With interest we read the article by Hooper et al. about the histopathological and ultrastructural findings on autoptic muscle biopsy in a ~60yo female with a previous history of pre-diabetes, arterial hypertension, and hyperlipidemia, who experienced a fatal infection with SARS-CoV-2, manifesting as interstitial pneumonia requiring intubation and artificial ventilation [1]. She died one week after having been tested positive for SARS-CoV-2 from intractable arterial hypotension, bradycardia, and respiratory and metabolic acidosis [1]. Histology of the skeletal muscle revealed fibrin micro-thrombi, perimysial micro-hemorrhages, adjacent vacuolar degeneration and necrosis, and minimal inflammatory infiltration [1]. Electron microscopy revealed degenerated cells with cytoplasmic condensation, degenerated mitochondria, and cytoplasmic clusters of SARS-CoV-2 particles [1]. We have the following comments and concerns.

Involvement of the skeletal muscle in COVID-19 may not only manifest as myalgia, fatigue, or elevation of serum creatine-kinase (CK) but also as muscle weakness, atrophy, dermatomyositis, critical ill myopathy, myasthenia, myasthenic syndrome, or rhabdomyolysis [2-4].

Missing in the report is the medication the patient received since hospitalisation. Since some of the compounds given to treat COVID-19 are myotoxic (e.g. steroids, chloroquine, azithromycin) [5], it is crucial to know the drugs given since admission. The influence of these compounds on muscle morphology should be discussed.

Since SARS-CoV-2 may affect peripheral nerves and secondarily the skeletal muscle [6,7], we should know if the abnormalities detected on autopsy were attributable to neuropathy and concomitant myopathic changes. The results of nerve conduction studies (NCSs) and needle electromyography (EMG) should be provided.

We should know if the patient complained about any neuromuscular symptoms already on admission and the medication the patient was regularly taking prior to admission, missing in this respect is the discussion about neuromuscular compromise already prior to admission. Did the patient suffer from a subclinical neuromuscular disorder (NMD) already before hospitalisation? 

Missing is a discussion about the discrepancy between the mild abnormalities on muscle histology and the sometimes-severe muscle compromise, even leading to muscle weakness and rhabdomyolysis. According to the presented morphological abnormalities, myopathy in COVID-19 patients is rather due to side effects from the treatment applied, pre-existing, subclinical muscle pathology, or due to secondary immune-mechanisms than from viral myositis. 

Thrombo-embolic events are a common complication of SARS-CoV-2 infections [8]. We should know if pulmonary embolism, as detected on autopsy, was already detected intra vitam and if the patient received anticoagulation. 

Overall, this appealing autopsy study has some limitations, which need to be addressed before drawing conclusions. Muscle damage due to drugs given for COVID-19 or prior to admission, previous NMD, and nerve damage with secondary muscle pathology need to be excluded. The findings suggest that severe muscular compromise in COVID-19 is rather due to non-viral pathophysiology than due to viral myositis.

Peptic ulcer is an excoriated area of stomach or intestinal mucosa caused principally by the digestive action of gastric juice or upper small intestinal secretions. Since NSAID abuse is the main exogenous cause of refractory peptic ulcer the present model was chosen. In the present study gastric ulceration was induced by single dose of Aspirin 400 mg/kg on 7th day of the experiment. The experiment consists of treatment with the test herb and standard drug for seven days and on seventh day inducing the ulcer with aspirin. On 8th day pyloric ligation was performed on all the rats under light ether anesthesia on fasted animals over night from 7th day after pyloric ligation. The stomach was replaced and abdomen was then sutured. After 4 hours the rats were sacrificed with proper doses of ether and stomach was dissected out. After that stomach was opened along the greater curvature and the contents were collected in test tubes for analysis. The mucosa of the stomach was examined for ulcers and subjected for gastric mucus estimation. In all the parameters estimated it was found that the Methanolic Extract of Rhizomes of Alpinia Nigra (MERAN) showed similar results as of the standard drug Omeprazole which was significantly better than the aspirin control group. The findings of the present study put forward Alpinia Nigra as a promising new anti-ulcerogenic agent, which can be further evaluated with more refined techniques and innovate formulations with least adverse for the treatment of gastric ulcers.

