Electroencephalographic and imaging profile in a subacute sclerosing panencephalitis (SSPE) cohort: a correlative study.

OBJECTIVE: There are only a few studies correlating diverse radiological and EEG features of subacute sclerosing panencephalitis (SSPE). The objective of the study was to (a) describe EEG profile and (b) correlate it with the clinical and imaging data of patients with confirmed SSPE. METHODS: This study was conducted at a University teaching hospital in south India and involved 58 patients (M:F=37:21, age: 12.3, SD 4.8 years) of SSPE. Diagnosis of SSPE was based on the characteristic clinical manifestations, and raised IgG (1:625) anti-measles antibody in cerebrospinal fluid (CSF) by ELISA in all the patients. Scalp EEGs were recorded on 16 channel machines using standard parameters and procedures. The EEG, clinical and imaging data were reviewed. RESULTS: EEGs were frequently abnormal: typical (37) and atypical (21). Diffuse slowing of background activity (BGA) was noted in 46 records being asymmetrical in six. Periodic complexes were periodic (32), quasi-periodic (21) or a-periodic (4). Periodic complexes (PC) (amplitude: 370.7, SD 171.2 microV; duration - 1.7, SD 2.0 s; inter-complex interval: 8.4, SD 9.2s) were symmetrical in 39 and asymmetrical in 19. CT (32) and MRI (23) scans were normal in 16 patients while others had white matter (15), cerebral edema (8), cerebral atrophy (8), basal ganglia (2), and thalamic (2) changes. There was an independent association of frontally dominant slowing of BGA (p=0.04) and typical PCs (p=0.03) with the diffuse cerebral edema on imaging. White matter changes correlated with slowing of BGA (p=0.04), but not with typical PC (p=0.16). CONCLUSIONS: This study provides valuable insight into the structural and clinical correlates of EEG changes in SSPE. SIGNIFICANCE: Irrespective of the incidence of occurrence of SSPE in a community, a clinician should be aware of the wide spectra of EEG findings. This study also discusses the possible underlying structural and clinical correlates.     

Adenoid hypertrophy presenting with systemic hypertension

A two and half year old male child was seen with systemic hypertension, left ventricular dysfunction, mitral regurgitation and congestive cardiac failure. Examination revealed adenoid hypertrophy. He was also suffering from obstructive sleep apnea. He was being treated with anti-hypertensive and anti-failure drugs. Adenoidectomy was performed following which obstructive sleep apnea symptoms disappeared and his cardiac status improved markedly. Subsequently he was weaned off anti-hypertensive and anti-failure therapy.     

A clinical and microbiological study of puerperal sepsis in a tertiary care hospital in India

Objective: This prospective study was carried out to evaluate the clinical profile and bacterial isolates among women with puerperal sepsis in a tertiary hospital in North India.

Materials and methods: Women with puerperal sepsis (n?=?45) admitted from January 2015 to April 2016 were followed prospectively. Cultures were obtained from cervix, blood, urine, and pyoperitoneum. Initial antibiotics were cefotaxime or piperacillin with tazobactam plus amikacin plus clindamycin or metronidazole and were changed according to sensitivity.

Results: Out of 7887 deliveries during this period, 45 (0.2%) women had puerperal sepsis. 16 (35.5%) delivered in the present hospital, 25 (55.5%) at another health care facility, and 4 (8.9%) at home. Delivery was by cesarean section (CS) in 24/45 (53.3%) and vaginal in 21/45 (46.6%). Grade 1 sepsis occurred in 21, grade 2 in two, and grade 3 in 22 women. Majority (29/45 or 64.5%) had no risk factor for puerperal sepsis. There were two (4.4%) deaths and 13/45 (28.8%) had near-miss morbidity. Pathogenic bacteria were isolated in 33/45 (73.3%) in cervical swab (69%), blood, urine, or pus culture with no significant difference in the bacterial yield or species isolated between cotton or polyester swabs (p?>?.05). Escherichia coli were the commonest isolate and was sensitive to amikacin in all. Five had stillbirths and 4/40 neonates developed sepsis but recovered.

