Altered expression of activating transcription factor 3 in the hippocampus of patients with mesial temporal lobe epilepsy-hippocampal sclerosis (MTLE-HS)

Aim of the study: Activating Transforming factor 3 (ATF3) is a stress induced gene and closely associated with neuro-inflammation while Transforming growth Factor Beta (TGFβ) signalling is also reported to be involved in neuro-inflammation and hyper-excitability associated with drug resistant epilepsy. Animal model studies indicate the involvement of ATF3 and TGFβ receptors to promote epileptogenesis. Human studies also show that TGFβ signalling is activated in MTLE-HS. However, lack of studies on ATF3 and TGFβRI expression in MTLE-HS patients exists. We hypothesize that ATF3 and TGFβRI might be expressed in hippocampi of patients with MTLE-HS and playing role in epileptogenesis. Materials & methods: Protein expression of ATF3 and TGFβRI was performed by western blotting. Localisation of ATF3 was performed by immunohistochemistry and immunoflorescence. Results: Protein expression of ATF3 and TGFβRI was significantly up-regulated in hippocampi of patients as compared to controls. Also ATF3 IR was significantly expressed in hippocampi of patients and ATF3 was expressed predominantly in cytoplasm as compared to nucleus. No correlation was found between ATF3 expression and epilepsy duration and seizure frequency. Conclusions: ATF3 and TGFβRI are both important players in neuro-inflammation and might potentiate epileptogenesis in these patients.

Integrated Proteomics and Protein Co-expression Network Analysis Identifies Novel Epileptogenic Mechanism in Mesial Temporal Lobe Epilepsy

Over 50 million people worldwide are affected by epilepsy, a common neurological disorder that has a high rate of drug resistance and diverse comorbidities such as progressive cognitive and behavioural disorders, and increased mortality from direct or indirect effects of seizures and therapies. Despite extensive research with animal models and human studies, limited insights have been gained into the mechanisms underlying seizures and epileptogenesis, which has not translated into significant reductions in drug resistance, morbidities, or mortality. To better understand the molecular signaling networks associated with seizures in MTLE patients, we analyzed the proteome of brain samples from MTLE and control cases using an integrated approach that combines mass spectrometry-based quantitative proteomics, differential expression analysis, and co-expression network analysis. Our analyses of 20 human brain tissues from MTLE patients and 20 controls showed the organization of the brain proteome into a network of 9 biologically meaningful modules of co-expressed proteins. Of these, 6 modules are positively or negatively correlated to MTLE phenotypes with hub proteins that are altered in MTLE patients. Our study is the first to employ an integrated approach of proteomics and protein co-expression network analysis to study patients with MTLE. Our findings reveal a molecular blueprint of altered protein networks in MTLE brain and highlight dysregulated pathways and processes including altered cargo transport, neurotransmitter release from synaptic vesicles, synaptic plasticity, proteostasis, RNA homeostasis, ion transport and transmembrane transport, cytoskeleton disorganization, metabolic and mitochondrial dysfunction, blood micro-particle function, extracellular matrix organization, immune response, neuroinflammation, and cell signaling. These insights into MTLE pathogenesis suggest potential new candidates for future diagnostic and therapeutic development.

MicroRNA Signatures for Pancreatic Cancer and Chronic Pancreatitis: Expression Profiling by NGS

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a deadly disease due to the lack of early detection. Because chronic pancreatitis (CP) patients are a high-risk group for pancreatic cancer, this study aimed to assess the differential miRNA profile in pancreatic tissue of patients with CP and pancreatic cancer.

METHODS

MiRNAs were isolated from formalin-fixed paraffin-embedded pancreatic tissue of 22 PDAC patients, 18 CP patients, and 10 normal pancreatic tissues from autopsy (C) cases and processed for next-generation sequencing. Known and novel miRNAs were identified and analyzed for differential miRNA expression, target prediction, and pathway enrichment between groups.

RESULTS

Among the miRNAs identified, 166 known and 17 novel miRNAs were found exclusively in PDAC tissues, while 106 known and 10 novel miRNAs were found specifically in CP tissues. The pathways targeted by PDAC-specific miRNAs and differentially expressed miRNAs between PDAC versus CP tissues and PDAC versus control tissues were the proteoglycans pathway, Hippo signaling pathway, adherens junction, and transforming growth factor-β signaling pathway.

CONCLUSIONS

This study resulted in a set of exclusive and differentially expressed miRNAs in PDAC and CP can be assessed for their diagnostic value. In addition, studying the role of miRNA-target gene interactions in carcinogenesis may open new therapeutic avenues.

Spongiform leukoencephalopathy unveiled in an autopsy of a drug abuser

Toxic leukoencephalopathy (TLE) is a rare neurological debilitating and fatal condition. It has been previously associated with exposure to leukotoxic offenders such as chemotherapy, cranial radiation, certain drugs, and environmental factors. Currently, it is a commoner white matter syndrome resulting from increased substance abuse, classically by inhaled heroin and other opioids. Herein, we report a case of fatal TLE unveiled in an autopsy of a drug abuser. A 24-year-old male was found dead on the roadside. A day before, he was located in a state of delirium. In this case, the autopsy findings and histopathology characteristics of cerebral cortex involvement particularly directed to speculate the heroine as the principal offender.

Secondary infections in COVID-19: Antemortem and postmortem culture study

Background

Secondary bacterial infections during COVID-19 hospitalization have been reported in about 6-15% of patients.

Aims

To study the secondary bacterial infections that affected the COVID-19 patients during their hospitalisation and to unearth the bacteriological profile of samples obtained after their demise.

Settings and Design

This prospective study was carried out at a COVID-19 dedicated, apex tertiary care centre in North India from July 2020 to April 2021.

Methods and Materials

Samples of 268 patients were considered for the study. Nasopharyngeal swab specimen, blood, and tissue (lung) were collected from the deceased body as early as possible and processed.

Statistical Analysis

Statistical analyses were performed using STATA version 11.1 (Stata Corp., College Station, TX, USA).

Results

A total of 170 samples were received from patients before their death, which included blood, urine, respiratory samples, pus, and cerebrospinal fluid. Forty-four pathogens were isolated, which consisted of Acinetobacter baumannii (43.1%), Klebsiella pneumoniae (36.3%), Escherichia coli (11.3%), and Pseudomonas aeruginosa (4.5%), Enterococcus faecium (4.5%). Two hundred fifty-eight samples were collected from the deceased bodies wherein the nasopharyngeal sample was highest, followed by tissue and blood. A total of 43 pathogens were isolated among them which included A. baumannii (44.1%), followed by K. pneumoniae (25.5%), E. coli (20.9%), P. aeruginosa (6.97%) and Enterobacter cloacae (2.3%). All these isolates were highly resistant to antimicrobials.

Conclusions

In our study, bacterial profiles in antemortem and postmortem samples were found to be similar, suggesting that resistant pathogens may be the cause of mortality in COVID-19 infected hospitalised patients.

Strain-rate-dependent material properties of human lung parenchymal tissue using inverse finite element approach

Automobile crashes and blunt trauma often lead to life-threatening thoracic injuries, especially to the lung tissues. These injuries can be simulated using finite element-based human body models that need dynamic material properties of lung tissue. The strain-rate-dependent material parameters of human parenchymal tissues were determined in this study using uniaxial quasi-static (1 mm/s) and dynamic (1.6, 3, and 5 m/s) compression tests. A bilinear material model was used to capture the nonlinear behavior of the lung tissue, which was implemented using a user-defined material in LS-DYNA. Inverse mapping using genetic algorithm-based optimization of all experimental data with the corresponding FE models yielded a set of strain-rate-dependent material parameters. The bilinear material parameters are obtained for the strain rates of 0.1, 100, 300, and 500 s-1. The estimated elastic modulus increased from 43 to 153 kPa, while the toe strain reduced from 0.39 to 0.29 when the strain rate was increased from 0.1 to 500 s-1. The optimized bilinear material properties of parenchymal tissue exhibit a piecewise linear relationship with the strain rate.