Hilton and colleagues in 2006 published a manuscript on the number needed to treat (NNT) describing how to convert more commonly reported statistics (dichotomous outcomes) into the NNT (the mathematical inverse of the absolute risk reduction), utilising the PEDro downloadable spreadsheet and nine manuscripts on the physiotherapy evidence database (PEDro) (varied clinical disciplines). It is easily interpretable, explicit and describes how many patients need to be treated with the new intervention in order for one additional patient to have the desired outcome compared with the number expected to have that outcome under the standard treatment or placebo. Subsequently in order to comprehend how often there is reporting of NNT in systematic reviews and clinical trials a PEDro search was conducted in order to ascertain how many systematic reviews and clinical trials report NNT. A simple search; search words ‘number needed to treat’ identified 248 records. 176 records (71% of the total) reported NNT in the abstract. The remainder either didn’t report NNT in the abstract (5.5%) or it stated that copyright release for the abstract had not been granted (23.5%) so verification wasn’t possible. The 176 records were then placed into arbitrarily chosen clinical specialty categories.

Posology is one of the cardinal principles of homoeopathy The article discusses various aspects of homeopathic posology – its types, indication, administration of doses.

Background: Multiple recent studies have found metabolic syndrome (MS) to be associated with chronic infections like hepatitis B. Very few studies have been reported from India. The current study is aimed to identify any relationship between MS and chronic hepatitis B infection. Materials: 47 treatments naïve CHB patients and 50 age and sex matched controls with age more than 18 years were included in the study. Metabolic syndrome was defined using NCEP-ATP III 2004 criteria. Chronic hepatitis B (CHB) was diagnosed by the presence of HBsAg and anti-hepatitis B core antibody (IgG). Patients were clinically evaluated and biochemical estimation, ultrasound abdomen, HBV DNA were done in every patient. Exclusion criteria included chronic hepatitis other than hepatitis B, concomitant HIV/HCV coinfection, chronic inflammatory disease like RA and patients on lipid lowering drugs. Observations: Out of 47 cases, 9 had MS (19.1%vs 20% in control). CHB patients had lower mean total cholesterol (126.34±43.97 mg/dL vs 155.3±42.4 mg/dL p=0.001), lower mean triglyceride (109.04±40.75 mg/dL vs 136.33±60.88 mg/dL, p=0.01), lower mean HDL level (25.25±12.05 mg/dL vs 35.61±11.47 mg/dL, p<0.001) level than controls. Out of 9 patients who had metabolic syndrome, 5 (20.83%) had HBV DNA above median (82200 IU/mL). Conclusion: Current study found a lower incidence of MS in CHB infection with significantly lower level of TC, HDL-C and TGL; Higher DNA load was associated with lesser incidence of MS.

Introduction: Safe motherhood is a priority program in Bangladesh, aiming to restrain maternal deaths. Meanwhile, knowledge, practices, accessibility, and service quality are considered keys to improve service utilization. This study was conducted to identify knowledge and practices of maternal health care among the nurses. Objective: The General objective of the study is to know the Knowledge about the maternal health services among the nurses. Methodology: The consecutively descriptive cross-sectional design is followed in this study. There are 80 respondent were selected from public hospitals of the Sylhet city. Data was collected by self-developing instrument. Result: The study found that the knowledge of nurses was satisfactory mean 3.98 out of 5 but main concern point was nurses have low knowledge about read article Conclusion: High maternal and neonatal mortality rate is the burning issue for Bangladesh and it is due to unskilled attendants, low status of women, poor quality of health services during antenatal and post natal period. Nurses have important role in providing quality of health care to the pregnant women .To improve the quality of care it is important to improve knowledge and practice of the nurses on specific issue. They also need training and job motivation for improving their skill.