Conclusions: Escherichia coli was the commonest pathogen and was uniformly sensitive to amikacin, which may be included among the initial antibiotics to treat puerperal sepsis in India.     

Relative percentage signal intensity recovery of perfusion metrics—an efficient tool for differentiating grades of glioma

Objective:

Glioma classification and characterization may be facilitated by a multiparametric approach of perfusion metrics, which could not be achieved by conventional MRI alone. Our aim is to explore the potential of relative percentage signal intensity recovery (rPSR) values, in addition to relative cerebral blood volume (rCBV) and relative cerebral blood flow (rCBF) of first-pass T₂* dynamic susceptibility contrast (DSC) perfusion MRI, in differentiating high- and low-grade glioma.

Methods:

This prospective study included 39 patients with low-grade and 25 patients with high-grade glioma. rPSR, rCBV and rCBF were calculated from the first-pass T₂* DSC perfusion MRI. rPSR was calculated using standard software and validated with dedicated perfusion metrics analysis software. The statistical analysis was performed using analysis of variance and receiver operating characteristic (ROC) curves.

Results:

Variation in rPSR, rCBV and rCBF values between low- and high-grade gliomas were statistically significant (p < 0.005). The ROC curve analysis for each of them yielded 96% sensitivity and 71.8% specificity; 88% sensitivity and 69.2% specificity; and 72% sensitivity and 66.7% specificity. The area under the curve (AUC) from the ROC curve analysis yielded 0.893, 0.852 and 0.702 for rPSR, rCBV and rCBF, respectively. The rPSR calculation with the validation software yielded 92.3% sensitivity and 72% specificity with an AUC of 0.864.

Conclusion:

rPSR inversely correlates while rCBV and rCBF values directly correlate with the tumour grade. Furthermore, the overall diagnostic performance of rPSR is better than rCBV and rCBF values.

Advances in knowledge:

rPSR of T₂* DSC perfusion is an indicator of blood–brain barrier status and lesion leakiness, which has not been explored yet compared with the usual haemodynamic parameters, rCBV and rCBF.Gliomas, the most common primary brain tumour of the brain, are heterogeneous, showing highly varied histopathological features during malignant transformation of the tumour reflecting alterations in the tumour vasculature.¹ The broad category of glioma represents approximately 30% of all the tumours. Low-grade astrocytomas (60–70%) and oligodendrogliomas (10–30%) are two common subtypes of low-grade gliomas. Among them, glioblastoma and astrocytoma account for 75% of gliomas.² With the advent of advanced imaging technologies, heterogeneity in gliomas such as neovascularization, angiogenesis, loss of blood–brain barrier (BBB) integrity, tortuousness, disorganized and highly permeable vessels may be non-invasively measured with the help of perfusion imaging.^3–5 Dynamic susceptibility contrast (DSC) perfusion MRI is a widely accepted tool for evaluating the haemodynamic characteristics of the brain, which are of great interest since it helps in assessing the malignancy of the tumour. The common haemodynamic parameters assessed using perfusion MRI are relative cerebral blood volume (rCBV) and relative cerebral blood flow (rCBF).^6–8 In this study, we use a comparatively newer parameter, relative percentage signal intensity recovery (rPSR), whose potential has not been exploited to its best for haemodynamic calculations, even though this parameter has shown promise in the differentiation of brain tumours.^9–11 PSR is the percentage of the signal intensity recovered at the end of the first pass of the contrast agent with respect to the pre-contrast baseline signal intensity. After the administration of the contrast agent, there is a sudden decrease in the signal intensity owing to the variation in the local magnetic field leading to T₂* decay, which is seen as a dip in the mean signal intensity–time curve, and then the signal returns towards the baseline.^9–11The tumour rCBV provides information about the tumour blood levels and degree of angiogenesis but fails to provide information regarding capillary permeability. This drawback of DSC-MR perfusion imaging can be addressed by evaluating the rPSR obtained from the signal intensity–time curve formed at the end of the first pass of contrast agent in DSC-MR perfusion imaging.^9,10 Previous studies have observed that the contrast agent leakage, size of the extravascular space and the rate of blood flow that reflects the alterations in capillary permeability are related to rPSR.^10,11 There are reports which state that information regarding capillary permeability and lesion leakiness can be gathered from the signal intensity–time curve obtained from the first-pass T₂* DSC perfusion. Usually, this is performed using dynamic contrast-enhanced perfusion MRI, which involves additional scan time and also post-processing assumptions and extrapolations.^9–11Lupo et al⁴ was the first to report the characterization of high-grade gliomas using the PSR and peak height. rPSR is the only parameter among the different perfusion metrics which takes into account the leakage factor for the characterization of heterogeneity of brain tissues, compared with the other two parameters rCBV and rCBF where the leakage is neglected during the evaluation. The rPSR values of lower grade gliomas have not been explored, and hence an effort to differentiate between high- and low-grade gliomas using this new parameter will be advantageous. Hence, in the present study, we have evaluated all the parameters rPSR, rCBV and rCBF of low- and high-grade gliomas to find the potential of rPSR to differentiate different grades of glioma over the other two conventionally used parameters rCBV and rCBF. rPSR values were evaluated using two different standard software programs. Furthermore, we have performed a test for correlation between these parameters.     

