Defecation Syncope: A Rare Manifestation in Covid Patients

Introduction: Physical activity leads to raised oxygen demand. This causes desaturation in patients with moderate to severe ARDS. Case Report: A 65yr/M was admitted complaining of breathlessness, cough and fever. RT-PCR was positive, inflammatory markers raised and HRCT Thorax consistent with covid findings. The patient was a known hypertensive taking Tab. Telmisartan (40mg). He had received 1st dose of Covishield vaccine. Treatment was initiated according to covid protocol. Oxygen therapy via NRBM mask at 10-15 litres was started and saturation maintained at 90-95%. On 9th day of admission, pt’s. saturation fell to 77%, while defecating. Subsequently, similar episodes were noted. Saturation fell to 55% transiently prompting BiPAP intervention. On Day 12 a severe episode of desaturation was noted but patient improved, without needing intubation. Diagnosis of Defecation Syncope was made. Discussion: Defecation Syncope (DS) is a parasympathetic response to the exerted pressure on the rectum and diaphragm, and closure of the epiglottis during defecation. Initially there is rise in BP and bradycardia, then rapid fall in BP leading to decreased cerebral perfusion causing syncope. Secondly, raised intra-abdominal pressure causes the diaphragm to exert greater pressure on the thoracic cavity. A (V/Q) mismatch causes hypoxia and desaturation in such patients. Constipation predisposes to DS. Conclusion: While these patients perform voiding activity, adequate fluid therapy should be initiated. Oxygen flow should be increased. Laxatives should be used judiciously. Emergency trolley should be kept on standby. Occasionally, such patients may have fatal outcomes. Patients should be under vigilance of healthcare providers.

Pleomorphic Xanthoastrocytoma with Oligodendroglioma-Like Areas with Negative 1p19q Co-Deletion

The most common mixed glioma encountered in routine surgical practice is oligoastrocytoma (OA); however, its is currently considered a vanishing entity. The 2016 classification of the World Health Organization (WHO) discourages the diagnosis of tumors as mixed glioma. The recommendations are that diffuse gliomas, including those withmixed or ambiguous histological features, should be subjected tomolecular testing. Dual-genotype OAs are not yet a distinct entity or variant in the classification. We report a case ofmixed glioma: a pleomorphic xanthoastrocytoma (PXA)mixed with an oligodendroglioma. The immunohistochemistry (IHC) pattern of isocitrate dehydrogenase 1 (IDH1) negativity with retained nuclear expression of the alpha-thalassemia x-linked intellectual disability syndrome (ATRX) protein, and 1p19q co-deletion negativity in both the components enabled its identification as a mixed glioma rather than a collision tumor. To the best of our knowledge, the case herein presented is the fourth case of PXA with oligodendroglioma. Out of the other three reported cases, only one was of a collision tumor with a dual genotype, and the other two showed similar molecular signatures in both components. The present article discusses the histological, immunohistochemical and molecular features of the aforementioned case.

Successful Transcatheter PDA Device Closure in an Adult with Retrograde Wiring and Antegrade Snaring Approach

Patent ductus arteriosus accounts for 5 – 10% of all congenital heart disease in children. Currently, transcatheter closure is standard of care. Device closure in PDA is usually done by an antegrade technique where PDA is crossed from the PA side. In some patients, this universal procedure may not be successful due to anatomical differences. In such patients, the retrograde technique with retrograde wiring and antegrade snaring approach followed by PDA device closure may be used successfully to close PDA. We report such a case of difficult PDA device closure where the antegrade technique was not successful and PDA device closure was completed by retrograde approach.

