Item Analysis of Single Best Response Type Multiple Choice Questions for Formative Assessment in Obstetrics and Gynaecology.

Background: MCQs (multiple choice questions) can be used to assess higher-order skills and be utilised for creating a question bank. Purpose of Study Aim: To perform post-validation item analysis of MCQs constructed by medical faculty for formative assessment of final-year medical students and to explore the association between difficulty index (p value) and discrimination indices (DI) with distractor efficiency (DE). Methods: An observational study was conducted involving 50 final-year MBBS students and 10 faculty members for a period of one year (October 2020 to September 2021). After training the faculty in item analysis, a MCQ test was prepared after collecting the peer-reviewed 25 MCQs (five each from various subtopics of the subject). The result of this test was used to calculate the FV (facility value), DI (discrimination index), and DE (distractor efficiency) of each item. Student and faculty feedback was also obtained on a five-point Likert scale. Results: The mean FV was 46.3 ± 19.3 and 64% of questions were difficult; the mean DI was 0.3 ± 0.1 and 92% of questions could differentiate between HAG (high achiever's group) and LAG (low achiever's group); the mean DE was 82% ± 19.8 and 48% of items had no NFDs (non-functional distractors). Conclusion: MCQs can be used to assess all the levels of Bloom's taxonomy. Item analysis yielded 23 out of 25 MCQs that were suitable for the question bank.

Air Nozzle Injury: Barotrauma Resulted From an Industrial Accident.

Industrial accidents involving compressed air can lead to significant colonic injuries, ranging from minor tears to complete perforations. This study investigates a case of colonic barotrauma in a 40-year-old male oil refinery worker who suffered symptoms of lower abdominal discomfort, distension, and tenderness following the application of compressed air to his anus. Diagnostic tests, including blood count, abdominal X-ray, and ultrasonography, indicated fecal impaction, dilated bowel loops, and free gas under the diaphragm. An exploratory laparotomy revealed a 4 cm x 2 cm hole in the colon at the hepatic flexure. There were also small breaks in the mucosa at the junction of the recto-sigmoid. We surgically repaired the perforation with primary closure, metrogyl lavage, and the placement of an intra-abdominal pelvic drain. Two weeks later, the patient recovered without any complications and was discharged. This case report highlights the severe risks of non-medical compressed air exposure, as well as the critical need for immediate surgical intervention and preventive safety measures in industrial settings.

Revisiting the tubercular zone: A poor prognostic finding on neuroimaging.

Central nervous system tuberculosis accounts for approximately 1-2% of cases but with a high morbidity and mortality burden. A 37-year-old female presented with fever and headache for 15 days followed by altered sensorium with associated dystonic posturing of both upper limbs and lower limbs (left>right side). The patient's condition deteriorated despite optimal antitubercular treatment and other supportive measures for two weeks. An MRI brain was suggestive of areas of diffusion restriction in the right caudate nucleus, anterior limb of internal capsule, genu, and anteromedial thalamus. The patient ultimately succumbed to death. Tubercular zone infarctions carry an ominous prognosis and can be considered an indicator of morbidity and mortality in patients with tuberculous meningitis (TBM).

Lateral sacral artery aneurysm.

A rare case of aneurysm of the lateral sacral artery is reported. This 46-year-old female presented with complaints of bowel and bladder incontinence and decreased perianal sensation for the past 15 months. She underwent laminectomy and diskectomy for the diagnosis of a prolapsed disk at peripheral hospital where the surgeon was confronted with a severe and unexpected hemorrhage, and surgery was aborted without effective treatment. Prior medical history includes hypertensive kidney disease with a renal transplant eight years ago. Magnetic resonance imaging and angiographic findings were suggestive of a lateral sacral artery aneurysm. Patient with a history of renal transplant and presenting with cauda equina require a more thorough assessment, and a differential of lateral sacral artery aneurysm should always be kept in mind. Our purpose is to report the pre-operative features of the lateral sacral artery aneurysm and its treatment modalities.

Guillain Barre syndrome mimicking brain death.

