those “sudden onset, severe headaches” that do not strictly fulfill the definition criteria are also labeled as “TCH” and investigated with the same speed and in the same sequence and managed based on the underlying cause. This article begins by questioning the validity and usefulness of this “one minute” arbitrary time frame to define “TCH,” particularly since this time frame is very difficult to assess in practice and is usually done on a presumptive subjective basis. The article concludes with suggestions for modification of the current investigation protocol for this emergency headache scenario. This proposal for “a change in practice methodology” is essentially based on (1) the fact that in the last two decades, we now have evidence for many more entities other than just subarachnoid hemorrhage that can present as “TCH” or “sudden onset, severe headache” and (2) the evidence from literature which shows that advances in imaging technology using higher magnet strength, better contrast, and newer acquisition sequences will result in a better diagnostic yield. It is therefore time now, in our opinion, to discard current theoretical time frames, use self-explanatory terminologies with practical implications, and move from “lumbar puncture (LP) first” to “LP last!”
PMCID: PMC4980948  PMID: 27570377
Cerebrospinal fluid examination; investigation protocol; lumbar puncture; magnetic resonance imaging; subarachnoid hemorrhage; sudden onset severe headache; thunderclap headache
2.  Adverse Events in Robotic Surgery: A Retrospective Study of 14 Years of FDA Data 
PLoS ONE  2016;11(4):e0151470.
Use of robotic systems for minimally invasive surgery has rapidly increased during the last decade. Understanding the causes of adverse events and their impact on patients in robot-assisted surgery will help improve systems and operational practices to avoid incidents in the future.
By developing an automated natural language processing tool, we performed a comprehensive analysis of the adverse events reported to the publicly available MAUDE database (maintained by the U.S. Food and Drug Administration) from 2000 to 2013. We determined the number of events reported per procedure and per surgical specialty, the most common types of device malfunctions and their impact on patients, and the potential causes for catastrophic events such as patient injuries and deaths.
During the study period, 144 deaths (1.4% of the 10,624 reports), 1,391 patient injuries (13.1%), and 8,061 device malfunctions (75.9%) were reported. The numbers of injury and death events per procedure have stayed relatively constant (mean = 83.4, 95% confidence interval (CI), 74.2–92.7 per 100,000 procedures) over the years. Surgical specialties for which robots are extensively used, such as gynecology and urology, had lower numbers of injuries, deaths, and conversions per procedure than more complex surgeries, such as cardiothoracic and head and neck (106.3 vs. 232.9 per 100,000 procedures, Risk Ratio = 2.2, 95% CI, 1.9–2.6). Device and instrument malfunctions, such as falling of burnt/broken pieces of instruments into the patient (14.7%), electrical arcing of instruments (10.5%), unintended operation of instruments (8.6%), system errors (5%), and video/imaging problems (2.6%), constituted a major part of the reports. Device malfunctions impacted patients in terms of injuries or procedure interruptions. In 1,104 (10.4%) of all the events, the procedure was interrupted to restart the system (3.1%), to convert the procedure to non-robotic techniques (7.3%), or to reschedule it (2.5%).
Despite widespread adoption of robotic systems for minimally invasive surgery in the U.S., a non-negligible number of technical difficulties and complications are still being experienced during procedures. Adoption of advanced techniques in design and operation of robotic surgical systems and enhanced mechanisms for adverse event reporting may reduce these preventable incidents in the future.
PMCID: PMC4838256  PMID: 27097160
3.  The art of history-taking in a headache patient 
Annals of Indian Academy of Neurology  2012;15(Suppl 1):S7-S14.
Headache is a common complaint that makes up for approximately 25% of any neurologists outpatient practice. Yet, it is often underdiagnosed and undertreated. Ninety percent of headaches seen in practice are due to a primary headache disorder where there are no confirmatory tests, and neuroimaging studies, if done, are normal. In this situation, a good headache history allows the physician to recognize a pattern that in turn leads to the correct diagnosis. A comprehensive history needs time, interest, focus and establishment of rapport with the patient. When to ask what question to elicit which information, is an art that is acquired by practice and improves with experience. This review discusses the art of history-taking in headache patients across different settings. The nuances of headache history-taking are discussed in detail, particularly the questions related to the time, severity, location and frequency of the headache syndrome in general and the episode in particular. An emphasis is made on the recognition of red flags that help in the identification of secondary headaches.