Background: Osteoporosis is a disease that weakens bones to the point where they break easily—most often, bones in the hip, backbone (spine), and wrist. Osteoporosis is called a “silent disease. This study was undertaken with the objective to assess the knowledge about risk and preventive factors for osteoporosis among Ortho OPD patients in civil hospital Rohru. Material & Methods: This cross sectional study was conducted between Aug- December 2020  among Ortho OPD patients in civil hospital Rohru selected by  convenience  Sampling Technique.Information regarding their socio-demographic characteristics and knowledge, regarding risk and  preventive factors for osteoporosis were obtained using a self-administered, pre-tested, semi-structured questionnaire. Data was analyzed using Epi info v7 software using appropriate statistical tests. Results: In the present study, 35% (140) of the Patients fall were below 40 years of age while 65% (260) were above 40 years.  54% (216) of patients were male and 46% (184) were female. Among the total patients, 182(45.5%) didn’t know about any risk factor of osteoporosis. 180 (45%) respondents told that Inadequate amounts of dietary calcium is the risk factor of osteoporosis followed by , Lack of physical activity by 176(44%) and low vitamin D intake by 167(41.75%). Maximum patients 184(46%) told that  Eating calcium-rich foods help in preventing osteoporosis followed by Calcium and Vitamin D supplements by 167 (41.75%), and Enough vitamin D through sunlight by 154(38.5%). Also in the present study, 182(45.5%) patients didn’t know about the preventive factors of osteoporosis. Conclusion: Still almost half of the respondents didn’t know about the risk as well as preventive factors of osteoporosis. Eating calcium-rich foods, healthily and balanced diet, Calcium and Vitamin D supplements and getting enough vitamin D through sunlight helps in prevention of osteoporosis.

Background: Diarrhea disease is one of the commonest causes of morbidity and mortality among under 5 children around the world. The disease stems from a multi factorial etiology, some of which include; exposure to poor environmental, socio-demographic and behavioral factors. Objective: To evaluate the risk factors associated with diarrhea disease among under 5 children presenting at Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria. Methods: This was a case-control study carried out with 70 case study population of children that had diarrhea disease and 70 control group of children who did not have diarrhea disease. The study was carried out using interviewer-administered questionnaires to access and collect data from the mothers/ caregivers of these under 5 children. Result: At a confidence interval of 0.32-0.56, there were statistically significant relationships between diarrhea disease and some risk factors as follows- poor hygiene practices increased diarrhea diseases among them four folds (x 2 =6.987; p=0,001;0R=4.0), poor maternal education (illiteracy) brought about threefold increase in the disease (x=7.194, p=0.001, OR=3.00). Others were wealth index (poverty) (x2=9.317, p=0.002, OR=2.0), poor sanitation practices (poor sanitation) (x2=7.406, P=0.00, OR=2.0) level of cleanness of water used by and for the child (x2=7.125; P=0.002; OR=2). Breastfeeding and water chlorination were protective for diarrhea disease (OR=0.6, P=0.002) and (OR=0.001; P=0.001) respectively. Conclusion: Poor hygiene practice is the strongest risk factor associated with diarrhea disease, followed by maternal educational level, family wealth index; poor sanitation practice and cleanness of the water used by and for the under 5 children. Adequate prevention targeting these factors will hopefully reduce the incidence of diarrhea disease among the under 5 children.

Central retinal vein occlusion (CRVO) is one of the major causes of severe vision impairment and blindness. The prevalence of retinal artery or vein occlusion in the general population increases with age. ADPKD patients are at risk for developing central retinal vascular occlusions at a younger age. Here we report a case of ADPKD with central retinal vein occlusion.

Background: Scrub typhus is endemic and documented zoonotic disease in the state of Himachal Pradesh as the climatic and geographical conditions are conducive for spread of vector of this disease. This study was done to study the Climate and Environmental factors associated with new diagnosed cases of scrub typhus and risk factors in paediatric population. Material & Methods: This cross-sectional Sero-Epidemiological study was conducted in the department of Paediatrics and Microbiology, Indira Gandhi Medical College, Shimla from 1^st June 2017   to   30^th Nov 2018. The study participants were newly diagnosed paediatric scrub typus cases(n-102) and data was analysed using Epi info7 software using appropriate statistical tests. Results: Majority 45 (44.1%) of cases were diagnosed in the month of September, followed by 35(34.3%) in the month of October, 12(11.8%) in the month of August and only 4(3.9%) in the month of November with decreasing trend corresponding to the onset of winters as Only 6 (5.9%) cases were found in rest of the months. Majority of scrub typhus cases 86(84.3%) were reported from humid subtropical climate in this study. 51(50%) Scrub Typhus cases were reported from altitude range below 1500 metre in this study. 75.5% (77) Cases were reported from climate zone with annual rainfall below 1500mm/yr. Majority of scrub typhus cases 38(37.3%%) were recorded from the areas with average temperature >20 degree centigrade. Conclusion: To determine the climatic risk factors for scrub typhus there is an urgent need of well-designed multi-centric study to elaborate on the decadal change in the climate, temperature, rainfall and humidity.