Erythrocyte fatty acids and desaturase indices in early pregnancy are associated with risk of preeclampsia

Preeclampsia (PE) is a pregnancy disorder that may be associated with inadequate maternal nutrition. Fatty acids are vital for placental and fetal growth. Fatty acid desaturases, key enzymes influencing the metabolism of polyunsaturated fatty acids, are reported to be associated with cardiometabolic risk. Any imbalance in the levels of omega-3 and omega-6 fatty acids can result in increased inflammatory response. The current study reports the levels of erythrocyte fatty acids and desaturase index across gestation in women who develop PE (n = 108) and compares them with non-PE women (n = 216). Maternal erythrocyte fatty acids were measured at 4 time points during pregnancy (i.e., 11-14, 18-22, 26-28 weeks and at delivery) using gas chromatography. Maternal total erythrocyte saturated fatty acids and omega-6/omega-3 fatty acid ratio was higher in the PE group as compared to the non-PE group at 11-14 weeks and 18-22 weeks respectively. Maternal Δ5 desaturase index was lower while Δ6 desaturase index was higher in the PE group at 11-14 and 18-22 weeks. Maternal stearoyl CoA desaturase-18 (SCD-18) index was lower at 11-14 weeks and at delivery. These changes were mainly observed in the early onset PE (EOP) group. Δ6 desaturase index at 11-14 weeks predicted the risk of EOP. Imbalance in fatty acid levels and desaturase indices predate the clinical diagnosis of PE, indicating their role in its pathophysiology. Measurement of fatty acids and desaturase indices in early pregnancy merits evaluation as predictors of risk of PE.

Pathological Spectrum and β-APP Immunoreactivity as a Diagnostic Tool of Diffuse Axonal Injury following Traumatic Brain Injury: A Novel Classification

Aim  Different deposition patterns and grading systems used to define and identify DAI remain discordant and to date these are a challenge in clinical practice. Our main objective was to study the post-mortem axonal changes and develop a grading system to identify DAI on the basis of histopathological and immunoreactive β-amyloid precursor protein (β-APP) observations in severe TBI cases. Methods  Prospective study with 35 decedents with sTBI (GCS score ≤ 8) was conducted and samples were collected from three different sites-corpus callosum, thalamus and brain stem. Serial sections from each site were stained with hematoxylin and eosin (H&E), and immunohistochemistry (IHC) of β-APP. Results  We developed a grading system based on histopathological characteristics to assess the overall damage of axonal injury. We found maximum histopathological changes in cases with prolonged stay. Corpus callosum showed maximum changes in both gradings. Curiously, we also detected axonal swellings with H&E staining. Usually neglected, the thalamus also showed significant histopathological and immunoreactive changes for sTBI. Conclusion  Our study based on histopathological and β-APP scoring system to define and identify DAI thus facilitates accurate diagnosis of DAI post mortem, which has forensic implications, and may further contribute toward survival and improvement of quality of life of sTBI patients.

Post-mortem detection of a calcifying fibrous pseudotumor at a rare site-A case report

ABSTRACT

We report the case of a 48 year old man brought-in-dead to the trauma unit following an alleged accidental fall from a multi-storied building. Autopsy findings were consistent with traumatic injuries to the head, chest and spine. Incidentally, a bit of the diaphragm with a pearly white lobulated mass over the pleural surface was observed. Histopathological examination detected a calcifying fibrous pseudotumour (CFPT), confirmed by positive immunostaining for cluster of differentiation protein-34 (CD34) and vimentin (focally). CFPTs are slow-growing pseudotumours that are clinically benign with extremely low rate of recurrence and this might just be the first reported case of CFPT on the diaphragm. This shall further aid clinicians to diagnose these rare yet significant soft tissue tumors in uncommon sites.

Alterations of oligodendrocyte progenitor cells (OPCs) with survival time in humans following high impact brain trauma

BACKGROUND

As there is a lack of comprehensive literature regarding the molecular environment of the human brain emphasizing on oligodendrocyte progenitor cells (OPCs) following high impact brain trauma. The protagonist of OPCs post severe traumatic brain injury (sTBI) provides a significant thrust towards estimating time elapsed since trauma as well as developing novel therapeutic approaches. The present study was carried out to study post trauma alterations pertaining to myelin sheath and oligodendrocyte response with survival time.

MATERIALS AND METHODS

In the present study, victims (both male and female) of sTBI (n = 64) were recruited and contrasted with age and gender matched controls (n = 12). Post mortem brain samples from corpus callosum and grey white matter interface were collected during autopsy examination. Extent of myelin degradation and response of OPC markers Olig-2 and PDGFR-α were evaluated using immunohistochemistry and qRT-PCR. STATA 14.0 statistical software was used for data analysis with P-value<0.05 considered statistically significant.

RESULTS

Timewise qualitative correlation with extent of demyelination performed using LFB-PAS/IHC-MBP, IHC Olig-2 and mRNA expression revealed tendency towards remyelination in both corpus callosum and grey white matter interface. Number of Olig-2 positive cells was significantly higher in sTBI group as compared to control group (P-value: 0.0001). Moreover, mRNA expression studies of Olig-2 showed significant upregulation in sTBI patients. mRNA expression of Olig-2 and PDGFR-α in sTBI patients showed significant variation with respect to survival time (p value:0.0001).

CONCLUSION

Detailed assessment of post TBI changes implementing various immunohistochemical and molecular techniques shall potentially reveal intriguing and important inferences in medicolegal practices and neurotherapeutics.

Correlation of age at seizure onset with GABAA receptor subunit and chloride Co-transporter configuration in Focal cortical dysplasia (FCD)

Focal cortical dysplasia (FCD) represents a group of malformations of cortical development, which are speculated to be related to early developmental defects in the cerebral cortex. According to dysmature cerebral development hypothesis of FCD altered GABAA receptor function is known to contribute to abnormal neuronal network. Here, we studied the possible association between age at seizure onset in FCD with the subunit configuration of GABAA receptors in resected brain specimens obtained from patients with FCD. We observed a significantly higher ratio of α4/α1 subunit-containing GABAA receptors in patients with early onset (EO) FCD as compared to those with late onset (LO) FCD as is seen during the course of development where α4-containing GABAA receptors expression is high as compared to α1-containing GABAA receptors expression. Likewise, the influx to efflux chloride co-transporter expression of NKCC1/KCC2 was also increased in patients with EO FCD as seen during brain development. In addition, we observed that the ratio of GABA/Glutamate neurotransmitters was lower in patients with EO FCD as compared to that in patients with LO FCD. Our findings suggest altered configuration of GABAA receptors in FCD which could be contributing to aberrant depolarizing GABAergic activity. In particular, we observed a correlation of age at seizure onset in FCD with subunit configuration of GABAA receptors, levels of NKCC1/KCC2 and the ratio of GABA/Glutamate neurotransmitters such that the patients with EO FCD exhibited a more critically modulated GABAergic network.