A 49-year-old female patient presented at the hospital with a history of herpetic blisters, frequent episodes of vomiting and loose stools, bilateral upper and lower limb weakness, and diminishing sensorium. She was diagnosed with hyponatraemia and respiratory failure and later became unconscious with absent brainstem reflexes. The patient was initially treated for herpetic encephalitis, a chronic obstructive pulmonary disease with acute exacerbation, hyponatraemia and neuroparalytic snake bite. Further evaluation, however, identified the uncommon Guillain Barre syndrome presentation with overlap of Bickerstaff brainstem encephalitis. This is an uncommon disorder characterised by the involvement of higher mental functions, fixed dilated pupils, absent brainstem reflexes and quadriplegia that resembles a neuroparalytic snake bite and brain death. After receiving intravenous immunoglobulins for treatment, the patient completely recovered.

A case of early intraventricular haemorrhage following ventriculoperitoneal shunt: An entity requiring consideration.

The ventriculoperitoneal shunt (VP shunt) is one of the most common neurosurgical procedures performed in daily practice. Various complications following a VP shunt are as follows: post-procedure shunt-related infections, shunt block, shunt displacement or exteriorisation and haemorrhage associated with it. Delayed intraventricular haemorrhage is a relatively uncommon complication following the aforementioned procedure. Here we present an atypical case of a 72-year-old male who presented with subarachnoid haemorrhage with hydrocephalus and underwent a VP shunt, following which the patient had early intraventricular haemorrhage (eIVH) with an unfortunate outcome. Here, we propose pathophysiology and risk factors for eIVH.

Therapeutic Potential of Catechin as an IKK-ß Inhibitor for the Management of Arthritis: In vitro and In vivo Approach.

Background: Rheumatoid arthritis (RA) is associated with increased levels of cytokines, for instance, nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and interleukin-1 (IL-1), which exhibit potent pro-inflammatory effects and are contributing factors to disease progression. A range of cytokines, cell adhesion molecules, and enzymes that are implicated in the debilitating effects of RA are transcribed by nuclear factor kappa. Objectives: The purpose of this research was to characterize the efficacy of "catechin" as an IkappaB kinase-beta (IKK-ß) inhibitor in collagen-induced arthritis (CIA) model in mice, as IKK-ß is crucial in the transmission of signal-inducible NF-κß activation. Methods: Arthritis was brought on in Bagg and Albino, but it is written BALB/c (BALB/c) male mice through subcutaneous immunization with bovine type II collagen on days 0 and 21. Catechin is given orally every day after the onset of the disease. Clinical evaluation of the prevalence and severity of the condition was done throughout the trial, and biochemical testing was done at the end (day 42). Results: In vitro findings of the study demonstrated catechin as a potent inhibitor of IKK-ß with Half maximal Inhibitory Concentration (IC50) values of 2.90 µM and 4.358 µM in IKK-ß and NF-κß transactivation activity assay, respectively. Furthermore, catechin (dose range of 10-100 mg/kg, p.o.) was effective in reducing disease incidence and clinical signs in a dose-dependent manner, with an Effective Dose for 50% of the population (ED50) value of 79.579 mg/kg. The findings of this study demonstrate dose-dependent efficacy in terms of both disease severity (clinical scoring) and inflammatory markers (biochemical evaluation of the serum and joints). Conclusions: IKK inhibitors are a prospective target for the creation of new therapeutics for arthritis and other inflammatory diseases because it has been suggested that this enzyme is crucial in the pathophysiology of RA. The finding of this study suggests that "catechin" represents a novel inhibitor of IKK-ß with promising anti-inflammatory activity.

Study of Clinicoradiological Profile in Posterior Reversible Encephalopathy Syndrome: An Experience from North India.

Background: Posterior reversible encephalopathy syndrome (PRES) is a reversible condition. The Main pathological feature is vasogenic cerebral edema with predominant involvement of posterior part of the cerebrum. Clinical symptoms range from headache, seizure, and vision loss. We evaluated the clinicoradiological features of patients with PRES and their clinical outcome. Materials and methods: A retrospective study with 30 cases from January 2014 to May 2017. Results: Of thirty patients, 18 were females and twelve patients were male. The Mean age of the patients was 38.6 years. The most common presentation was seizure (66.6%) followed by altered mental status (53.3%) and headache (40%). The Main comorbid illnesses in our study were renal disease (36.7%), hypertension (23.3%), eclampsia, and postpartum sepsis (26.7%). The Most common site was the occipito-parietal region in the magnetic resonance imaging brain (66%). Atypical presentation involved the temporal lobe (16%), basal ganglia (6%), and microhemorrhage (6%). The Outcome was good with 20% mortalities. Conclusion: PRES is a reversible condition and has a good outcome in most patients. In our study, seizure was the most common presentation and renal disease is the most common comorbid illness. How to cite this article: Goyal G, Jeswani J. Study of Clinicoradiological Profile in Posterior Reversible Encephalopathy Syndrome: An Experience from North India. Indian J Crit Care Med 2022;26(4):501-505.