Outcomes of junctional ectopic tachycardia ablation in adult population—a multicenter experience

Purpose

Idiopathic junctional ectopic tachycardia (JET) is typically refractory to antiarrhythmic agents. Catheter ablation for JET is feasible but is associated with high risk of unintended atrioventricular (AV) block. There is limited data on the appropriate procedural technique and clinical outcomes with catheter ablation for idiopathic JET in adults.

Methods

This is a multicenter, retrospective study of all adult patients (age?≥?18 years) who underwent catheter ablation for idiopathic JET. Patient, procedural characteristics, and long-term outcomes were evaluated.

Results

Fifteen patients [radiofrequency ablation (RF)?=?14 and cryoablation?=?1) were treated with catheter ablation. The median age was 58 years with 67% males. All patients underwent mapping of the right atrium and the aortic cusps prior to energy delivery. The location of earliest activation in relation to the atrioventricular (AV) node was postero-superior in 73% (11/15), posterior in 13% (2/15), and superior in 13% (2/15) respectively. Acute success was 100%. Arrhythmia recurrence occurred in 53% (8/15) all of whom underwent a repeat ablation. High-grade AV block requiring permanent pacemaker occurred in 20% (3/15). At 12-month follow-up in the redo-ablation group, 37.5% (3/8) had recurrence of the arrhythmia two of which underwent a third ablation procedure.

Conclusion

Catheter ablation of idiopathic JET in adults is associated with a high rate of recurrence requiring multiple procedures and high risk of AV block requiring a permanent pacemaker. Mapping and ablation of the non-coronary cusp can be considered as the arrhythmia was controlled in 3 patients with no inadvertent AV block.

     

Pregnancy associated spontaneous coronary artery dissection: A case report and review of literature

BACKGROUNDPregnancy-associated spontaneous coronary artery dissection (PSCAD) is an important cause of chest pain and acute myocardial infarction in pregnant and postpartum women. Pregnancy is considered an isolated risk factor for spontaneous coronary artery dissection. The etiology, pathogenesis, and incidence of PSCAD are not known.CASE SUMMARYWe present a case of a 33-year-old postpartum female who presented with sudden onset chest pain and was diagnosed with spontaneous coronary artery dissection and needed urgent catheterization revealing left anterior descending coronary artery dissection. She underwent emergent coronary artery bypass graft surgery with good post-operative recovery.CONCLUSIONMost patients with PSCAD can be managed conservatively with medical management and have good outcomes. Patients with high-risk presentations benefit from the invasive approach. Coronary artery bypass graft may be required in select few patients based on angiography findings. Due to the risk of recurrent spontaneous coronary artery dissection, subsequent pregnancies are discouraged.     