When "No-Smoking" is not enough: Hypoxia and nicotine acetylcholine receptor signaling may drive lung adenocarcinoma progression in never-smokers

The question of how lung cancer progresses in never-smokers remains largely unanswered. In our analysis of data from 1727 lung cancer patients, we observed a difference of only 47 days in the overall survival between lung adenocarcinoma patients who were smokers vis-a-vis never-smokers - the disease has a poor prognosis irrespective of the smoking status, or gender. We have investigated the possible collaboration between the nAChR and hypoxia signaling pathway to explicate a mechanism of disease progression in never-smokers using patient-derived tumor cells. We found a previously unidentified increase in both acetylcholine and nAChR-α7 levels in non-small cell lung cancer cells in hypoxia. A similar increase in ubiquitously expressed nAChR-α7 transcripts was also observed in other cancer lines and primary tumor tissues. A direct binding of HIF-1α with the hypoxia-response element (HRE) present at -48 position preceding the transcriptional start site in nAChR-α7 promoter region was established. Crucially, the increased acetylcholine levels in hypoxia drove a feedback loop via modulation of PI3K/AKT pathway to stabilize HIF-1α in hypoxia. Further, hypoxia-mediated metastasis and induction of HIF-1α in these cells was significantly reversed by bungarotoxin, an antagonist of nAChR-α7. The nAChR-AKT-HIF network needs to be further investigated to conclusively prove its mechanism and to explore its therapeutic potential. Our study gives a plausible explanation for the equally worse prognosis of lung adenocarcinoma in never-smokers wherein the nAChR signaling is enhanced in hypoxia by acetylcholine in the absence of nicotine.

SARS-CoV-2 antigen detection in deceased bodies: implications for infection prevention

Background & objectives

High transmissibility of the SARS-CoV-2 has significant implications on healthcare workers' safety, preservation, handling, transportation and disposal of the deceased bodies. The objective of this study was to detect SARS-CoV-2 antigen in nasopharyngeal samples and its implications in handling and care of COVID-19 deceased bodies.

Methods

A study was conducted at a dedicated COVID-19 centre on deceased individuals from April to December 2020. Rapid antigen test (RAT) and reverse transcription (RT)-PCR was compared on all the SARS-CoV-2 positive cadavers recruited in the study.

Results

A total of 115 deceased individuals were included in the study. Of these, 79 (68.7%) were male and 36 (31.3%) were female and majority were in the age group of 51-60 yr [31 (27%)]. SARS-CoV-2 antigen test was positive in 32 (27.8%) and negative in 83 (72.1%) individuals. The mean time interval between deaths to the sample collection was 13.2 h with interquartile range of eight to 20 h. Reverse transcription (RT)-PCR was used as the reference test and 24 (20.9%) cases were true positive; 93.6 per cent [95% confidence interval (CI) 88.8-98.4%] sensitivity, 45.2 per cent (95% CI 35.5-55%) specificity, 60.2 per cent (95% CI 50.6-69.8%) positive predictive value and 88.8 per cent (95% CI 82.7-95%) negative predictive value of antigen test was computed.

Interpretation & conclusions

SARS-CoV-2 antigen test was positive beyond 19 h in COVID-19 deceased individuals. Antigen test was found to be highly sensitive in the deceased. Patients, suspected of having died due to COVID-19, can be screened by this method. As infectiousness of the virus in the deceased bodies cannot be directly concluded from either the antigen or RT-PCR test, yet possible transmission cannot be completely ruled out. Strict infection control measures need to be followed during the handling and clearance of COVID-19 cadavers.

Transcriptomic profiling of nonneoplastic cortical tissues reveals epileptogenic mechanisms in dysembryoplastic neuroepithelial tumors

Low-grade dysembryoplastic neuroepithelial tumors (DNTs) are a frequent cause of drug-refractory epilepsy. Molecular mechanisms underlying seizure generation in these tumors are poorly understood. This study was conducted to identify altered genes in nonneoplastic epileptogenic cortical tissues (ECTs) resected from DNT patients during electrocorticography (ECoG)-guided surgery. RNA sequencing (RNAseq) was used to determine the differentially expressed genes (DEGs) in these high-spiking ECTs compared to non-epileptic controls. A total of 477 DEGs (180 upregulated; 297 downregulated) were observed in the ECTs compared to non-epileptic controls. Gene ontology analysis revealed enrichment of genes belonging to the following Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways: (i) glutamatergic synapse; (ii) nitrogen metabolism; (iii) transcriptional misregulation in cancer; and (iv) protein digestion and absorption. The glutamatergic synapse pathway was enriched by DEGs such as GRM4, SLC1A6, GRIN2C, GRM2, GRM5, GRIN3A, and GRIN2B. Enhanced glutamatergic activity was observed in the pyramidal neurons of ECTs, which could be attributed to altered synaptic transmission in these tissues compared to non-epileptic controls. Besides glutamatergic synapse, altered expression of other genes such as GABRB1 (synapse formation), SLIT2 (axonal growth), and PROKR2 (neuron migration) could be linked to epileptogenesis in ECTs. Also, upregulation of GABRA6 gene in ECTs could underlie benzodiazepine resistance in these patients. Neural cell-type-specific gene set enrichment analysis (GSEA) revealed transcriptome of ECTs to be predominantly contributed by microglia and neurons. This study provides first comprehensive gene expression profiling of nonneoplastic ECTs of DNT patients and identifies genes/pathways potentially linked to epileptogenesis.

ACE2 protein expression in lung tissues of severe COVID-19 infection

Angiotensin-converting enzyme 2 (ACE2) is a key host protein by which severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) enters and multiplies within cells. The level of ACE2 expression in the lung is hypothesised to correlate with an increased risk of severe infection and complications in COrona VIrus Disease 2019 (COVID-19). To test this hypothesis, we compared the protein expression status of ACE2 by immunohistochemistry (IHC) in post-mortem lung samples of patients who died of severe COVID-19 and lung samples obtained from non-COVID-19 patients for other indications. IHC for CD61 and CD163 was performed for the assessment of platelet-rich microthrombi and macrophages, respectively. IHC for SARS-CoV-2 viral antigen was also performed. In a total of 55, 44 COVID-19 post-mortem lung samples were tested for ACE2, 36 for CD163, and 26 for CD61, compared to 15 non-covid 19 control lung sections. Quantification of immunostaining, random sampling, and correlation analysis were used to substantiate the morphologic findings. Our results show that ACE2 protein expression was significantly higher in COVID-19 post-mortem lung tissues than in controls, regardless of sample size. Histomorphology in COVID-19 lungs showed diffuse alveolar damage (DAD), acute bronchopneumonia, and acute lung injury with SARS-CoV-2 viral protein detected in a subset of cases. ACE2 expression levels were positively correlated with increased expression levels of CD61 and CD163. In conclusion, our results show significantly higher ACE2 protein expression in severe COVID-19 disease, correlating with increased macrophage infiltration and microthrombi, suggesting a pathobiological role in disease severity.

Clinico-pathological features in fatal COVID-19 infection: a preliminary experience of a tertiary care center in North India using postmortem minimally invasive tissue sampling

OBJECTIVES

To study the histopathology of patients dying of COVID-19 using post-mortem minimally invasive sampling techniques.

METHODS

This was a single-center observational study conducted at JPNATC, AIIMS. Thirty-seven patients who died of COVID-19 were enrolled. Post-mortem percutaneous biopsies were taken from lung, heart, liver, kidney and stained with hematoxylin and eosin. Immunohistochemistry was performed using CD61 and CD163. SARS-CoV-2 virus was detected using IHC with primary antibodies.

