Brivaracetam Intravenous Formulation in Epilepsy Management in India : A Position Statement

Brivaracetam (BRV), a propyl analog of levetiracetam, has been shown to be safe and effective in Indian patients with uncontrolled focal epilepsy. A series of advisory board meetings involving pediatricians, neurologists, and physicians were held across India to evaluate the role of IV BRV in India and formulate a position statement. The panelists opined that the potential role of BRV in the acute management of increased seizure activity, especially status epilepticus, should be explored in the Indian context. Further, there is a dearth of Indian studies on the use of BRV in epilepsy patients aged below 16 years. IV BRV holds great potential to be the therapy of choice in epilepsy management owing to the fast mode of action and lesser risk of adverse effects.

A rare cause of gastric outlet obstruction

Gastric outlet obstruction is the clinical and pathophysiological consequence of any disease process that produces mechanical impediment to gastric emptying. It may be acute from inflammatory swelling and peristaltic dysfunction or chronic from cicatrix. Chronic inflammation of the duodenum may lead to recurrent episodes of healing followed by repair and scarring ultimately leading to fibrosis and stenosis of the duodenal lumen. We would like to present a unique case of an elderly lady presenting with intractable vomiting over 3 months, gradually progressive which aggravated on consuming solids initially to consuming liquids later. After thorough investigations a provisional diagnosis of chronic duodenal ulcer with gastric outlet obstruction probably due to cicatrix was made. On laparotomy there was a chronic scarred duodenal ulcer following a previously contained perforation which was causing the gastric outlet obstruction. Cholecystectomy, duodenoplasty and loop gastrojejunostomy was performed with no complications post-operatively. This is a rare case of previous contained duodenal perforation causing gastric outlet obstruction.

Retracted: When a giant ovarian cyst poses a diagnostic dilemma

The article " When a giant ovarian cyst poses a diagnostic dilemma" is retracted by the Editor-in-Chief, on the request of corresponding author and co-authors. The corresponding author informed that the patient described in this article, although willingly gave her consent for revealing her clinical data for publication, later withdrew her consent after knowing about the publication of clinical material during she came for a follow up visit.

Trends of suicidal hanging in Western Mumbai region

Background: The present study was conducted with aims to determine various epidemiological factors of death due to hanging in the western Mumbai region and variation in types of hanging deaths.Methods: Four year study conducted at H. B. T. Medical College & cooper Hospital, Mumbai for period of January 2015 to December 2018. During study period total 6338 of medico-legal autopsies were conducted, of which 228 (3.59%) autopsies were of death due to hanging.Results: T228 out of 6338 medicolegal autopsies were of death due to hanging making incidence rate 3.59 % of hanging. Age group most commonly involved in hanging was 21-30 years constitutes 41.22% cases of hanging deaths. Male victims constitute of 59.64% cases and female victims were 40.36% cases. In 96.5% cases place of hanging was closed place inside room 3.5% cases hangings takes place in open place. Most common ligature material used for hanging was dupatta/odani constitute 46.5% cases followed by rope in 20.17% cases.Conclusions: Young age group population between 21-40 years are more susceptible victims of suicides by hanging constitute 65.78% cases. Proper parental and social guidance and support could prevent suicides in this age group. Timely counselling of such vulnerable group victims could preventable. Effective prevention strategies are needed to promote awareness of prevention of suicides in young age group.

Morphometric analysis of the mandibular ramus and its clinical and medicolegal significance

Background: During natural calamities entire skeleton of single person could not be found. In such case, determination of sex with fragments of the bone available required range of data with proven accuracy. Hence this study is aimed at to provide range of data for minimum number of parameters of the ramus of the mandible.Methods: Three hundred dry mandibles of known sexes and bearing all teeth or intact alveolar margin were included in the study. Vertical height; maximum and minimum breadths of the ramus of the mandible were measured. All the data were analyzed for significance of the occurrence in relation to sex and laterality by means of paired t-test.Results: On the basis of all the three parameters together, we got 95% accuracy in determination of sex. Statistically significant differences were found in all parameters between male and female mandibles. The laterality distributions for all the parameters were found to be insignificant.Conclusions: Accurate determination of sex from the available bone fragments such as the ramus of the mandible required wide number of data from the least parameters that could be utilized medicolegally.

