Hyperammonemic coma in a post-partum patient with undiagnosed urea cycle defect

Urea cycle disorders (UCD) are common during neonatal period, and it is rarely reported in adults. We are reporting a patient presenting with post-partum neuropsychiatric symptoms rapidly progressing to coma. Markedly raised serum ammonia level on presentation with an initial normal magnetic resonance imaging (MRI) of brain and normal liver function tests led to the suspicion of UCD, which was confirmed on the basis of urine orotic acid and elevated serum amino acid levels. We had to resort to hemodialysis to correct the hyperammonemic coma, which was unresponsive to conventional anti-ammonia measures. She exhibited remarkable improvement with a progressive decline in serum ammonia with repeated hemodialysis and made a full recovery. Timely diagnosis and early institution of hemodialysis in the setting of a poor neurological status maybe considered a suitable treatment option.     

Anatomical basis of antropyloric transposition for fecal incontinence in humans: the infrapyloric approach

Purpose

Antropylorus transposition in the perineum for end-stage anal incontinence has shown to be feasible in humans. Vascular anatomy of the antro-pyloro-duodenal area is critical in preventing complications and increasing pyloric graft survival. This study was undertaken to examine the vascular anatomy of antro-pyloro-duodenal area in an attempt to safeguard the graft blood supply and improve its survival.

Methods

After obtaining preoperative CT angiography to delineate the infrapyloric artery (IP a.), bench dissection of resected pancreaticoduodenectomy specimens was performed in 12 patients. Ex vivo angiography of these specimens were also performed. Subsequent to the information obtained from these dissections, the method of antropylorus mobilization during transposition was modified in terms of the site of division of the right gastroepiploic a. (Rt GEA). Perioperative outcomes (graft related complications, fecal incontinence scores, Doppler flow studies, and manometry studies of the graft) were compared between the two groups.

Results

IP a. originated only from the Rt GEA in 8 cases (66 %) and from both the gastroduodenal a. and the Rt GEA in the rest. However, its origin solely from the gastroduodenal a. was not observed. The pyloric graft survival, pyloric valve pressures and Doppler flow velocities were significantly (p < 0.05) better when the infrapyloric a. was preserved following this refinement. However, no immediate significant difference in incontinence scores was observed.

Conclusions

Careful preservation of the pyloric valve vascularity by preserving the IP a. by dividing the Rt GEA at its origin increases vascularity, survival and contractility of the pyloric graft in perineum.     

Long-term sequelae of herpes simplex virus encephalitis–related white matter injury: correlation of neuropsychological outcome and diffusion tensor imaging

Journal of NeuroVirology - The pathophysiology of the memory impairment following Herpes Simplex virus encephalitis is not yet established and understood. This study attempts to elucidate the role...     

Ovicidal, repellent, adulticidal and field evaluations of plant extract against dengue, malaria and filarial vectors

Mosquitoes are insect vectors responsible for the transmission of parasitic and viral infections to millions of people worldwide, with substantial morbidity and mortality. Infections transmitted by mosquitoes include malaria, yellow fever, chikungunya, filariasis and other arboviruses. Insecticides of botanical origin may serve as suitable alternative biocontrol techniques in the future. The adulticidal activities of crude hexane, benzene, ethyl acetate, acetone and methanol leaf extracts of Acalypha alnifolia were assayed for their toxicity against three important vector mosquitoes, viz., Aedes aegypti, Anopheles stephensi and Culex quinquefasciatus. The adult mortality was observed after 24 h of exposure. All extracts showed moderate adulticide effects; however, the highest adult mortality was found in methanol extract were observed. The LC₅₀ values of A. alnifolia leaf extracts against adulticidal activity of (hexane, benzene, ethyl acetate, acetone and methanol) A. aegypti, A. stephensi and C. quinquefasciatus were the following: A. aegypti values were 371.87, 342.97, 320.17, 300.86 and 279.75 ppm; A. stephensi values were 358.35, 336.64, 306.10, 293.01 and 274.76 ppm; C. quinquefasciatus values were 383.59, 354.13, 327.74, 314.33 and 291.71 ppm. The results of the repellent activity of hexane, benzene, ethyl acetate, acetone and methanol extract of A. alnifolia plant at three different concentrations of 1.0, 3.0, and 5.0 mg/cm² were applied on skin of forearm in man and exposed against adult female mosquitoes. In this observation, this plant crude extracts gave protection against mosquito bites without any allergic reaction to the test person, and also, the repellent activity is dependent on the strength of the plant extracts. Mean percent hatchability of the ovicidal activity was observed 48 h post-treatment. The percent hatchability was inversely proportional to the concentration of extract and directly proportional to the eggs. Mortality of 100 % with methanol extract of A. alnifolia was exerted at 125 and 300 ppm. The larval density was decreased after the treatment of plant extracts at the breeding sites (water bodies system) of vector mosquitoes, and hence, these plant extracts are suitable alternatives of synthetic insecticides for mosquito vector management.These results suggest that the leaf solvent plant extracts have the potential to be used as an ideal eco-friendly approach for the control of mosquitoes. This study provides first report on the mosquito ovicidal, repellent and adulticidal activities of these plant extracts against mosquito vector species from India.     

