We are indeed very happy to inform you that the Bombay Hospital Journal has now adopted an online submission and processing system and the total workflow from now on will be on the electronic platform. The journal has been included in the Index Copernicus.

We all know Dr. O. P. Kapoor as a phenomenon. The great teacher that he is, the great clinician that he is, the enchanting human being that he is, and the fantastic editor that he has been for the Bombay Hospital Journal.

Bombay Hospital was one of the first few institutes in India to offer neurological services. They were initiated by Dr. R. G. Ginde and Dr. Eddie P. Bharucha, who were colleagues at the King Edward Memorial Hospital as well. Dr. Bharucha completed his early education in Mumbai (then Bombay) and pursued his medicine and neurology at the University College Hospital, London. While there, he was fascinated by the approach of Sir Francis Walsh, who mentored him. He was one of the first few Indian doctors who practiced full time neurology [Figure 1].

Menopausal hormone therapy (MHT) is surrounded by controversies after the path breaking reports from Women's Health Initiative (WHI) trial were published in 2002. The universal hormone therapy policy used before WHI became obsolete after 2002. Majority of women who were already taking MHT discontinued the therapy all over the world. Even practitioners stopped prescribing MHT. After a few years, a ""timing hypothesis"" emerged and a ""window-of-opportunity"" was conceptualized supported by newer safety data for the initiation of menopausal hormone therapy. This means that MHT is best given immediate postmenopausal stage for a short duration of time. MHT started many years after the onset of menopause and continued for long duration following menopause reported more side effects hence use of MHT decreased drastically. However due to beneficial results, Danish Osteoporosis Prevention Study (DOPS) and the Kronos Early Estrogen Prevention Study (KEEPS), interest has been regenerated in MHT. Excellent symptom relief can be provided by MHT for healthy women who experience menopausal symptoms. MHT poses a low risk in these healthy women with no comorbidities. When MHT is initiated in elderly women and in those with comorbidities, it may be associated with increased risk. Prior discussion with patient about hormone therapy is a must before starting MHT. Personalized discussion with patient about symptoms, treatment goals, analysis of age, time since menopause, and consideration of comorbidities influences decision-making about starting MHT. We recommend further studies on menopausal hormone therapy for better understanding of risk versus benefit of MHT.

Key words: Hormone replacement therapy, Menopausal hormone therapy, Menopause

Context: Studies of TN in the Indian context are few; moreover, no study has evaluated the relation between sleep and TN.
Aims: To study the clinical and laboratory features of Indian patients with trigeminal neuralgia (TN) with special reference to sleep. Settings and Design: Tertiary care setup
Methods and Material: Patients fulfilling International classification of headache disorders-3 beta criteria for TN seen from January 2009 to December 2013 were included. Patients with secondary TN were excluded. Patients underwent detailed history and clinical examination. Particular attention was given to painful awakenings. Detailed MRI evaluations were performed with CISS sequences to study the trigeminal area. Medications required to control the pain were tabulated and analysed.
Results and Conclusions: Fifty four patients were included in the study. The commonly observed female preponderance was not seen and V1 affection was far more common than previously documented. In spite of detailed evaluation, vascular loop was encountered in less than one fourth of patients. Exploring the relation between TN and sleep, significant number of patients (40%) with TN got up from sleep because of pain; which is much frequent than documented by most studies. All the patients who woke up from sleep due to pain had affection of V2, suggesting a role of tactile stimulation of V2 dermatome during sleep

Key words: Trigeminal neuralgia, Sleep, Painful awakenings, Vascular loop

Background and Aim: Nasal pack is used for the control of bleeding and to prevent post-operative complications in septoplasties. An alternative to nasal packing is a nasal septal splint with clip which can be used postoperatively in septoplasties. Hence, we are doing a retrospective observational study of the septoplasties cases performed in our institute using splint with clip postoperatively and assessing post-operative signs, symptoms, and complications.
Case Description: The study involves 40 patients aged between 21 years and 47 years who were having deviated nasal septum and underwent septoplasty between November 2017 and November 2019 in the Department of ENT, ESIC Model Hospital, Guwahati, after taking inclusion and exclusion criteria. Postoperatively, symptoms such as headache, dysphagia, sleep disturbance, epiphora, and bleeding were assessed. During nasal septal splint and clip removal, pain and bleeding were assessed. Post-operative complications such as hematoma, synechiae, and septal perforation were noted.
Conclusion: was observed that patients had less postoperative symptoms, less pain, and bleeding following splint and clip removal and lesser post-operative complications.
Clinical Significance: Nasal splint with clip may be used as a safe alternative to nasal packing.