Heart rate variability is one of the markers of autonomic functions. Heart rate variability is being studied extensively now because of the increasing incidence of cardiac deaths throughout the world. Objective: To study the effect of both fast and slow tempo music on heart rate variability. Methodology: This study was conducted on 24 subjects. ECG in lead II position was recorded after ten minutes of rest after which subjects were exposed to either fast or slow tempo music for 5 minutes each and HRV was recorded following that. The frequency domain parameters were taken for the analysis and the results were analysed using SPSS. Results: It was observed that LF which is a marker of sympathetic activity increased after heavy music and HF which is a marker of parasympathetic activity decreased after heavy music and increased after light music as compared to resting parameters. Conclusion: Music has an effect on the heart rate variability parameters and light music has a relaxing effect and hence light music can be used for stress management.

Background: Secondary chronic open angle glaucoma associ1ated with PEX or pseudoexfoliative glaucoma (PEXG) accounts for approximately 25% of all glaucoma and represents the most common identifiable cause of glaucoma. The aim of this study was to compare the corneal endothelial morphology and hexagonal cell ratio percentage between eyes having PEX without glaucomatous changes in comparison with patients suffering from pseudo exfoliative syndrome with glaucoma. Methodology: The present cross-sectional analytical study was conducted in the Department of Ophthalmology, Indira Gandhi Medical College, Shimla among the selected patients of pseudo exfoliation with glaucoma from July 2018 through June 2019 i.e. one year. The morphometric properties were measured by using non-contact specular microscopy (Topcon SP-1P Version 1.41) P value <0.05 was considered to be statistically significant. Results: Mean Endothelialcell Density (ECD) respectively in PEX and PEXG was 2586.33±505.156 cells/mm² and 2248.50±479.91 cells/mm²(p<0.001) whereas the Mean Hexagonal Ratio (HR) was found to be 29.74±9.15% and 32.41±16.44% respectively (p=0.499). Conclusion: This research shows that in eyes with PEX syndrome, both with and without glaucoma, ECD was statistically significantly lower than in the PEX with glaucoma, which may increase the risk of corneal decompensation after intraocular surgeries.

Derangements in blood lipids Have always been strongly associated with cardiovascular disorders. The aim of our study was to measure the arterial blood pressure and evaluate the lipid profile For the purpose of predicting the risk of cardiovascular diseases in Abak, Southern Nigeria. A cross sectional study was conducted involving 710 randomly selected subjects, 367 with elevated blood pressure and 343 with normal blood pressure, attending free medical outreaches Study was carried out in Abak between March to December 2019. The study population was stratified in three different age groups; young adults (18-40 years), middle aged (41-60 years) and elderly (>60 years). Blood pressures, total cholesterol, triglycerides, low density lipoproteins and high density lipoproteins were measured using standard procedures. The results showed that the mean systolic and diastolic blood pressures of normotensive subjects were 124.45 ± 3.03 mmHg and 78.44±4.21 mmHg respectively. The mean serum lipid profiles of normotensives in mg/dl were 189.44±7.36, 149.73±7.16, 75.26±6.50 and 84.15±5.50 for Total Cholesterol, Triglycerides, HDL-Cholesterol and LDL-Cholesterol respectively. The mean systolic and diastolic blood pressures of hypertensive subjects were 162.67±5.01 mmHg and 96.33±3.27 mmHg respectively. The serum lipid profiles of hypertensives in mg/dl were 216.32±29.97, 238.27±29.92, 39.55±2.01, 155.60±21.91, for Total Cholesterol, Triglycerides, HDL-Cholesterol and LDL-Cholesterol respectively. We concluded that whereas there was no derangement in the serum lipid profile of normotensives evaluated, while most hypertensive persons had some coexisting dyslipidaemias, which predicted varying degree of cardiovascular and cerebrovascular complications among hypertensives the population.

With interest we read the article by Chen about a 52yo female with diabetes and end-stage renal disease (ESRD), requiring hemodialysis, who experienced sudden onset fever, delir, elevated lactate, and epilepsy being initially diagnosed as herpes simplex encephalitis (HSE) [1]. Surprisingly, work up for lactic acidosis revealed mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome due to the variant m.3243A>G [1]. The study has a number of shortcomings. 