Predictors of Presenting Seizures in Acute Cerebral Vein and Dural Sinus Thrombosis.

BACKGROUND AND PURPOSE: Risk of seizure is significantly higher in cerebral vein and dural sinus thrombosis (CVST) compared to other stroke subtypes. There is paucity of literature on predictors of presenting seizures in CVST. This study was designed to investigate the risk and predictors of seizures in CVST at presentation. METHODS: Total 181 consecutive patients with CVST were retrospectively analyzed. RESULTS: Total 181 patients with CVST were enrolled (age range, 14 to 96 years; mean age, 34.64±14.66 years). A total of 44 patients had presenting seizures. Younger age (p=0.028), involvement of superficial cortical veins (p=0.016), presence of hemorrhagic venous infarct (p≤0.001) and involvement of frontal lobe (p≤0.001) were significantly related to the presenting seizures on the univariate analysis. The hemorrhagic venous infarct (odds ratio [OR], 4.44; 95% confidence interval [CI], 1.89-10.44; p=0.001) and involvement of the frontal lobe (OR, 10.66; 95% CI, 4.02-28.29; p≤0.001) were independently associated with the presenting seizures on the multivariate analysis. CONCLUSIONS: About one fourth of the patients with CVST had presenting seizures. The patients with hemorrhagic venous infarct in the frontal region are more prone to have presenting seizures.

Clinical Presentation, Neuroimaging Findings, and Predictors of Brain Parenchymal Lesions in Cerebral Vein and Dural Sinus Thrombosis: A Retrospective Study.

INTRODUCTION: Cerebral venous sinus thrombosis (CVST) is an unusual cause of stroke with potentially serious consequences. This study was designed to investigate the clinical and neuroimaging features in patients with CVST and to analyze the predictors of brain parenchymal lesions. MATERIALS AND METHODS: A retrospective study of 181 patients with CVST was conducted in a tertiary care hospital. RESULTS: Of 181 patients (age range 14-96 years, mean age: 34.64 ± 14.66 years), 121 were female (66.9%). Most of the patients were in their third decade of life. Headache (47.51%) was the most common clinical presentation followed by seizures (24.31%). Transverse sinus (TS) (77.9%) was the most common site of venous sinus thrombosis. Brain parenchymal lesions were present in 63%, and each patient had subarachnoid and intraventricular hemorrhage. Hemorrhagic venous infarct was the most common brain parenchymal lesion (37.57%). Frontal region (25.4%) was the most common site of brain parenchymal lesions followed by frontoparietal region (21.9%). Women were more likely to have brain parenchymal lesions (72.4%, P = 0.034). Headache was the most common clinical presentation in patients without brain parenchymal lesions while seizures with brain parenchymal lesions. Straight sinus thrombosis was more likely to be associated with brain parenchymal lesions (P = 0.009). CONCLUSION: CVST presents in young and more commonly in females. TS was the most common site of venous sinus thrombosis. Female gender, seizures, altered sensorium and focal neurological deficit at presentation, and straight sinus thrombosis were more likely associated with the presence of brain parenchymal lesions.

A rare case of hemolytic disease of newborn due to weak D (D unknown) antigen in child.

We are reporting a rare case of hemolytic disease of newborn with weak D antigen in child. A 3rd order male child of G3P3A0 mother was admitted at 8th h of life with jaundice. Blood group of both mother and child were A Rh D negative. Baby's direct coombs test was positive. Weak D antigen was positive in baby. Hematological parameters showed all the signs of ongoing hemolysis, and the bilirubin level was in the zone of exchange transfusion. Exchange transfusion was done. An intravenous immunoglobulin was given to child after that. Mother had a history of first normal healthy male child with O Rh D positive blood group. Second male child expired on 3rd postnatal day due to bilirubin encephalopathy that had A Rh D negative blood group with positive direct coombs test.