Key words: Clip, Deviated nasal septum, Septal splint, Septoplasty

Aim: This study aims to evaluate the impact of the coronavirus disease (COVID)-19 pandemic on orthopedic practice by conducting an online survey among the orthopedic surgeons in India.
Materials and Methods: The survey (Google form) consisted of 20 questions concerning three topics: Four questions were addressed to the origin and surgical experience of the participant, 12 questions dealt with the potential disruption of orthopedic practice, and four questions addressed the influence of the pandemic on the particular surgeon.
Results: Around 2000 orthopedic surgeons were contacted through email and social networking sites, of which 452 surgeons responded. Regarding arthroplasty procedures, only 17.2% of the participants stated that these procedures were being performed, of which 7.6% were operating regularly, while 9.6% were facing some delay. Around 80% of the participants stated that arthroscopic procedures were completely halted at their health-care centers. The surgeons also voiced their grievances regarding hampered post-operative follow-ups and physical rehabilitation.
ConclusionDue to the COVID-19 pandemic, the orthopedic practice in India is reported to be suffering from a severe disruption of services with a drastic reduction in arthroscopic procedures such as rotator cuff repair and cruciate ligament reconstruction and elective total joint arthroplasty. Only life and limbthreatening pathologies such as acute trauma management are currently being adequately attended to by most of the surgeons. The long-term effects of the lapse of services cannot be predicted as yet and should be considered very significant.

Key words: Orthopedic practice, Coronavirus disease-19, Elective surgery, Trauma, Total joint arthroplasty

Background: Tuning fork tests are commonly performed for bedside evaluation of hearing. There is a controversy about the most useful frequency of tuning fork for the bedside testing of hearing.
Methods: In the present study, the sensitivity and specificity of Rinne and Weber test were calculated using 128, 256, 512, and 1024 frequencies in 50 successive patients referred for evaluation of hearing. Pure tone audiometry formed the standard reference.
Results: Rinne test showed poor sensitivity (32%, 32%, 17%, and 15% with 128 Hz, 256, 512, and 1024 Hz tuning forks, respectively), but good specificity (98%) for detecting conducting hearing loss. Weber test showed good sensitivity for detecting unilateral hearing loss (71%, 92%, 85%, and 71%) and poor specificity (44-50%). Sensitivity improved with higher degrees of hearing loss.
Conslusions: The present study found that the 256 Hz tuning fork was more sensitive than the 128, 512, and 1024 Hz forks for evaluation of Rinne as well as Weber test. Hence, 256 seems to be the most suitable frequency for bedside testing of hearing.

Key words: Tuning fork test, Frequency, Sensorineural hearing loss

Aim: This study aims to assess the association between the ocular axial length (AL) and the pathogenesis of central retinal vein occlusion (CRVO) at a tertiary care hospital.
Methods: This study included patients of unilateral CRVO. Informed consent was obtained, followed by comprehensive history taking, ophthalmic evaluation, systemic investigations as per protocol, and ocular investigations including OCT/FFA, depending on the requirement of the patient and duration of disease. Fifteen women and 15 men with a mean age of 64.98 years were selected. ALs of the affected (study group) and unaffected eye (control group) were measured by A-scan ultrasonography (US).
Results: The mean AL of affected eyes in males was 23.0267 mm and that in unaffected eyes was 23.191 mm (P = 0.000). The mean AL of affected eyes in females was 23.0131 mm and that in unaffected eyes was 23.030 mm (P = 0.000). The ALs of affected eyes were shorter than those of unaffected eyes (P = 0.000). These differences were statistically significant. The Cronbach's a found is 0.925, which suggests a strong correlation between AL and CRVO. A comparison was also made between the ALs and CRVO based on the gender, and no statistical difference was found.
Conslusions: Our study confirms the existence of shorter ALs in the affected eye of patients of CRVO on comparison with the unaffected eye. It also confirms that this difference is statistically significant in the total population and in each gender.

Key words: Community health, health-care management, non-communicable disease

My White coat hails hundreds of behaviors in pain, I hardly remember their names, so I recognize them with an ailment, so as to unscramble things in my brain.

Respiratory failure as the presenting feature is uncommon in neurodegenerative diseases. We report a case of 58-year-old male presenting as hypercapnic respiratory failure and stridor due to vocal cord paralysis accompanied with severe autonomic dysfunction, gait, and sleep changes. Examination showed cerebellar ataxia and autonomic dysfunction. Tracheostomy was necessary. Magnetic resonance imaging showed bilateral signal abnormality in middle cerebellar peduncles and favoring multisystem atrophy (MSA). The objective of this case report is to remind readers that MSA should be considered in differential diagnosis of unexplained respiratory failure, stridor, and vocal cord paralysis in appropriate clinical circumstances. Relevant literature is reviewed.