RESULTS

The mean age was 48.7 years and 59.5% were males. Lung histopathology showed diffuse alveolar damage in 78% patients. Associated bronchopneumonia was seen in 37.5% and scattered microthrombi in 21% patients. Immunopositivity for SARS-CoV-2 was observed in Type II pneumocytes. Acute tubular injury with epithelial vacuolization was seen in 46% of renal biopsies. Seventy-one percent of liver biopsies showed Kupffer cell hyperplasia and 27.5% showed submassive hepatic necrosis.

CONCLUSIONS

Predominant finding was diffuse alveolar damage with demonstration of SARS-CoV-2 protein in the acute phase. Microvascular thrombi were rarely identified in any organ. Substantial hepatocyte necrosis, Kupffer cell hypertrophy, microvesicular, and macrovesicular steatosis unrelated to microvascular thrombi suggested that liver might be a primary target of COVID-19.

Transcriptomic profiling of high- and low-spiking regions reveals novel epileptogenic mechanisms in focal cortical dysplasia type II patients

Focal cortical dysplasia (FCD) is a malformation of the cerebral cortex with poorly-defined epileptogenic zones (EZs), and poor surgical outcome in FCD is associated with inaccurate localization of the EZ. Hence, identifying novel epileptogenic markers to aid in the localization of EZ in patients with FCD is very much needed. High-throughput gene expression studies of FCD samples have the potential to uncover molecular changes underlying the epileptogenic process and identify novel markers for delineating the EZ. For this purpose, we, for the first time performed RNA sequencing of surgically resected paired tissue samples obtained from electrocorticographically graded high (MAX) and low spiking (MIN) regions of FCD type II patients and autopsy controls. We identified significant changes in the MAX samples of the FCD type II patients when compared to non-epileptic controls, but not in the case of MIN samples. We found significant enrichment for myelination, oligodendrocyte development and differentiation, neuronal and axon ensheathment, phospholipid metabolism, cell adhesion and cytoskeleton, semaphorins, and ion channels in the MAX region. Through the integration of both MAX vs non-epileptic control and MAX vs MIN RNA sequencing (RNA Seq) data, PLP1, PLLP, UGT8, KLK6, SOX10, MOG, MAG, MOBP, ANLN, ERMN, SPP1, CLDN11, TNC, GPR37, SLC12A2, ABCA2, ABCA8, ASPA, P2RX7, CERS2, MAP4K4, TF, CTGF, Semaphorins, Opalin, FGFs, CALB2, and TNC were identified as potential key regulators of multiple pathways related to FCD type II pathology. We have identified novel epileptogenic marker elements that may contribute to epileptogenicity in patients with FCD and could be possible markers for the localization of EZ.

Increased levels of α4-containing GABAA receptors in focal cortical dysplasia: A possible cause of benzodiazepine resistance

Benzodiazepines are the first choice of anti-epileptic drugs used to treat seizures. However, it has been seen that their efficacy decreases with time leading to drug insensitivity, plausibly caused by an alteration in the expression of the benzodiazepine biding site on GABA_A receptors. This study was designed to investigate if the differential expression of GABA_A receptor subunits α1/α4/γ2/δ across the postsynaptic sites could contribute to benzodiazepine resistance in patients with focal cortical dysplasia (FCD), the most common cause of drug resistant epilepsy in pediatric population. Differential gene and cellular expression of GABA_A receptor subunits α1, α4, γ2 and δ were evaluated and validated using qPCR and immunohistochemistry. Whole cell patch clamp studies were performed on pyramidal neurons of resected cortical FCD samples to measure the spontaneous GABA_A receptor activity. Upregulation of α4-and γ2-subunits containing GABA_A receptors were observed at both mRNA and protein level. α1-and δ-subunits containing GABA_A receptors did not show any significant changes. Flumazenil treatment did not affect the kinetics of GABAergic events in FCD; however, it significantly reduced the frequency and amplitude of spontaneous GABAergic activity in non-seizure control samples. Our results demonstrate the enhanced expression of α4-containing GABA_A receptors and GABAergic activity in pyramidal neurons which in turn may contribute to benzodiazepine resistance in FCD patients.

Altered hippocampal kynurenine pathway metabolism contributes to hyperexcitability in human mesial temporal lobe epilepsy-hippocampal sclerosis

BACKGROUND AND PURPOSE

Glutamate receptor-mediated enhanced excitatory neurotransmission is typically associated with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). Kynurenic acid and quinolinic acid are two important tryptophan-kynurenine pathway metabolites that modulate glutamate receptor activity. This study was designed to test the hypothesis that alteration in metabolism of tryptophan-kynurenine pathway metabolites in the hippocampus of patients with MTLE-HS contributes to abnormal glutamatergic transmission.

EXPERIMENTAL APPROACH

Levels of tryptophan-kynurenine pathway metabolites were determined using HPLC and LC-MS/MS in hippocampal samples from patients with MTLE-HS, compared with autopsy and non-seizure control samples. mRNA and protein expressions of tryptophan-kynurenine pathway enzymes were determined by qPCR and Western blot. Spontaneous glutamatergic activities were recorded from pyramidal neurons in the presence of kynurenine and kynurenic acid, using whole-cell patch clamp.

KEY RESULTS

Levels of kynurenic acid were reduced and quinolinic acid levels were raised in hippocampal samples from MTLE-HS patients, whereas kynurenine levels remained unaltered, compared with levels in non-seizure controls. Spontaneous glutamatergic activity in MTLE-HS hippocampal samples was higher than that in non-seizure controls. Treatment with kynurenine inhibited glutamatergic activity in non-seizure control samples but not in MTLE-HS samples. However, exogenously applied kynurenic acid inhibited glutamatergic activity in both non-seizure control and MTLE-HS hippocampal samples. Also, levels of kynurenine aminotransferase II and its cofactor pyridoxal phosphate were reduced in MTLE-HS samples.

CONCLUSION AND IMPLICATIONS

Our findings indicate that altered metabolism of tryptophan-kynurenine pathway metabolites in hippocampus could contribute to hyperglutamatergic tone in patients with MTLE-HS.

Integrated Genome-Wide DNA Methylation and RNAseq Analysis of Hippocampal Specimens Identifies Potential Candidate Genes and Aberrant Signalling Pathways in Patients with Hippocampal Sclerosis

Background and Aims

DNA methylation and demethylation play a crucial role in the regulation of gene expression, though their interplay during pathogenesis of hippocampal scelerosis (HS) remains elusive. The present study was designed to investigate the DNA methylation regulated changes in expression of HS patients.

Methods

We performed integrative analysis of genome-wide CpG-DNA methylation profiling and RNA sequencing to profile global changes in promoter methylation and gene expression in HS patients. Real time PCR was performed to validate the findings of methylation and RNA sequencing.

Results

A total of 16040 sites showed altered DNA methylation in all the CpG islands. Of these, 3185 sites were in the promoter regions, of which 66 genes showed an inverse correlation between methylation and expression. These genes are largely related to pathways predicted to participate in axon guidance by semaphorins, MAPK, ionotropic glutamate receptor pathway, notch signaling, regulatory activities related to TFAP2A and immune response, with the most distinct ones included TFAP2A, NRP1, SEMA3B, CACNG2, MAP3K11, and ADAM17.

Conclusion

We performed integrated analysis of genomic methylation signature and differential gene expression patterns of hippocampal tissues resected from patients with HS for the first time. Collectively, our findings implicate DNA methylation as a critical regulator of the pathogenic mechanisms of epileptogenesis associated with HS.