Ramsay Hunt Syndrome with Multiple Cranial Neuropathies: Role of Pulse Steroid Therapy with Newer Antiviral Agent in Nonresponding Hiccoughs and Laryngeal Palsy.

Ramsay hunt syndrome (RHS) is characterised by herpetic blisters (small vesicles) of the skin of the external canal, pinna and/or the oral mucosa and severe otalgia (ear pain) along with acute peripheral facial paralysis and/or vestibulocochlear dysfunction (e.g., vertigo, hearing loss, hyperacusis, tinnitus). RHS with multiple cranial neuropathies is rare, more severe, and usually intractable. A combination therapy of antiviral agents and steroids is the preferred treatment. We present a case of 30-year-old man suffering from RHS with multiple cranial neuropathies treated effectively with combination therapy of intravenous pulse steroid therapy and newer antiviral agent for intractable hiccoughs and laryngeal palsy.

Anatomical Variations of Cerebral MR Venography: Is Gender Matter?

PURPOSE: Knowledge of variations in the cerebral dural venous sinus anatomy seen on magnetic resonance (MR) venography is essential to avoid over-diagnosis of cerebral venous sinus thrombosis (CVST). Very limited data is available on gender difference of the cerebral dural venous sinus anatomy variations. MATERIALS AND METHODS: A retrospective study was conducted to study the normal anatomy of the intracranial venous system and its normal variation, as depicted by 3D MR venography, in normal adults and any gender-related differences. RESULTS: A total of 1654 patients (582 men, 1072 women, age range 19 to 86 years, mean age: 37.98±13.83 years) were included in the study. Most common indication for MR venography was headache (75.4%). Hypoplastic left transverse sinus was the most common anatomical variation in 352 (21.3%) patients. Left transverse sinus was hypoplastic in more commonly in male in comparison to female (24.9% versus 19.3%, p = 0.009). Most common variation of superior sagittal sinus (SSS) was atresia of anterior one third SSS (15, 0.9%). Except hypoplastic left transverse sinus, rest of anatomical variations of the transverse and other sinuses were not significantly differ among both genders. CONCLUSION: Hypoplastic left transverse sinus is the most common anatomical variation and more common in male compared to female in the present study. Other anatomical variations of dural venous sinuses are not significantly differ among both genders.

Attitude of epilepsy patients and their attendants for participating in research on status epilepticus.

To evaluate the reason joining in status epilepticus (SE) trial by epilepsy patients and attendants and their preferences for types of trials and consent. The participants were interviewed after giving a SE case summary. Their demographic details, reason of consenting or non-consenting and preference of trials and type of consent were noted. The responses of the patients and attendants were compared. 77 subjects participated and 47 (61 %) were willing to participate in the trial mainly due to self-interest (treatment by specialist, best treatment and treatment availability only by trial). The reasons for unwilling were apprehension and lack of will. The participants preferred a head-to-head trial over a placebo-controlled (21 vs. 3), proxy consent rather than waived consent (16 vs. 6) and preconsent (16 vs. 3). These responses were not different between patients and attendants. 61 % subjects were willing to participate in SE trial especially in head-to-head trial with proxy consent.

Utility of different seizure induction protocols in psychogenic nonepileptic seizures.

Psychogenic non epileptic seizure (PNES) can be induced by several induction tests but their relative usefulness has not been evaluated. In this study, we report the sensitivity and specificity of various induction tests in the diagnosis of PNES and assess their discomfort level. The induction tests were: (a) compression of temple region (CTR), (b) verbal suggestion (VS), (c) tuning fork application (TFA), (d) moist swab application (MSA), (e) torch light stimulation (TLS) and (f) saline injection (SI). Up to 3 trials were done for each test except for normal saline injection which was given once. For comparison of these tests, patients with epileptic seizures were included as controls. The time to precipitate PNES was recorded and patients' discomfort levels were noted on a 0-10 scale. Video EEG was recorded in the PNES patients. 140 patients with PNES and 50 controls with epileptic seizures were included. The diagnostic yield of CTR was 65.7%, TFA 61.4%, MSA 60.7%, SI 55.6%, VS 54.3% and TLS 40.7%. These tests did not induce seizures in the controls. All these tests had 100% specificity and 100% positive predictive value in the diagnosis of PNES. The maximum discomfort was reported with SI and minimum with MSA. The similarity of efficacy and discomfort with CTR and TFA appear to be the most optimal induction techniques when compared with VS, AMS, TLS, and SI.