Percutaneous Balloon Mitral Valvotomy and Percutaneous Coronary Intervention of Left Anterior Descending Artery in Combined Procedure

In countries like India rheumatic heart disease (RHD) is still a common problem, and with improvements in diagnosis and treatment, the lifespan of these patients is increased. With increase in the lifespan, these patients may develop coronary artery disease (CAD) and present as acute coronary syndrome (ACS). In some cases especially RHD with severe mitral stenosis (MS), thrombus that develop in left atrium may embolize in one of the coronary arteries, leading to acute coronary syndrome. We report a case of 51 year old female who was a known case of rheumatic heart disease and now presented with acute coronary syndrome. Patient was hemodynamically unstable and underwent percutaneous balloon mitral valvotomy (PBMV) and percutaneous coronary intervention (PCI) simultaneously. We here discuss the possible complications that need to be addressed in such scenario and how can we approach such cases. This is first of such intervention at our institute and also there are very few such records available online. Patient tolerated the procedure well with significant clinical improvement.

Successful Primary PCI in a Patient with Acute Myocardial Infarction and Cardiogenic Shock with Super-dominant Right Coronary Artery and Absent Left Circumflex Artery

Super-dominant right coronary artery and the absent left circumflex artery is a rare congenital coronary anomaly, with only a few cases reported in the literature. Left anterior descending artery arises directly from the left anterior coronary cusp. Rare coronary anomalies are sometimes encountered during primary percutaneous interventions, which may lead to changes in the course of action. We report a case of a 38-year-old patient admitted with acute anterior wall myocardial infarction and cardiogenic shock. Coronary angiography revealed super-dominant right coronary artery and absent left circumflex artery. There was thrombotic occlusion of the proximal left anterior descending artery. The patient underwent successful primary percutaneous intervention of the left anterior descending artery with a good result, was discharged after 5 days. Our case also shows the importance of taking coronary angiogram of the contralateral artery first, before taking the shoot of the infarct-related artery.

Successful Percutaneous Balloon Dilatation of Membranous Sub-aortic Stenosis in a 22 Year Old Pregnant Patient

Congenital obstruction of the left ventricular outflow tract comprises a heterogeneous group of disorders, with obstruction potentially occurring below, above, or at the level of the aortic valve. Subvalvular stenosis is the second most common type of left ventricular outflow tract obstruction, of which discrete membranous type is the most common. Although surgical resection of the subaortic membrane is the treatment of choice in discrete membranous subaortic stenosis, in selected patients with isolated membranous subaortic stenosis, without significant aortic insufficiency, percutaneous balloon tearing of the membrane results in reduction in the degree of left ventricular outflow tract obstruction and symptomatic relief. We report a case of 22 year old pregnant patient admitted with NYHA class III breathlessness, found to have discrete membranous subaortic stenosis. Balloon aortic valvuloplasty was performed in the patient with good result. Patient underwent normal vaginal delivery at 38 weeks. Both mother and newborn were asymptomatic. Patient is asymptomatic on subsequent follow-ups.

Coronary artery bypass surgery in the presence of cerebrospinal fluid rhinorrhea.

A seventy eight year old male patient was admitted in our hospital with headache, vomiting, irritability and confusion. Initially he was diagnosed as a case of pyogenic encephalitis. Further investigations revealed that patient had cerebrospinal fluid rhinorrhea and coronary artery disease. He successfully underwent coronary artery bypass grafting and cerebrospinal fluid leak repair.

Prospective study of level of serum zinc in patients of febrile seizures, idiopathic epilepsy and CNS infections.

The present study was carried out to study serum zinc levels for it’s prognostic significance as well as for it’s role in pathophysiology of febrile seizures, idiopathic epilepsy and acute CNS infections. In the present study, 100 cases who were admitted in our hospital during March 2009 to August 2010, aged between 1 month to 18 yrs were selected on the basis of clinical history, physical and CSF examination. They were grouped as groupA (pyogenic meningitis), group B (febrile seizures), group C (idiopathic epilepsy), group D (other acute CNS infections), group E (cerebral malaria) and group F (control). Cases of cerebral palsy, neuroanatomical malformations, neurobehavioural disorders, neurodegenerative disorders and drug induced neurological manifestations were not included in the present study. Mean serum zinc level was significantly lower in groups A, B & E, while no significant difference was observed in group C & D as compared to the control. No significant difference in serum zinc level was detected in relation to outcome and degree of consciousness in any of the study groups.