Key words: Multisystem atrophy, Middle cerebellar peduncle, Hypercapnic respiratory failure

Myasthenia gravis (MG) is an immune mediated, post-synaptic neuromuscular transmission disorder, presenting with predominant ocular, bulbar, and/or proximal fluctuating weakness and fatiguability. Distal and asymmetric onset of symptoms in MG is rare and could lead to delay in diagnosis especially when fatiguability or fluctuation is not clearly reported as a prominent initial symptom - as seen with our patients. We report three cases of distal MG who presented with predominant distal, asymmetric hand weakness. Their clinically diagnoses for referral to the electrodiagnostic (EDx) laboratory were: Chronic inflammatory demyelinating peripheral neuropathy, C8T1 motor radiculopathy, and multifocal motor neuropathy. It was in the EDx laboratory that the diagnosis of MG was suspected in these patients. Since the routine EDx tests were normal in all three patients - A repetitive nerve stimulation test (RNST) was done - which was positive in the affected muscles and hence a diagnosis of distal MG made. (This is the protocol followed in our laboratory) These patients were then found to have high serum levels of antibodies to acetyl choline receptors - confirming the diagnosis of MG. RNST is not routinely done in all patients sent for EDx testing and none of these patients had a reference for the same - however, using a protocol based method of EDx testing, lead to the diagnosis of a treatable condition. Electrodiagnostician need to be aware of this presentation of MG and follow protocols or the diagnosis could be missed.

Key words: Distal limb weakness, Myasthenia gravis, Repetitive nerve stimulation test, Repetitive nerve stimulation test
Key message: The diagnosis of MG could be missed when patients present with symptoms of isolated distal hand weakness. Clinicians and electrodiagnosticians must be aware of this rare presentation of a treatable condition. In our EDx laboratory a protocol is followed – When all routine tests are normal in a patient with history of weakness, a RNST test performed is on the weak muscles. What is well known: Myasthenia gravis presents with ocular, bulbar, and proximal limb weakness What is less known: Myasthenia gravis can rarely present with predominant distal weakness of hand muscles

case of anterior uveitis for 4 months. Posterior segment examination revealed vitritis with a granulomatous epiretinal membrane (ERM) over the macula. She was also found to have IgG antibodies positive against toxoplasma. Anti-toxoplasma treatment was initiated, and a vitrectomy with ERM peeling was performed. The peel was sent for histopathological examination and was found to be positive for histiocytes. Later, an intravitreal dexamethasone implantation was done. Her best-corrected visual acuity was 6/9, approximately 12 months after the initial diagnosis. A case of toxoplasmic retinochoroiditis can masquerade as a case of chronic anterior uveitis, and benefits from combined medical and surgical treatment.

Key words: Disease transmission, infectious diseases, retinochoroidal granuloma

It was indeed extremely worrisome for us; when our patient; a 41-year-old diabetic lady with autoimmune posterior scleritis with a follow-up of about 8 months; on 12.5 mg/day of oral prednisolone, weekly subcutaneous 25 mg methotrexate and 3 monthly 750 mg pulsed intravenous cyclophosphamide tested positive for SARS-CoV-2 after having an episode of fever and body ache for 5 days; in June 2020. Increased predisposition to infection because of our immunosuppressive treatment and possible worse outcome was our logical concerns. This led us to study the interaction of the human immune system with SARS-CoV-2 and the implications that such an interaction would have; in a patient on immunomodulatory treatment.

The COVID-19 pandemic saw us go through four phases of lockdown in India; starting from March 25, 2020, to May 31, 2020; before announcement of the various phases of unlock starting June 1, 2020; with us currently being in Unlock 5.0; at the time that we write this letter to the editor. Through all these phases of lockdown-unlock, what remained common and most prominent was the message of Soap-Mask-Social (SMS) Distancing; as possibly the foremost preventive measures against COVID-19 infection. The face mask is ubiquitous and rightly perceived now, as an important part of our clothing.

Maturing from teenage into being in its twenties; the 21^st century; in the year 2020, seems to have goals of being a ""change-maker"" almost akin to a young entrepreneur; and turning completely rebellious; as if with a plan; almost as if to reiterate, that life cannot not be the same anymore and a ""new normal"" would have to be adopted by all strata of society; at least till we, as a civilization is not able to overcome this pandemic through steps like mass vaccination campaigns; whenever, effective vaccines are available. Purely from an environmental perspective; while the initial period of the pandemic and the consequent lockdown saw something akin to an environmental revival with the air getting cleaner; the rivers getting much less polluted and vivid pictures of wild animals roaming fearlessly on city streets; it became difficult for us humans; to get out of our homes for simple social activities without feeling a fear of getting infected by the potentially fatal virus; leading to the wide scale use of face masks among other prescribed COVID appropriate behavior.