Unpleasant Subjective Emotional Experiencing of Pain

The field of pain medicine that once began as a supportive and compassionate care, adding value to the management of acute and chronic ailments, has now transformed into a vital and essential specialty with structured training programs and service units with professionals dedicating their careers to it. The expansion of understanding of the direct relationship of pain relief to the quality of life, uncovering of neuronal pathways, and technological advances in imaging as well as in interventional techniques have all contributed to this phenomenal growth. However, there is a growing concern whether the training programs and the specialized practitioners are gradually limiting their skilled inputs primarily within the sensory realm of the pain experience with sophisticated interventional techniques and relegating its subjective and emotional dimensions to perfunctory realms within the schema of service provision. While the specialty is still young, if we can understand the inherent aspect of these dimensions within the pain experience and acknowledge the gaps in service provision, it may be possible to champion development of truly comprehensive pain relief programs that responds effectively and ethically to a patient''s felt needs. This article attempts to position the subjectivity of pain experience in context and surface the need to design complete systems of pain relief services inclusive of this dimension. It presents authors’ review of literature on perspectives of ‘unpleasant subjective emotional experiencing of the pain” to elucidate possible clinical implications based on the evidences presented on neuro-biology and neuro-psychology of the pain experience; the aim being to inspire systems of care where this dimension is sufficiently evaluated and managed.     

Mechanism-based Classification and Physical Therapy Management of Persons with Cancer Pain: A Prospective Case Series

Context:

Mechanism-based classification (MBC) was established with current evidence and physical therapy (PT) management methods for both cancer and for noncancer pain.

Aims:

This study aims to describe the efficacy of MBC-based PT in persons with primary complaints of cancer pain.

Settings and Design:

A prospective case series of patients who attended the physiotherapy department of a multispecialty university-affiliated teaching hospital.

Material and Methods:

A total of 24 adults (18 female, 6 male) aged 47.5 ± 10.6 years, with primary diagnosis of heterogeneous group of cancer, chief complaints of chronic disabling pain were included in the study on their consent for participation The patients were evaluated and classified on the basis of five predominant mechanisms for pain. Physical therapy interventions were recommended based on mechanisms identified and home program was prescribed with a patient log to ensure compliance. Treatments were given in five consecutive weekly sessions for five weeks each of 30 min duration.

Statistical Analysis Used:

Pre–post comparisons for pain severity (PS) and pain interference (PI) subscales of Brief pain inventory-Cancer pain (BPI-CP) and, European organization for research and treatment in cancer-quality of life questionnaire (EORTC-QLQ-C30) were done using Wilcoxon signed-rank test at 95% confidence interval using SPSS for Windows version 16.0 (SPSS Inc, Chicago, IL).

Results:

There were statistically significant (P < 0.05) reduction in pain severity, pain interference and total BPI-CP scores, and the EORTC-QLQ-C30.

Conclusion:

MBC-PT was effective for improving BPI-CP and EORTC-QLQ-C30 scores in people with cancer pain.     

Acyldepsipeptide activated ClpP1P2 macromolecule of Leptospira,an ideal Achilles’ heel to hamper the cell survival and deregulate ClpP proteolytic activity

Antibiotic acyldepsipeptide (ADEP) targets the bacterial ClpP serine protease and can inhibit the growth of numerous bacterial species by activating/dysregulating the protease activity within the cell. The spirochete Leptospira interrogans harbors two ClpP isoforms (LepClpP1 and LepClpP2). Supplementation of ADEP in the Leptospira growth medium resulted in the inhibition of bacterial growth. The ADEP mediated activation of the LepClpP mixture was dependent on the time allowed for the self-assembly of LepClpP1 and LepClpP2. The dynamic light scattering of the LepClpP mixture in the presence of the ADEP indicated a conformational transformation of the LepClpP machinery. Serine 98, a catalytic triad residue of the LepClpP1 in the LepClpP1P2 heterocomplex, was critical for the ADEP mediated activation. The computational prototype of the LepClpP1P2 structure suggested that the hydrophobic pockets wherein the ADEPs or the physiological chaperone ClpX predominantly dock are exclusively present in the LepClpP2 heptamer. Using the ADEP as a tool, this investigation provides an insight into the molecular function of the LepClpP1P2 in a coalition with its ATPase chaperone LepClpX. The shreds of the evidence illustrated in this investigation verify that ADEP1 possesses the ability to control the LepClpP system in an unconventional approach than the other organisms.     

Acute Flaccid Quadriparesis in a Recovering COVID-19 Patient: A Clinical Dilemma

How to cite this article: Sabharwal P, Chakraborty S, Tyagi N, Kumar A. Acute Flaccid Quadriparesis in a Recovering COVID-19 Patient: A Clinical Dilemma. Indian J Crit Care Med 2021;25(2):238–239.