Study Of Pattern Of Distribution Of Mylohyoid Bridging And Their Clinical Implications

Background: The occurrence of mylohyoid bridges in mandible resulting compression of inferior alveolar andmylohyoid nerves, and vessels, is important cause of neuropathy in this region.Aim and objective: The present study was aimed at analyzing influence of sex and laterality in the occurrence ofmylohyoid bridging in Indian population, and establishing a clue to the underlying causes of paraesthesia ofidiopathic origin, in the territory of inferior alveolar and mylohyoid nerves.Methods: We studied 300 human mandibles (141 female and 159 male) for location and degree of mylohyoidbridging.Results: We found mylohyoid bridges in 15.66% mandibles. The proximal bridging was found more frequentlythan the distal bridging. The mylohyoid bridges were found in 7.8% female and 13.2% in male mandibles studied.We found mylohyoid bridges on 5% on right side and 5.66% on the left side, bilateral bridging was found in 5.33%mandibles.Conclusion: The frequency of occurrence of mylohyoid bridging was higher in male; however, laterality was not tobe significant amongst the mandibles studied. The location and degree of mylohyoid bridging are one of theimportant etiological factors of paraesthesia in the region of inferior alveolar and mylohyoid nerves distribution.

Anterior Wall Myocardial Infarction With Conduction Defect And It's Outcome During Hospital Stay

Background: Qrbb myocardial infarction has high mortality and morbidity. So we want to study in hospital outcome of qrbbb myocardial infarction Methods: It is a prospective study. We studied qrbbb mi patients admitted in our hospital from December 2016 to June 2017 Results: About 90% of patients had heart failure. And 80% of patients required ventilatory support in the form of non–invasive positive pressure ventilation (NIPPV) or invasive ventilation. About 37% of patients had ventricular arrhythmias. Thrombolysis with streptokinase was done in 64% of patients and with tenecteplase for 20% of the patients. Percutaneous transluminal coronary angioplasty (PTCA) was done in 47% patients. Two patients had pharmacoinvasive PTCA. 16% of patients were conservatively treated due to late presentation. 24% patients died during hospital stay while 76% got discharged. 14% of patients had reversal of rbbb wave. 14% had stent thrombosis. 100% of patients had left anterior descending artery (LAD) disease. While 10% had left main coronary artery disease and 14% had triple vessel disease (TVD), 10% were sent for coronary artery bypass grafting (CABG). Conclusions: qRBBB AWMI carries high mortality of 24% with 90% of patients going in to heart failure. Ejection fraction is a good predictor of death and diabetes is a covariate of predictor of death.

Clinical relevance of morphological variations in origin and insertion of lumbricals of hand in South Gujarat population.

Background & objectives: Lumbrical muscles, though small in size, have a significantly greater role to play in the intricate movements of the fingers.The great functional significance and morphological variations of lumbrical muscles as described in the literature, prompted us to undertake a detailed study of these muscles to know more about it and its significant value in the design of surgical procedures. Methods: We dissected lumbricals of hands of 40 human adult cadavers which were available from the Department of Anatomy. In the present study, variation in origin (include architecture), insertion (include split insertions, misplaced insertions or absence of muscles), the lengths of muscle belly and tendon of all lumbricals were studied and noted. Results: We found variations were more common on the right side. The second lumbrical was bipennate in 12.5% cases. The third lumbrical showed split insertion in 15% cases. The fourth lumbrical showed misplaced insertion in 10% cases. The proximal attachment of lumbricals can extend into the carpal tunnel (specially first and second) in 15% cases. Conclusion: The study provides valuable information to surgeons thus avoiding complications from local anesthetic, surgical and other invasive procedures.

How can we prevent birth of fetus with holoprosencephaly? anatomical and embryological aspects of holoprosencephaly.

Objectives: Holoprosencephaly is a rare condition characterized by different degrees of fused ventricles of the brain resulting from impaired midline cleavage of the embryonic forebrain. The present study aimed to identify cases of holoprosencephaly over a period of three years, to assess the incidence of this malformation, and if possible, prevention of birth of such malformed fetus or infant through genetic counseling. Methods: Diverse features of holoprosencephalic fetus or infant and incidence of holoprosencephaly were studied at GSL Medical College, Rajahmundry; Andhra Pradesh. Results: Incidence found for holoprosencephaly is 2.58 per 10,000 births. Out of total four cases of holoprosencephaly two cases were of alobar and there was each case of semilobar and lobar holoprosencephaly. In two cases there was association between holoprosencephaly and gestational diabetes and in another two cases; there was a familial distribution of holoprosencephaly. Conclusion: Prenatal diagnosis of this rare disorder and genetic counseling has immense importance to prevent holoprosencephaly.