Efficient in vitro plant regeneration via leaf base segments of indica rice (Oryza sativa L.).

A reliable and reproducible protocol has been developed for high frequency plant regeneration from 4-5 mm long leaf base segments of 4 days old in vitro germinated seedlings of indica rice (Oryza sativa) cultivar Rasi. The effect of age of seedlings, position of leaf base segments and optimum concentration of 2,4-D on callus induction frequency was investigated with a future aim to use leaf bases for biolistic and Agrobacterium-mediated transformation experiments. Friable, nodular and white to pale yellow embryogenic callus cultures (206 mg fresh weight /explant) were obtained from the first basal segments of rice seedlings on Linsmaier and Skoog (LS) medium supplemented with 2,4-D (11.3 microM) and 3.0 microM thiamine-HCL. Plant regeneration was achieved after the transfer of 54 days old embryogenic callus cultures to Murashige and Skoog (MS) medium supplemented with BAP (2.2 microM) and NAA (0.27 microM). In vitro regenerated plants with multiple shoots and roots transferred to sterile soil in growth chamber and maintained in greenhouse exhibited normal growth and were phenotypically similar to plants germinated from seeds.

Surgical outcome of cortical dysplasias presenting with chronic intractable epilepsy: A 10-year experience.

Background: There has been sparse description of cortical dysplasias (CDs) causing intractable epilepsy from India. Aim: Clinical retrospective study of CDs causing intractable epilepsy that underwent surgery. Materials and Methods: Fifty-seven cases of CDs reviewed (1995 till July 2006) are presented. All patients had intractable epilepsy, and underwent a complete epilepsy surgery workup (inter ictal electroencephalography (EEG), video EEG, MRI as per epilepsy protocol, SPECT {interictal, ictal with subtraction and co-registration when required}, and PET when necessary). Surgical treatment included a wide exposure of the pathology with a detailed electrocorticography under optimal anesthetic conditions. Mapping of the sensori-motor area was performed where indicated. Procedures included resection either alone or combined with multiple subpial transactions when extending into the eloquent areas. Results: Our study had 28 (49.12%) cases of isolated focal CDs, and 29 (50.67%) with dual pathology. Average age at the time of onset of seizures in our series was 7.04 years (three months to 24 years), and average age at the time of surgery was 10.97 years (eight months to 45 years). Among coexistent pathologies, one had associated MTS, 16 had coexistent gangliogliomas and 12 (dysembryonic neuroepithelial tumor) DNTs. At an average follow-up of 3.035 years (range 5-10 years), three patients were lost to follow-up. Fifty-one per cent (29/57) patients had a good outcome (Engel Grade I) and 26%(15/57) had a Grade II outcome. Conclusion: Cortical dysplasias have a good outcome if evaluated and managed with concordant electrical and imaging modalities.

Health-related quality of life using QOLIE-31: Before and after epilepsy surgery a prospective study at a tertiary care center.