The first shortcoming is that no heteroplasmy rates in any affected or non-affected tissue were provided. Knowing heteroplasmy rates is crucial for interpreting the phenotype, for predicting the further disease trajectory and the outcome of this patient, and for genetic counselling [2]. 

The second shortcoming is that first degree relatives were not systematically investigated for clinical manifestations of a mitochondrial disorder (MID) and for the presence or absence of the m.3243A>G variant. Knowing the phenotype and genetic background of first degree relatives is crucial for assessing the intrafamilial phenotypic heterogeneity, for assessing the variability of heteroplasmy rates within a family, and for genetic counselling [3].

Third, the patient received valproic acid (VPA) despite the diagnosis MELAS. From VPA it is well known that it is potentially mitochondrion-toxic [4]. In patients carrying POLG1 variants even fatalities from acute liver failure have been reported [5]. After recording periodic lateralised epileptiform discharges (PLEDS) [1], VPA was replaced by levetiracetam (LEV), upon which EEG abnormalities disappeared completely [1]. Improvement of the EEG activity upon discontinuation of VPA suggests that VPA exhibited indeed a mitochondrion-toxic effect.

A fourth shortcoming is that it was not discussed if progression and deterioration of the phenotype had been favoured by the long-term use of sirolimus or tacrolimus. From sirolimus it is well known that it can be muscle toxic and may go along with myopathy [6]. From tacrolimus it is well known that it may cause mitochondrial dysfunction and apoptosis [7], which can be improved by application of antioxidants [8]. Since transplantation entails immunosuppression, and since immunosuppression is potentially mitochondrion-toxic, transplantation in MID patients must be considered carefully. 

A fifth shortcoming is that no reference limits for the reported figures were provided, why interpretation of the results remains vague. 

A sixth shortcoming is that the patient did not receive nitric-oxide (NO) precursors for the first stroke-like lesion (SLL). It is conceivable that application of NO-precursors after the first SLL in a left lateral temporal distribution, might have prevented the development of the second SLL. Oral NO-precursors have been shown beneficial even for preventing the recurrence of a SLL [9]. 

We do not agree that the patient had a late-onset MELAS syndrome [1]. Since the patient had short stature since early childhood, experienced renal dysfunction at young age, and hypoacusis since age 35y [1], the index patient manifested with MELAS much earlier than anticipated. Patients of short stature should generally raise the suspicion of a MID, since growth hormone deficiency is a frequent feature of MIDs,

HSE should be delineated from a SLL in MELAS not only by application of imaging studies but rather by investigations of the CSF. CSF investigations most likely can differentiate these two entities. We do not agree that patients with suspected HSE and MELAS should receive antiviral medication until MELAS is excluded. Even anti-viral agents can be mitochondrion-toxic [10]. 

We do not agree with the notion that progression of the SLL is “unique” as mentioned in the discussion [1]. On the contrary, spreading and regression are typical features of a SLL. Missing in table 1 are the lactate levels.

Overall, this interesting case report has a number of shortcomings which need to be addressed before drawing conclusions as those provided. Immunosuppressants as well as antiviral agents should be applied with caution in MID patients. 

Background: Worldwide, diarrhea is the record leading cause of deaths in children, with rotavirus being the most common diarrheal pathogen irrespective of the country’s level of development. It’s recognized that hospitalization for Rotavirus Gastroenteritis (RV GE) represents the severe end of the spectrum of the disease, for that, the vaccine trial was introduced in our country. Our main objective was to study the impact of the vaccination program for Rotavirus (RV) on disease burden among the Lebanese infants and children under 5 years of age who have been diagnosed with acute gastroenteritis from 2016 to 2017. In addition to estimating the effectiveness of both included vaccines in our country. Methods: This was a retrospective database study between years 2016-2017, wherein data on infants and children younger than 5 years who have been diagnosed with acute Gastroenteritis (GE), has been collected from the electronic admission database or other records from the participating hospitals. Results: In Lebanon, the rate of hospitalized patients with RV GE was found around 31.9% during 2016-2017. Overall, 30.4% were vaccinated against RV among hospitalized children for all GE. Therefore, vaccination against RV was associated with reduction of the incidence of disease, as well as the clinical severity and number of hospitalizations among immunized patients compared to those non-immunized. Same effectiveness was found between the 2 types of vaccines. Conclusion: The findings of our study confirm the positive impact of RV vaccines on the control of RV diarrheal disease in Lebanon and the reduction of the disease burden upon introduction of the RV vaccine into the routine immunization schedule in children. This result suggests that maximizing vaccine coverage may lead to further reductions in GE RV mortality and hospitalizations.