Anatomical variations in formation and branching pattern of the femoral nerve in iliac fossa: A study in 64 human lumbar plexuses.

Femoral nerve is used for nerve block in several surgeries and is vulnerable to compression in tight ilio-psoas compartment. The knowledge of origin and variations of femoral nerve in iliac fossa is important for anatomists, anesthetists and surgeons to prevent iatrogenic femoral nerve palsy. We dissected 32 human cadavers to study the anatomy of the femoral nerve. We dissected the lumbar plexus bilaterally; dissected the psoas major muscle to see formation of the femoral nerve. We measured the length of the femoral nerve from its formation to inguinal ligament; and recorded variations of the femoral nerve with digital photography. The average length of the femoral nerve was 144 mm. Anatomical variations of the femoral nerve were found in 25% lumbar plexuses. These variations included abnormally long L2 root, early division of the femoral nerve, origin of lateral cutaneous nerve of thigh from the femoral nerve, origin of nerve to pectineus from the femoral nerve in iliac fossa, splitting of the femoral nerve into two slips by psoas major or accessory slips of iliacus muscle. The aim of this study was to highlight variations in branching pattern of the femoral nerve in iliac fossa for appropriate exposure of the femoral nerve.

Hepatoprotective activity of six polyherbal formulations in paracetamol induced liver toxicity in mice.

Background & objective: Polyherbal formulations available with a wide range of indications like protective to liver, appetite and growth promoters, gastrointestinal and hepatic regulator, as treatment for hepatic dysfunction, for hepatic regeneration as well as liver stimulant and tonic. Despite the widespread use, there is a lack of scientifi c evidence on their effi cacy and safety. This study was undertaken to evaluate the hepatoprotective activity of six commercially available formulations, namely Liv 52, Livergen, Livokin, Octogen, Stimuliv and Tefroliv in acute liver toxicity in mice model induced by paracetamol (PCM). Methods: Swiss albino mice of either sex were used, divided in 28 groups with six in each group. The dose of the polyherbal formulations was calculated from human dose (20 ml/day) using a standard conversion table. They were given as pretreatment (2.60 ml/kg/day) for 7 days by oral route twice a day prior to PCM administration. Hepatotoxicity was induced by administering a single oral dose of PCM (500 mg/kg bw) on day 8. The study parameters were conducted on day 9. The biochemical parameters included liver enzyme levels alanine tranaminases (ALT), aspartate transaminases (AST) and alkaline phosphatase (ALP). The pharmacological and pathological parameters were phenobarbitone sleeping time and macroscopic and microscopic changes of liver tissues respectively. Results: PCM toxicity signifi cantly increased ALT, AST and ALP (321.00 ± 87.93, 273.17 ± 45.68, 257.50 ± 17.64 IU/l vs normal control, 33.33 ± 0.61, 89.33 ± 9.50, 152.17 ± 11.40 IU/l respectively, P<0.05), prolonged phenobarbitone induced sleeping time (from 277.50 ± 8.04 min to 335.83 ± 7.00 min, P<0.05). When PCM higher dose (1g/kg p.o. single dose) was used, the liver tissue, in macroscopic appearance, showed extensive necrosis associated with haemorrhages. Low dose (500 mg/kg p.o. single dose) showed punctate haemorrhagic necrosis of liver tissue. In the microscopic studies, PCM induced toxicity showed haemorrhages, fatty changes and necrosis. The pretreatment in low doses (2.6 ml/kg/day) with liquid formulations of Liv 52 and Livergen reversed the PCM induced liver toxicity. At higher doses (5.2 ml/ kg/day), all the six herbal formulations conclusively showed marked benefi cial effects in the studied pharmacological, biochemical and histological parameters. Interpretation & conclusion: The present fi ndings demonstrated the effi cacy of polyherbal liquid formulations at two dose levels in PCM induced hepatotoxicity in mice. However, it suggests that a dose adjustment may be necessary to optimize the effects in clinical settings.

Hepatoprotective activity of six polyherbal formulations in CCl4-induced liver toxicity in mice.