Background: Outcome following epilepsy surgery has traditionally been measured in terms of relief of seizures. However, changes in health-related quality of life (HRQOL) after surgery for intractable epilepsy are also important to document. There are no studies on the Indian population which assess the outcome of epilepsy surgery in terms of HRQOL. Materials and Methods: We conducted a prospective study on the patients undergoing epilepsy surgery for intractable seizures, between February 2004 and May 2006 at our center. All patients cleared for epilepsy surgery by the epilepsy surgery team were taken up for study. All patients Results: Thirty-six patients satisfying the inclusion/exclusion criteria were included in the analysis. Twenty-nine of these (Group 1) had good seizure outcome (Engel 1 and 2), while seven patients (Group 2) had poor seizure outcome (Engel 3 and 4) at six months. Overall, 77% of all study patients were completely seizure-free at follow-up. There was no baseline difference in the seven domains of QOLIE-31 between the two groups. There was very significant improvement (P value> 0.005 using paired sample T test) in all the domains of QOLIE-31 in the good outcome group after surgery. Health-related quality of life improvement was seen in all the domains in the poor outcome group also, however, it was statistically significant only for the following parameters: seizure worry, overall QOL, emotional wellbeing, energy fatigue and social functioning domains. Improvement in seizure worry, overall QOL, emotional wellbeing and social functioning was significantly more in Group 1 as compared to Group 2. Conclusion: Complete seizure-free state after surgery is associated with very significant improvement in HRQOL parameters. Several, but not all parameters of HRQOL as assessed by QOLIE-31, improved after surgery even in the poor seizure outcome group. The improvement in domains of seizure worry, overall QOL, emotional wellbeing and social functioning is significantly more in those patients in whom complete seizure-free state is achieved.

Neuropathological spectrum of lesions associated with intractable epilepsies: a 10-year experience with a series of 153 resections.

BACKGROUND: Surgical management of intractable epilepsies is currently an established mode of therapy in various clinical settings. AIMS: To retrospectively evaluate the neuropathological findings in both temporal and extratemporal lobe resections in such patients. MATERIALS AND METHODS: The study included resected specimens from patients with intractable epilepsy managed at a tertiary care hospital of India, during a 10-year period (1995-2004). RESULTS: A total of 153 patients, with mean age of 19.4 years and male predominance (73.2%) were included in the study. Overall, there was a predilection for the temporal lobe (73.2%), while 41cases were extratemporal in location. On histopathology, mesial temporal sclerosis (MTS) (24.8%) was the commonest lesion, followed by tumors (19.6%) and isolated focal cortical dysplasia (FCD - 15.11%). Other less common findings included Rasmussen encephalitis, non-specific gliosis and vascular malformations. In addition, 20.9% (32 cases) had dual lesions, majority of which included FCD with ganglioglioma (15 cases) or with dysembryoplastic neuroepithelial tumor (12 cases). In the temporal lobe, neoplasms and dual lesions formed the majority (apart from MTS), unlike dual lesions followed by neoplasms and FCD, in the extratemporal location. CONCLUSION: This series demonstrates that most patients with chronic intractable epilepsy have significant histopathological findings and highlights the neuropathological spectrum of such lesions, in the Indian context. This was similar to that reported from the West, but different from the single Indian series available in the literature. Further, the overall profile of temporal lobe lesions was not different from the extratemporal ones.

Role of shunt surgery in pediatric tubercular meningitis with hydrocephalus.

This study was designed to evaluate the indications for ventriculoperitoneal shunting in cases of children with tubercular meningitis, presenting with hydrocephalus. Thirty seven children (less than 18 years of age) of tubercular meningitis with hydrocephalus (TBMH) who underwent ventriculoperitoneal shunting over a three year period (1999 to 2001) were included in the study. Sixteen (43%) children were Palur stage II, 15 (40%) stage III, and 6 (16%) stage IV. Fifteen (40%) children had received antitubercular therapy for less than 4 months and 17 (46%) received therapy for more than 4 months prior to presentation. Five (14%) children had not previously received antitubercular therapy. Shunt related complications occurred in 11 (30%) children and 3 children had undergone revision of the shunt multiple times. Good outcome was seen in 16 (43%) children. Thirteen (35%) had moderate disability and 6 (16%) had severe disability at 3 months of follow up. 62% (n =10) children in grade II had a good outcome compared to 40% (n = 6) in grade III. All six children in grade IV had a poor outcome. 2 children, both having multiple infarcts, died and the remaining 4 were left with severe disability. We recommend shunt placement in all children of grade II and III TBMH as this policy has yielded the best results. For grade IV children external ventricular drainage, followed by shunting if improvement occurs remains the most cost-effective procedure.