Pilot testing of a computer-based self-instructional module on organ donation for improvement in knowledge and acceptability of nurses working in the intensive care unit of a tertiary care institute

Objectives:

Nurses are an integral team member in intensive care units (ICU) and can play important role in facilitating the organ donation process. Hence, the sensitisation of these nurses is important. The aim of the study was to assess the effectiveness of a computer based self-instruction module (CBSIM) in terms of improving the knowledge and acceptability of nurses in relation to organ donation.

Materials and Methods:

In this prospective study, 56 nurses working in an ICU were enrolled using the total enumeration technique. After filling up of the demographic profile, nurses attempted online pre-test, containing 20 randomly selected multiple-choice questions (MCQs) from a validated and pre-tested question bank containing 150 MCQs. The intervention consisted of self-paced CBSIM containing nine modules on different aspects of organ donation. The intervention was completed in 25 ± 5 days, followed by an online post-intervention test. Acceptability of the CBSIM by nurses about organ donation was assessed as a secondary outcome on a 5-point Likert scale.

Results:

A significant gain in knowledge scores was observed after the CBSIM (4.9 ± 1.14 vs. 7.35 ± 1.34, P < 0.001) with high acceptability of CBSIM by most of the nurses (59.2%).

Conclusion:

CBSIM was effective in improving the knowledge of nurses related to organ donation and highly acceptable to most of the nurses working in ICU. Hence, CBSIM can be used as a method of learning for nurses.

A cadaveric study on the rate of strain-dependent behavior of human anterior cruciate ligament

Purpose: Failure of anterior cruciate ligament often occurs in young sports personnel hampering their career. Such ACL ruptures are quite prevalent in sports such as soccer during dynamic loading which occurs at more than one rate of loading. In this work, a structural constitutive equation has been used to predict the forces acting on ACL for different rates of loading. Methods: Ligaments with distal femur and proximal tibia were subjected to tensile loading to avoid crushing of tissue ends and slipping at higher rates of strain. Custom designed cylindrical grippers were fabricated to clamp the distal femur and proximal tibial bony sections. To estimate parameters for the model, eighteen fresh cadaveric femur-ACL-tibia complex (FATC) samples were experimented on by pure tensile loading at three orders of rates of strain viz., 0.003, 0.03, and 0.3 s–1. The experimental force-elongation data was used to obtain parameters for De-Vita and Slaughter’s equation. The model was validated with additional tensile experiments. Results: Statistical analysis demonstrated failure stress, Young’s modulus and volumetric strain energy to vary significantly as a function of rate of strain. Midsection failure was observed only in samples tested at 0.03 s–1. Femoral or tibial insertion failure were observed in all other experiments irrespective of rate of strain. Conclusion: Human FATC samples were tensile tested to failure at three rates of strain using custom-designed cylindrical grippers. A structural model was used to model the data for the ACL behaviour in the linear region of loading to predict ligament behaviour during dynamic activities in live subjects.

A cadaveric study on the rate of strain-dependent behaviour of human anterior cruciate ligament

PURPOSE

Failure of anterior cruciate ligament often occurs in young sports personnel hampering their career. Such ACL ruptures are quite prevalent in sports such as soccer during dynamic loading which occurs at more than one rate of loading. In this work, a structural constitutive equation has been used to predict the forces acting on ACL for different rates of loading.

METHODS

Ligaments with distal femur and proximal tibia were subjected to tensile loading to avoid crushing of tissue ends and slipping at higher rates of strain. Custom designed cylindrical grippers were fabricated to clamp the distal femur and proximal tibial bony sections. To estimate parameters for the model, eighteen fresh cadaveric femur-ACL-tibia complex (FATC) samples were experimented on by pure tensile loading at three orders of rates of strain viz., 0.003, 0.03, and 0.3 s^-1. The experimental force-elongation data was used to obtain parameters for De-Vita and Slaughter's equation. The model was validated with additional tensile experiments.

RESULTS

Statistical analysis demonstrated failure stress, Young's modulus and volumetric strain energy to vary significantly as a function of rate of strain. Midsection failure was observed only in samples tested at 0.03 s^-1. Femoral or tibial insertion failure were observed in all other experiments irrespective of rate of strain.

CONCLUSION

Human FATC samples were tensile tested to failure at three rates of strain using custom-designed cylindrical grippers. A structural model was used to model the data for the ACL behaviour in the linear region of loading to predict ligament behaviour during dynamic activities in live subjects.

Postmortem redistribution of ketamine in ocular matrices: A study of forensic relevance

The present study evaluates the postmortem redistribution of ketamine in ocular matrices, such as vitreous humor, aqueous humor, and ocular tissues in an animal model. To understand the redistribution of ketamine and its metabolite (norketamine) in the ocular matrices, an in vivo study was performed in rabbits. The rabbits were divided into two groups: perimortem and postmortem. The postmortem samples were collected at 17 h after the administration of ketamine (40 mg/kg) intravenously. For a better understanding of the metabolism of ketamine in eyes, an ex vivo study was conducted in goat eyes after administration of ketamine intravitreally. The samples were analyzed by LC-MS/MS and the levels of ketamine and norketamine in these matrices were compared with that of whole blood and plasma. The results of the in vivo study showed a decrease in ketamine levels in whole blood and plasma while an increase in ocular matrices at postmortem. Though, in most cases, this increase/decrease was statistically insignificant. Moreover, there was an increase of norketamine level in ocular matrices. Ex vivo study also shows the presence of norketamine in ocular matrices of goat eyes. The presence of norketamine in goat eyes may be indicative of the metabolism of ketamine in the eyes.

A Study to Ascertain the Expression of Aquaporin 4 and Neuropeptide Y in the Jejunal Mucosa Secondary to Traumatic Brain Injury in Humans

Introduction Gastrointestinal (GI) dysfunction is a common complication in patients with traumatic brain injury (TBI). Studies in rats have shown alterations in intestinal mucosa to correlate with severity and duration of TBI. There is lack of such evidence in humans. So we intended to find correlation between histopathological changes and expression of aquaporin 4 (AQ4) and neuropeptide Y (NPY) in jejunal mucosa in post TBI patients.

Materials and Methods Autopsy specimens of jejunum were obtained from patients who had died due to TBI (n = 20), patients dying due to traumatic injury other than TBI, and patients who were brought dead (diseased controls n = 20). Abdominal trauma was the exclusion criterion for both. Jejunal specimens were grossly examined and then analyzed histopathologically and graded immunohistochemically for AQ4 and NPY. Unpaired t-test was used to compare results.

Results After exclusion, 19 cases and 17 controls were studied. No significant difference was observed in the microscopic findings between cases and controls (p-value = 0.70). The expression of AQ4 was more in cases (p-value = 0.04). NPY expression was not significantly different (p-value = 0.93).

Conclusion AQ4 can hence be used as a marker of GI injury post TBI. Histopathological examination cannot distinguish between these changes.

Simulation Based Skills Training in Neurosurgery and Contemporary Surgical Practices

Neurosurgery training is based on a time-bound apprenticeship model, resulting in mentor-dependent, non-uniform, anecdotal, slow skills acquisition, sometimes with morbid consequences. The complexity of neurosurgical procedures and constraints of present education have demands for alternative methods of training. The use of simulation in surgical skills training was pioneered by work in laparoscopy, which began only in the last 25 years. Existing neurosurgery training model should be supplemented with efficient skills training curricula.