With interest we read the article by Baccarella et al. about two children with multisystem inflammatory syndrome (MIS) due to an infection with SARS-CoV-2, clinically manifesting with increased intra-cranial pressure (ICP) and as right sixth cranial nerve palsy and headache (patient-1), respectively as right sixth nerve palsy and papilledema (patient-2) [1]. Clinical manifestations resolved upon a spinal tap and application of the MIS-C protocol (steroids, intravenous immunoglobulins (IVIG), tocilizumab) (patient-1) and upon application of solely the MIS-C protocol (patient-2) [1]. We have the following comments and concerns.

We do not agree that patient-2 had an increased ICP [1]. The opening pressure on spinal tap was 14cm H₂O and there were no indirect signs of increased ICP on cerebral magnetic resonance imaging (MRI), suggesting that the ICP was normal. The speculation that the ICP was increased during the initial hospitalisation for COVID-19 is also unsupported. Thus, the title of the article is inappropriate. 

A further shortcoming is that there is no discussion about the discrepancy between normal ICP and papilledema in patient-2. An explanation should be provided for these discordant findings and it should be acknowledged that such a discrepancy is not unusual and has been previously reported [2]. Causes of papilledema in the absence of increased ICP, such as optic neuritis, anterior ischemic optic neuropathy (AION), compressive optic neuropathy, papillophlebitis, or neuroretinitis should be discussed. We should be informed about the neuro-ophthalmologic investigations of both patients. 
 

It is unclear why patient-2 received intravenous immunoglobulins (IVIG) and steroids during his first hospitalisation. We should be informed about the indication for these compounds. Additionally, all other drugs given to both patients during hospitalisation should be detailed. Since IVIG carry the risk of headache, thrombosis and aseptic meningitis as adverse reactions [3], it is conceivable that at least in patient-2 thrombosis of intracerebral veins could have been responsible for papilledema. 

Missing is how MIS was diagnosed in the two presented patients. Though it is mentioned that the diagnosis was established according to the Centers for Disease Control and Prevention diagnostic criteria [4], it remains unclear which criteria the two patients particularly met.

Though brain MRI was described as normal in both patients [1], we should be informed which modalities were applied, particularly if diffusion weighted imaging (DWI), apparent diffusion coefficient (ADC) maps, and susceptibility weighted imaging (SWI) were normal. 

Patient-1 was described with recovered heart function after lumbar puncture and application of the institutional MIS-C protocol, suggesting that the patient had reduced systolic function or heart failure on admission [1]. We should know the explanation for heart failure/systolic dysfunction, if the patient received specific treatment for it, and in case he did not receive specific treatment how to explain spontaneous recovery of heart function. Is it conceivable that the patient had experienced Takotsubo syndrome (TTS) triggered by headache, as has been previously reported as a trigger of TTS [5]. 

Both patients had double vision but it is not reported if the bulbs were in a concordant position and if double vision occurred in all bulb positions or only when looking into a certain direction. Supposing that diplopia occurred in all positions, all differentials of diplopia should be considered. 

The reported 6^th cranial nerve palsy in both patients may not only be due to increased ICP but could be also due to infectious neuropathy, retrograde invasion of the nerve by the virus, or cranial nerve involvement in Guillain Barre syndrome, increasingly recognised as a manifestation of COVID-19.

Overall, the study has several limitations, as outlined above, which should be met before drawing final conclusions.

Neurocysticercosis, the infection caused by the larval form of the tapeworm Taenia solium, is the most common parasitic disease of the central nervous system and the most common cause of acquired epilepsy worldwide. Visual loss in NCC is a serious consequence and can result either from direct ocular involvement or secondary to CNS involvement. Here we report a case of neurocysticercosis with bilateral papilledema.