Conjoined stent technique for radiation induced long segment carotid stenosis and pseudoaneurysm.

Radiation induced carotid stenosis (RICS) is known but challenging complication of head and neck irradiation. Endovascular revascularization is preferred treatment modality than surgical revascularization. Sometimes endovascular treatment may be difficult in view of long segment of stenosis and associated pseudoaneurysm. We report a unique technique of carotid stenting named as "conjoined stent technique" in a challenging case of RICS with long segment of stenosis and pseudoaneurysm. In this technique we overlapped distal end of one stent with proximal end of second stent to occlude pseudoaneurysm. "Conjoined stent technique" may be viable option in case of long segment of RICS with associated pseudoaneurysm and alternative to flow diverters in extracranial carotid pseudoaneurysm.

Intracerebral hemorrhage in young patients from a tertiary neurology center in North India.

OBJECTIVE: There is paucity of information on the etiology and predictors of outcome of intracerebral hemorrhage (ICH) in young patients which may have regional and ethnic differences. In this study, we report the etiology and predictors of outcome of ICH in young patients from North India. METHODS: 404 young patients with ICH (16-50 years) were retrospectively reviewed who were admitted in neurology service of a tertiary care teaching hospital in North India. The data were retrieved from the computerized hospital information service. The information about the demography, risk factors, clinical status, laboratory findings, CT/MRI features and angiography (CT, MRI or digital substraction) were noted. The etiology of ICH was ascertained based on clinical, laboratory and radiological findings. Outcome at 1 month was assessed using Glasgow Outcome Scale (GOS). RESULTS: The mean age of the patients was 41.6 years and 23.8% were females. Hypertension (57.2%), hypocholesterolemia (33.7%), alcohol (15.8%) and anticoagulant (3.5%) were the important risk factors. The etiology of ICH was hypertension in 320 (79.2%), vascular malformation in 17 (4.2%), coagulopathy in 16 (4%), cerebral venous sinus thrombosis (CVST) in 9 (2.2%), thrombocytopenia in 3 (0.7%), vasculitis in 2 (0.5%) and cryptogenic in 37 (9.2%) patients. The patients with cryptogenic ICH were younger, had better Glasgow coma scale (GCS) on admission and good outcome compared those with known etiology. The most common location of ICH was basal ganglion and thalamus (71.3%). 102 (25%) patients died, 161 (39.9%) had poor and 141 (34.9%) had good outcome. Hypertensive ICH patients had frequent death or disability (P<0.001). On multivariate analysis, low GCS score (P <0.001), large ICH (P=0.01) and high leukocyte count on admission (P=0.03) were significantly related to the 1 month mortality. CONCLUSION: Hypertension is the commonest cause of ICH in young Indian adults and its outcome is related to volume of ICH, GCS score and admission leukocyte count.

Experience of pediatric stroke from a tertiary medical center in North India.

OBJECTIVE: The etiology and outcome of pediatric stroke differs in different geographical regions and there is no comprehensive study from India. This study evaluates the etiology, type and predictors of outcome of pediatric stroke from Northern India. METHODS: 79 stroke patients aged 1month to 18years managed during 2001-2011 were retrospectively analyzed. Their mean age was 144.8months (0.6-18years) and 26 were females. Detailed history including stroke risk factors was noted. The clinical, imaging and laboratory findings were recorded. Stroke was classified as per neuroimaging findings. The predictors of death were evaluated by multivariate analysis. RESULTS: 62 (78.5%) patients had arterial ischemic stroke (AIS), 10 (12.7%) intracerebral hemorrhage (ICH) and 7 (8.9%) had cerebral venous sinus thrombosis (CVST). The underlying etiology was neuroinfections in 25, cardioembolic in 9, prothrombotic conditions in 5, arteriopathy in 4, arterial dissection in 3, mitochondrial cytopathy and cervical rib in 1 each and cryptogenic in 13 patients. 7 patients died. On multivariate analysis death was related to level of consciousness on admission. CONCLUSION: AIS is more common than ICH in this study and 8.9% patients died. Infection is the most common cause of pediatric stroke in Northern India which is amenable to therapy and is preventable.