Indomethacin-induced mitochondrial dysfunction and oxidative stress in villus enterocytes

Nonsteroidal anti-inflammatory drugs (NSAIDs) are known to cause small intestinal damage but the pathogenesis of this toxicity is not well established. Intestinal epithelial cells are thought to be affected by these drugs in the course of their absorption. These cells are of different types, viz. villus, middle and crypt cells. There is little information on which of these cells, if any, are particularly vulnerable to the effects of NSAIDs. This paper aimed to study the effects of indomethacin, an NSAID commonly used in toxicity studies, on different populations of enterocytes. Effects of the drug were assessed in terms of oxidative damage, mitotic activity, mitochondrial function and lipid composition in enterocytes isolated from the small intestine of rats that had been orally administered indomethacin. In addition, the effects of arginine and zinc in protecting against such changes were assessed. Cell viability, tetrazolium dye (MTT) reduction and oxygen uptake were significantly reduced in villus tip cells from rats dosed with the drug. Thymidine uptake was higher in the crypt cell fraction from these rats. Similarly, products of lipid peroxidation were elevated in the villus tip cells with a corresponding decrease in the level of the anti-oxidant, alpha-tocopherol. In isolated mitochondrial preparations from various enterocyte fractions, significant functional impairment and altered lipid composition were seen mainly in mitochondria from villus cells. Arginine and zinc pre-treatment were found to protect against these effects. These results suggest for the first time that the villus tip cells are more vulnerable to the damaging effects of indomethacin and that oxidative stress is possibly involved in this damage.     

Renal relapse in bilateral synchronous testicular lymphoma

Bilateral synchronous testicular lymphoma is an uncommon presentation of non-Hodgkin's lymphoma. A young man with non-Hodgkin's lymphoma of both testes synchronously is described here. He underwent bilateral orchiectomy, received chemotherapy, and was in complete remission when there was a relapse in the kidneys. Salvage chemotherapy was given. The patient developed progression of the residual lesion subsequently and was started on palliation with chlorambucil and prednisolone. He was alive at 34 months after diagnosis with disease.     

Oral glutamine attenuates indomethacin-induced small intestinal damage

The use of NSAIDs (non-steroidal anti-inflammatory drugs), although of great therapeutic value clinically, is limited by their tendency to cause mucosal damage in the gastrointestinal tract. In the small intestine, the effects these drugs have been shown to produce include inhibition of cyclo-oxygenase, mitochondrial dysfunction and free radical-induced oxidative changes, all of which contribute to the mucosal damage seen. Glutamine is a fuel preferentially used by enterocytes and is known to contribute to maintaining the integrity of these cells. In the present study, we investigated the effect of glutamine on indomethacin-induced changes in the small intestinal mucosa. Rats were given 2% glutamine or glutamic acid or isonitrogenous amino acids, glycine or alanine, in the diet for 7 days. Indomethacin was then administered orally at a dose of 40 mg/kg of body weight. After 1 h, the small intestine was removed and used for the measurement of parameters of oxidative stress and mitochondrial and BBM (brush border membrane) function. Evidence of oxidative stress was found in the mucosa of the small intestine of drug-treated rats, as indicated by significantly increased activity of xanthine oxidase (P < 0.001) and myeloperoxidase (P < 0.001), with corresponding decreases in the levels of several free radical scavenging enzymes and alpha-tocopherol (P < 0.001 in all cases). Levels of products of peroxidation were also significantly elevated (P < 0.001 for all the parameters measured). In addition, oxidative stress was evident in isolated intestinal mitochondria and BBMs (P < 0.001 for all the parameters measured), with associated alterations in function of these organelles (P < 0.001 for all the parameters measured). Supplementation of the diet with glutamine or glutamic acid prior to treatment with indomethacin produced significant amelioration in all the effects produced by the drug in the small intestine (P < 0.001 for all the parameters measured). Glycine and alanine were found to be much less effective in these respects.