The present study illustrates formulation, standardization, validation and evaluation of efficacy of neurosurgery skills training modules using formative and summative assessment. 160 regular residents and short-term trainees were trained over 3096 skills training sessions under formative assessment; 176 'graduate neurosurgeons' were trained with 12 skills training programs under summative assessment. Training involved skills development in micro-neurosurgery, high-speed drilling, neuroendoscopy and spine-instrumentation by practice on structured low and high-fidelity simulation models. The effectiveness of content, course modules, and teaching faculty on skills development were assessed using spot and gap-based evaluation.

Seven basic, 7 intermediate and 14 advanced skills training modules have been developed. Trainees rated 71% of overall training sessions as excellent quality content with 69·8%, 70·1%, and 71% respectively for micro-suturing and high-speed drilling, neuro-endoscopy and spine-instrumentation modules. Faculty with higher ratings was included as program instructors. On gap-based evaluation, >80% of responded trainees reported better orientation with high speed drilling followed by micro-neurosurgery and spine-instrumentation. Neuro-endoscopy training scored low assimilation into clinical practice.We suggest structured modular validated skills training curriculum to supplement the existing neurosurgery training. This would help in improving learning curve outside operation-rooms, at convenience and individualized needs of trainees under supervision, and would thus help in skills translation without endangering patients.

Mortality profile of geriatric trauma at a level 1 trauma center

Background:

The management of geriatric trauma patients is challenging because of the altered physiology and co-existent medical conditions. To study the in-hospital mortality profile of geriatric trauma victims and the parameters associated with the mortality, we conducted this retrospective analysis.

Methods:

In a retrospective review of geriatric trauma admissions (above 60 years) over a 3-year period, we studied the association of age, gender, comorbidities, mechanism of injury (MOI), Glasgow coma score (GCS), injury severity score (ISS), systolic blood pressure, and hemoglobin (Hb) level on admission with hospital mortality. Univariate and Multivariable logistic regression was used to estimate odds and find independent associated parameters. P < 0.05 was considered as statistically significant.

Results:

Out of 881 patients, 208 (23.6%) patients died in hospital. The most common MOI was fall (53.3%) followed by motor vehicle collision (31.1%) and other mechanisms (14.5%). The in-hospital mortality was significantly higher and adjusted odds ratio (OR) for mortality were higher for male gender (2.11 [1.04–4.26]), higher ISS (6.75 [2.07–21.95] for ISS >30), low GCS (<8) (4.6 [2.35–8.97]), low Hb (<9) (1.68 [0.79–3.55]), hypotension on admission (32.42 [10.89–96.52]) as compared to other groups. Adjusted OR was 3.19 (1.55–6.56); 7.67 (1.10–53.49); 1.13 (0.08–17.12) for co-existent cardiovascular, renal, and hepatic comorbidities, respectively.

Conclusion:

Male gender, higher ISS, low GCS, low Hb, hypotension on admission, co-existent cardiovascular, renal and hepatic comorbidities are associated with increased mortality in geriatric trauma patients.

TLR3 absence confers increased survival with improved macrophage activity against pneumonia

Toll-like receptor 3 (TLR3) is a pathogen recognition molecule associated with viral infection with double-stranded RNA (dsRNA) as its ligand. We evaluated the role of TLR3 in bacterial pneumonia using Klebsiella pneumoniae (KP). WT and TLR3-/- mice were subjected to a lethal model of KP. Alveolar macrophage polarization, bactericidal activity, and phagocytic capacity were compared. RNA-sequencing was performed on alveolar macrophages from the WT and TLR3-/- mice. Adoptive transfers of alveolar macrophages from TLR3-/- mice to WT mice with KP were evaluated for survival. Expression of TLR3 in postmortem human lung samples from patients who died from gram-negative pneumonia and pathological grading of pneumonitis was determined. Mortality was significantly lower in TLR3-/-, and survival improved in WT mice following antibody neutralization of TLR3 and with TLR3/dsRNA complex inhibitor. Alveolar macrophages from TLR3-/- mice demonstrated increased bactericidal and phagocytic capacity. RNA-sequencing showed an increased production of chemokines in TLR3-/- mice. Adoptive transfer of alveolar macrophages from the TLR3-/- mice restored the survival in WT mice. Human lung samples demonstrated a good correlation between the grade of pneumonitis and TLR3 expression. These data represent a paradigm shift in understanding the mechanistic role of TLR3 in bacterial pneumonia.

Efficacy, Immunogenicity, and Safety of a 9-Valent Human Papillomavirus Vaccine: Subgroup Analysis of Participants From Asian Countries

Background

A 9-valent human papillomavirus-6/11/16/18/31/33/45/52/58 (9vHPV) vaccine extends coverage to 5 next most common oncogenic types (31/33/45/52/58) in cervical cancer versus quadrivalent HPV (qHPV) vaccine. We describe efficacy, immunogenicity, and safety in Asian participants (India, Hong Kong, South Korea, Japan, Taiwan, and Thailand) from 2 international studies: a randomized, double-blinded, qHPV vaccine-controlled efficacy study (young women aged 16–26 years; NCT00543543; Study 001); and an immunogenicity study (girls and boys aged 9–15 years; NCT00943722; Study 002).

Methods

Participants (N = 2519) were vaccinated at day 1 and months 2 and 6. Gynecological samples (Study 001 only) and serum were collected for HPV DNA and antibody assessments, respectively. Injection-site and systemic adverse events (AEs) were monitored. Data were analyzed by country and vaccination group.

Results

9vHPV vaccine prevented HPV-31/33/45/52/58–related persistent infection with 90.4%–100% efficacy across included countries. At month 7, ≥97.9% of participants seroconverted for each HPV type. Injection-site AEs occurred in 77.7%–83.1% and 81.9%–87.5% of qHPV and 9vHPV vaccine recipients in Study 001, respectively, and 62.4%–85.7% of girls/boys in Study 002; most were mild to moderate.

Conclusions

The 9vHPV vaccine is efficacious, immunogenic, and well tolerated in Asian participants. Data support 9vHPV vaccination programs in Asia.

Clinical Trials Registration

NCT00543543; NCT00943722.

Tibial nerve schwanoma: short review of surgical management

Schwannoma is a benign, solitary nerve sheath tumour and accounting for about 5% of soft tissue tumours. It can occur along the peripheral nervous system in any part of body. It presents as a painless, swelling. We report an adult male presented with tibial nerve schwanoma underwent successful surgical excision. However, differentiation with neurofibroma is very important as surgical planning and prognosis is quite different. In lower limb usually incidence of neurofibroma is higher in contrast of upper limb. Pertinent literature and management are briefly discussed.

Epidemiological trends of fatal pediatric trauma: A single-center study

To evaluate the potential risk factors which increase the incidence of post-trauma complications and mortality in pediatric population.A retrospective cohort study was conducted on patients below 18 years of age with a fatal outcome who were admitted to an Indian level-1 trauma center between January 2013 and December 2015. This cohort was analyzed to determine the demographics, injury mechanism, injury severity, microbiological profile, and cause of death.In total, 320 pediatric patients with a fatal outcome were studied which showed male preponderance (71.56%). The median age of the patients was 11 years (range, 0.14-18 years). Median duration of stay was 1 day (range, 0-183 days). Fall and road traffic accidents were the common mechanisms of trauma while the main injury was head injury. In total, 857 clinical samples were received from 56 patients. The clinical samples from 35 (10.94%) patients were culture positive. Culture-proven infections were significantly correlated with the length of hospital stay (P = .001). In total, 212 organisms were isolated from 193 positive samples of which gram-negative bacteria were predominant (89.15%). The most common gram-positive bacterial isolate was Staphylococcus aureus (12, 52.17%), while Acinetobacter baumannii (66, 34.92%) was the most prevalent gram-negative bacterial isolate followed by Pseudomonas spp. (36, 19.05%), Klebsiella pneumoniae (35, 18.52%), and Escherichia coli (16, 8.47%). Up to 100% multidrug resistance was seen in both gram-positive and gram-negative bacterial isolates. The first 24 hours after trauma were the deadliest for our patients. Head/central nervous system injury was the primary cause of disabilities and early death whereas infection attributed to prolonged hospital stay.From these observations we concluded that management of pediatric trauma requires expert, multidisciplinary, and timely interventions. Moreover, nosocomial infections with multidrug resistant gram-negative bacteria challenges the accepted tenets of trauma care affecting the outcome of the pediatric population. Early identification of such high-risk patients' infection may facilitate early intervention. Thus, many deaths in pediatric group are preventable.