To evaluate pretreatment of six polyherbal liquid formulations (PLFs) commercially available in India, on CCl4-induced liver injury, Swiss albino mice were treated for 7 days with distilled water or PLFs (2.6 and 5.2 ml/kg body weight/day, po) followed by single sc injection of 50% (v/v) CCl4 in arachis oil at a dose of 1 ml/kg. The serum biochemical parameters such as alanine transaminases, aspartate transaminases and alkaline phosphatase were estimated. Phenobarbitone-induced sleeping time and liver histopathology were also carried out. CCl4-treated animals showed significant increase in the levels of liver enzymes, phenobarbitone-induced sleeping time and revealed fatty changes and centrizonal necrosis on histological examination of liver indicating hepatic damage. When pretreated with PLFs at a dose of 5.2 ml/kg body weight/day, the CCl4-induced changes were significantly reversed. The pretreatment with PLFs can prevent acute liver damage induced by CCl4 only at a higher dose. Therefore, it is suggested that a dose adjustment of these PLFs may be necessary for their optimal effects in human liver diseases.

Transient asymptomatic bradycardia in patients on infusional 5-fluorouracil.

The incidence of 5-fluorouracil (5-FU)-related cardiotoxicity seems to be dosage and schedule dependent. Although various other cardiac events have been reported in literature, a series of patients having transient asymptomatic bradycardia has not been reported in the literature as yet. We report such a series of patients who had transient asymptomatic bradycardia after being treated with continuous infusion 5-FU. We plan to do a Holter study during the period of bradycardia in subsequent patients and this may throw more light on the issue.

Malignant astrocytoma following radiotherapy for craniopharyngioma.

Radiation induced gliomas are uncommon. Occurrence of glioma following radiotherapy for craniopharyngiomas is extremely uncommon and only eight case reports have been so far published. We present our experience with one similar case of temporal gliomas occurring twelve years following radiotherapy for a sub totally excised craniopharyngioma. Although the exact mechanism of gliomas formation is unclear, their occurrence following conventional radiotherapy is a distinct possibility and signifies a poor prognosis.

Acephalus acardiac fetus.

Acephalus Acardia is an uncommon congenital malformation due to twin reverse arterial perfusion syndrome. In this condition the donor twin provides circulation for itself and the recipient acardiac twin. The acardiac twin is grossly abnormal with severe reduction anomalies of the upper part of the body. We report a case with autopsy findings and review of literature.

HLA Chimerism in allogenic haplo-identical peripheral blood stem cell transplant.

HLA antigens were used as markers to establish the presence of chimerism (i.e. simultaneous presence of two lymphocyte populations from recipient as well as donor) in a patient with chronic granulomatous disease treated with one haplotype matched stem cell transplant. Neutrophil engraftment occurred on Day 6 post peripheral blood stem cell transplant (PBSCT). Platelet counts were maintained above 20x10[9]/L. Six months after the allogenic PBSCT, lymphocyte population was chimeric and cells of both donor (father) and host HLA type were present. The patient revealed a shift in his HLA antigen profile and there was evidence of donor cell engraftment. The HLA phenotype A26,CwXX,B8,DRB1*03//A32,Cw4,B35,DRB1*16// represented his true phenotype whereas A11,Cw7,B62,DRB1*14 represented donor (father) origin.. HLA system as a genetic marker is a useful additional approach to determine engraftment following an allogenic haplo-identical stem cell transplantation.

Clinico-pathological study of cerebral aneurysms.

AIMS AND OBJECTIVES: A clinico-pathological study of cerebral aneurysms was undertaken to understand the histopathogical nature of the lesions and to ascertain possible etiological risk factors. MATERIAL AND METHODS: Of the 255 cases of cerebral aneurysms operated upon at our Institute during the two-year period between Jan 1999 to Dec 2000, a detailed study was conducted on 57 cases where the aneurysm sac could be excised and subjected to histopathological examination. Aneurysm sacs were fixed in 10% buffered formaldehyde and processed through graded alcohol. Paraffin-embedded sections were examined, using hematoxylin and eosin, Verhoeff van Gieson's and toluidine blue staining techniques. Histopathological observations were analyzed and correlated with clinical features. RESULTS: The ages of the patients ranged from 17-65 years and there were 33 males and 24 females. Twenty-six patients were chronic smokers and 19 patients had hypertension. There were 54 saccular and 3 fusiform aneurysms, predominantly involving the anterior circulation (52 cases) than posterior circulation (5 cases). In 35 cases, histopathological studies demonstrated mucoid deposits between hyperplastic cellular elements in the true and false aneurysm wall and/or parent artery or vasavasora. The changes were associated with dystrophic changes in the internal elastic lamina. CONCLUSION: Besides significant risk factors like smoking and hypertension, such mucoid vasculopathic changes may have predisposed vessels to structural weakness and aneurysm formation in our patients.