PMCID: PMC3444228  PMID: 23024567
Headache; history-taking; migraine
4.  Shear Bond Strength of Composite Veneers and Acrylic Veneer Bonded to Ni–Cr Alloy: A Laboratory Study 
A growing number of composite materials are being used as an alternative for veneering cast restorations. The objective of this investigation was to evaluate and compare the shear bond strength of UDMA based composite, restorative composite, and heat cure acrylic when veneered to Ni–Cr alloy and to evaluate the type of bond failure. Three different veneering materials were used: heat cure acrylic, UDMA based composite and a restorative composite. 10 samples were fabricated, each with heat cure acrylic and restorative composite and 20 samples were fabricated with UDMA based composite; thus, the total number of samples amounted to 40. All the samples were subject to shear bond stress fracture tests and observed for the type of bond failure. The greatest mean shear bond strength was recorded in relation to the UDMA based composite material when thermal conducting paste was used during the curing (10.51 MPa). The mean bond strength values of UDMA based composite without thermal conducting paste (8.92 MPa), heat cured acrylic veneering material (4.24 MPa) and restorative composite material (5.03 MPa) were significantly different from each other (p > 0.05). Samples veneered with heat cure acrylic veneering material and restorative composite material showed adhesive failure. Samples prepared with UDMA based composite veneering composite showed cohesive or predominantly cohesive failure. UDMA based composite veneering material when used with heat protection paste exceeds the shear bond strength requirement as suggested by Matsumura et al. (>10 MPa). A statistically significant association between the test groups and the type of failure was observed.
PMCID: PMC3120956  PMID: 22654348
Veneering composite; Shear bond strength; Bond failure
6.  Quality of life in patients with epilepsy in India 
People with epilepsy have impairment in their quality of life (QOL) due to effect of epilepsy on various aspects of their life and the medication effects. Systematic studies on QOL in epilepsy from developing countries are sparse.
To assess the QOL in people with epilepsy and to evaluate various factors affecting the QOL in them.
Materials and Methods:
People with generalized and partial epilepsy on medication aged more than 18 years were included in the study. The QOL was assessed with QOLIE-89 instrument. Statistical significance was evaluated by the use of Chi-square test and one-way analysis of variance (ANOVA).
Sixty people with epilepsy were studied among whom the older patients had lower overall QOL scores compared to younger patients. Female patients had lower scores compared to males. Married people had lower quality of health score. Patients with simple partial seizures had lowest overall QOL mean score. There was reduction in the overall QOLIE scores with increasing duration of the epilepsy. Patients who had their last seizure within 10 months prior to evaluation had lower mean overall scores.
QOL was impaired in people with epilepsy with increased impairment in women, older patients, simple partial seizures, and those with recent seizure.
PMCID: PMC3123012  PMID: 21716845
Epilepsy; marriage; quality of life
7.  Intracranial hypotension secondary to spinal arachnoid cyst rupture presenting with acute severe headache: a case report 
Headache is a common presenting complaint and has a wide differential diagnosis. Clinicians need to be alert to clues that may suggest an underlying secondary aetiology. We describe a novel case of headache secondary to intracranial hypotension which was precipitated by the rupture of a spinal arachnoid cyst.
Case report
A 51-year-old Indian female presented with sudden onset severe headache suggestive of a subarachnoid haemorrage. Investigations including a computed tomography brain scan, cerebrospinal fluid examination and a magnetic resonance angiogram were normal. The headache persisted and magnetic resonance imaging revealed bilateral thin subdural collections, a spinal subarachnoid cyst and a right-sided pleural effusion. This was consistent with a diagnosis of headache secondary to intracranial hypotension resulting from spinal arachnoid cyst rupture.
Spinal arachnoid cyst rupture is a rare cause of spontaneous intracranial hypotension. Spontaneous intracranial hypotension is a common yet under-diagnosed heterogeneous condition. It should feature significantly in the differential diagnosis of patients with new-onset daily persistent headache.
PMCID: PMC3018401  PMID: 21167026
8.  Post radiation chylous ascites: a case report 
Cases Journal  2009;2:9393.
We report a 64 years old gentleman with unresectable right-sided retroperitoneal liposarcoma, who underwent radiotherapy & subsequently developed chylous ascites. He failed conservative management of chylous ascites and this was successfully managed with a peritoneovenous shunt. The pathophysiology and management of post radiational chylous ascites is discussed.
PMCID: PMC2805653  PMID: 20069070
9.  The Global Campaign (GC) to Reduce the Burden of Headache Worldwide. The International Team for Specialist Education (ITSE) 
The Journal of Headache and Pain  2005;6(4):261-263.
The social perception of headache, everywhere at low levels in industrialised countries, becomes totally absent in developing ones. Headache disorders came into the World Health Organization’s strategic priorities after publication of the 2001 World Health Report. Among the leading causes of disability, migraine was ranked 19th for adults of both sexes together and 12th for females. The Global Campaign (GC) to Reduce the Burden of Headache Worldwide was planned by the major international headache organizations together with WHO in order to identify and remove those cultural, social and educational barriers recognised as responsible factors for the inadequate treatment of headache disorders worldwide. Within the GC activities, the education of the medical body will represents a central pillar. An International Team for Specialist Education (ITSE) has been created to train physicians from all over the world through the acquisition of a university level Master Degree in Headache Medicine. Once trained as headache specialists, physicians will become trainers, offering education in this field to other health care providers in their own countries. In this way they will give life to a cultural chain raising awareness locally of headache, its burden and its medical control.
PMCID: PMC3452013  PMID: 16362681
Academic formation; Master in Headache Medicine; Global Campaign Against Headache; Headache specialist education

Results 1-9 (9)