Effect of informed consent on patients undergoing gastrointestinal surgery and living donor liver transplantation and on their relatives in a developing country

Background

Informed consent is a systematic process for obtaining permission before conducting a healthcare intervention. In a developing country, gaining informed consent is generally perceived to be a ritual only to comply with legal requirements. The present study examined this by assessing the process of informed consent in patients undergoing gastrointestinal surgery or living donor liver transplantation (LDLT) and their relatives, based on their comprehension and overall satisfaction, in India.

Methods

All patients undergoing any gastrointestinal surgery or LDLT procedure between August 2015 and July 2016 and their relatives were included, and were administered a structured questionnaire 5 days after the procedure.

Results

The majority of patients (94·2 per cent) could recall the nature of their disease, the surgery performed (81·6 per cent) and anticipated complications (55·6 per cent). Among their relatives, these proportions were 97·8, 87·3 and 58·5 per cent respectively. Recall was associated with age, occupation and education among both patients and relatives. Patients undergoing LDLT, their donors and their relatives had better recall than those who had other gastrointestinal procedures (P < 0·001). Many patients found the process of informed consent useful and reassuring.

Conclusion

The details and risks of an operation were understood by most of the patients, especially those undergoing liver transplantation. Patients from developing countries can generally understand ‘informed consent’, and value it.

Standardization of the technique of silicon injection of human cadaveric heads for opacification of cerebral vasculature in Indian conditions

A surgeon's understanding of the surgical anatomy can be greatly enhanced by the dissection of preserved cadaveric specimens. A reliable and inexpensive biological model for testing and standardization of dye injection concentrations is proposed utilizing the goat's head as a biological model. The first phase was concerned with standardization of the dye by titrating its concentration and injecting various amounts into cerebral vessels of a goat's head until an optimal concentration had been ascertained. In the second phase, this optimum concentration of the dye was injected into four human cadaveric heads following the same technique standardized using the goat's head. Upon dissecting the four cadaveric human heads which were injected with silicon dyes and preserved in 10% formalin, the vessels were all well-opacified and the brain was of near normal consistency and good for dissection, without showing any features of putrefaction. The goat model, having similar color, texture, and the handling as the cadaveric head, offers an opportunity to test indigenously manufactured polymerizing dyes in the future. This biological model, therefore, has the potential to considerably reduce the cost of cadaver preparation.

Histological and morphometric analysis of dilated cardiomyopathy with special reference to collagen IV expression

INTRODUCTION

Collagen distribution alterations are well known in dilated cardiomyopathy. There are also changes in microvasculature along with other histomorphorphological features.

AIMS AND OBJECTIVES

To study the histomorphological features of DCM along with their quantitative correlation with LVEF. Alterations in collagen IV distribution pattern and microvasculature in DCM were also evaluated.

MATERIALS AND METHODS

The present study includes 34 right ventricular endomyocardial biopsies, 7 explanted native hearts and 41 autopsy control hearts. Sections were taken from lower half of right interventricular septum and stained for H and E, Masson trichrome and immunohistochemistry for CD34, SMA and Collagen IV to study the histological features, pattern of fibrosis, capillary and arteriolar distribution and collagen IV expression respectively. Morphometric analysis was carried out in all cases and controls using Image analysis software Image pro plus 7 and correlated with left ventricular ejection fraction.

RESULTS

The histomorphological changes of DCM include myocyte hypertrophy, nucleomegaly, and interstitial fibrosis. Interfiber fibrosis was the commonest. There was evidence of myocarditis, ischemic change and vessel wall alterations. Considerable alteration in Collagen IV distribution was observed with reduction in intensity and proportion of staining around myocytes quantified using Allred scoring against uniform pericellular staining in controls. Morphometric analysis revealed significant increase in nuclear area, myocyte width, percentage of fibrosis and reduction in capillary myocyte ratio in cases as compared to controls. There was no significant difference in arteriolar density. No significant association was observed between morphometric parameters and LVEF.

CONCLUSION

Histomorphological changes in DCM are non-specific. Quantitation of histological parameters cannot be used to predict the disease progression as there was no significant correlation with LVEF. There is appreciable alteration in Collagen IV distribution in DCM owing to extracellular matrix alterations.

Armored Brain Associated with Secondary Craniostenosis Development at 7-year following Ventriculoperitoneal Shunt Surgery during Infancy: Extremely Unusual Association and Review

Calcification is uncommon in chronic subdural hematoma and popularly known as calcified chronic subdural hematoma (CSSDH), and about hundred cases are reported in the form of isolated cases report. The calcified inner membrane of chronic subdural hematoma gets adherent to underlying cerebral cortex preventing re-expansion of the brain and producing mass effect. Calcification can develop in chronic subdural hematoma of traumatic origin or postmeningitic effusion or extremely rarely after shunt surgery. CCSDH is also known as armored brain or Matrioska head and those related to cerebrospinal fluid diversion ventriculoperitoneal (VP) shunt surgery, constitute one of the rare complications of shunt, and development is attributed to overdrainage of shunt. Authors report a unique case with bilateral calcified chronic subdural hematoma in an 8-year-old boy, who had VP shunt surgery for obstructive hydrocephalus at the age of 1 year of life, presented with feature of nonlocalized raised intracranial pressure; a diagnosis of suspected VP shunt malfunction was also considered; however, cranial computed tomography scan on current admission revealed the presence of bilateral calcified chronic subdural hematoma with secondary craniostenosis and managed successfully with burr-hole craniostomy and drainage of CCSDH. In a detailed PubMed and Medline search, authors could not get any publication regarding CSSDH associated with secondary craniostenosis developing following VP shunt surgery in infancy. The current case represents the first case in the Western literature developing secondary craniostenosis-associated CCSDH following shunt surgery in infancy, requiring surgical management. The clinical features, neuroimaging, and management of such rare case along with pertinent literature are reviewed briefly.

Effect of preservation methods on tensile properties of human femur-ACL-tibial complex (FATC) - a cadaveric study on male subjects

PURPOSE

Deep freezing and storing in formalin are some of the common techniques of human tissue preservation. However, the preservation modes affect the biomechanical properties of the tissues. In this work, the effects of the above-stated preservation tech- niques are compared with that of fresh cadaveric samples.

METHODS

FATC samples from male cadavers of age between 60 and 70 years were tested under tensile loading at a strain rate of 0.8 s-1. Fourteen FATC samples from soft embalmed cadavers were preserved for 3 weeks by two methods: (a) 10% formalin and (b) deep freezing at -20 ° C followed by thawing. Seven FATC samples from fresh ca- davers were experimented as control samples. The results were evaluated by a two-stage statistical process of Kruskal-Wallis H test and Mann-Whitney U-test.

RESULTS

It was observed that the failure force of fresh cadavers was the highest while that of preserved samples were approximately half the value. Failure elongation of frozen samples exceeded fresh samples while formalin samples failed at lesser elongations. Higher incidence of tibial insertion point or mid-section failures were observed in fresh samples while the higher incidence of ruptures at femoral insertion point was observed in the two preservation methods.

CONCLUSION

Tensile properties of fresh tissues vary significantly from that of formalin preserved or frozen preserved samples.

Study of death to preservation time and its impact on utilisation of donor corneas

To evaluate the impact of death-to-preservation time (DPT) on effective utilisation of donor corneas. In a prospective observational study conducted at our tertiary eye centre, donated corneas received over a 15-month period from November 2011 to January 2013 were evaluated. Donor age, donor refrigeration (done or not), DPT, endothelial cell density (ECD), corneal grading, clinical utilisation and surgical outcome after graft transplantation were noted. To analyse the impact of different DPT on donor cornea transplantation, primary outcome measures (corneal grading and endothelial cell density) and secondary outcome measures (primary graft failure and graft infection) were analysed. A total of 990 corneas were assessed. Primary outcomes showed no significant difference for higher DPT ( P > 0.01). ECD, where DPT was >12 h, was better for refrigerated corneas ( P < 0.001). Prolonged DPT had no significant effect on primary graft failure ( P = 0.131) and graft infection ( P = 0.137) in the first month after transplantation. We find that DPT should not be the only criteria to assess the cornea quality; other donor characteristics should be considered equally important. Donor refrigeration should be encouraged in cases where early retrieval is not possible.

Fatal road traffic accidents and their relationship with head injuries: An epidemiological survey of five years

In depth studies of fatal vehicular accidents provide valuable data for implementing effective emergency services to reduce the trauma related mortality and strengthening legal measures in peak hours of fatal accidents. We aimed to study, pattern of injuries especially fatal traumatic brain injuries occurring in vehicular accidents. Postmortem reports and clinical records of victims of road traffic accident autopsied during the period of 2001–2005 at Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi, were analyzed retrospectively. Out of total 7008 medico legal autopsies conducted during the study period, 2472 (35.27 %) were of vehicular accidents. The male/female ratio was 7.49:1. Commonest age group affected was between 21-40 years involving 1341 (54.24%) cases. Pre-hospital mortality was in 985 (39.84 %) cases. Fatal traumatic brain injuries were seen in 1699 (68.73%) cases. Skull fractures were found in 1183 (69.63%) cases of head injury; most common bone fractured was temporal bone (n=559, 47.25%). The commonest variety of intracranial hemorrhage was subdural hemorrhage (n=1514, 89.11%). The craniotomy was done in 297 (17.48%) cases; maximum mortality (41.07%) was seen within 4–ays. Most commonly injured abdominal organ was liver (n=532, 21.52%). No significant difference was evident in incidence of fatal vehicular accident on weekends and weekdays. However November month took maximum toll of deaths (n=273, 11.04%) of total vehicular accident fatalities in five year duration. 53.20% of fatal accident occurred between 6 PM and 6 AM. The results of study emphasize the need to improve the pre hospital care with provision of trauma services at site and to establish neurosurgical facilities with trauma registry.

Does the presence of Klebsiella pneumoniae carbapenemase and New Delhi metallo-β-lactamase-1 genes in pathogens lead to fatal outcome?

INTRODUCTION

Infections due to multidrug-resistant (MDR) pathogens are a medical challenge. There is considerable apprehension among clinicians regarding pathogens reported as carrying New Delhi metallo-β-lactamase-1 (NDM) and Klebsiella pneumoniae carbapenemase (KPC) genes from their patients. In the face of extremely high rates of antimicrobial resistance, it is essential to gauge the clinical significance of isolation of pathogens carrying these genes from clinical samples. This study compares the outcome of patients infected with pathogens carrying NDM/KPC genes versus those without these genes.

METHODS

The study was conducted over a 1-year period at a Level-1 trauma centre. Hospital-acquired infections were diagnosed on the basis of CDC's criteria. The correlation of isolation of a multi-resistant pathogen carrying KPC or NDM genes with the clinical outcome was ascertained.

RESULTS

A total of 276 consecutive patients admitted to the Intensive Care Units/wards of the JPNA Trauma Centre were included in this study. Of the 371 isolates recovered from these patients, 116 were from patients who had a fatal outcome. The difference in prevalence of blaNDMand blaKPCwas not significant in any genera of Gram-negative pathogens isolated from patients who survived versus those who had a fatal outcome.

CONCLUSION

Isolation of MDR pathogens carrying NDM/KPC genes from clinical samples is not always a harbinger of a fatal outcome. Efforts should be made to prevent cross-transmission of these pathogens.

Internal Carotid Artery Fibromuscular Dysplasia in a Child: Incidental Postmortem Finding after Head Injury

Fibromuscular dysplasia (FMD) is a rare, segmental, nonatheromatous, and noninflammatory arterial disease of unknown etiology. It predominantly involves renal artery (60–75%) followed by extracranial part of the internal carotid artery and vertebral arteries (25–30%). The disease typically affects middle-aged women and involves intermediate-sized arteries throughout the body. There are rare case reports of extracranial FMD compounding a trauma case. A patient was brought to trauma center emergency with a history of fall from height. There were one previous episode of seizure and two episodes of vomiting. His Glasgow Coma Scale on admission was E1V1M4. Noncontrast computed tomography of the head showed fracture on the right zygomatic, temporal, and parietal bone, with underlying thin subdural hemorrhage. The patient underwent left frontotemporoparietal decompressive craniectomy and lax duraplasty with bone flap in bone bank. On the 1^st postoperative day, he succumbed to his injuries despite timely surgery and necessary interventions. It was only postmortem when FMD was diagnosed in carotid artery by histopathological examination. On microscopy, intimal changes were seen in the form of expansion of subendothelial loose matrix with mesenchymal cells, thickening and hyalinization of the internal elastic lamina, areas of duplication and disruption of internal elastic lamina. Medial wall changes included thickening of the wall, focal loss of the smooth muscle, and replacement with fibrosis (dysplastic change). This case emphasizes the importance of considering this disease in the differential diagnosis of children and young adults with stroke (which subsequently lead to his fall).

Benefits and Pitfalls of Cadavers as Learning Tool for Ultrasound-guided Regional Anesthesia

Ultrasound-guided regional anesthesia (UGRA), like other basic skills, should be learnt in a simulation laboratory before performing on the patient. Cadavers provide an ideal tool for learning sonoanatomy and skills required for performing UGRA. On the basis of preservation technique used, the cadavers can be formalin embalmed cadavers, Thiel cadavers (soft cadavers), and fresh frozen cadavers. We compared three types of cadavers for performing ultrasound-guided upper and lower limb blocks. We observed that fresh frozen and Thiel cadavers were less smelling and had more realistic appearance as compared to formalin embalmed cadavers. It was seen that Thiel cadavers were more flexible and hence, rotation of neck, shoulder and knee was easier. Although images seen in most cadavers were comparable with live subjects but, Thiel cadavers provided more realistic model.

Battered baby syndrome

The problem of battered baby and child abuse is a much underreported condition, easily missed by the attending physician and autopsy surgeon. According to a study by the Ministry of Women and Child Development, India, in 2007, more than two-thirds (69%) of children, particularly in the age group of 5–12 years, faced physical abuse, mostly (89%) by parents. Sexual abuse occurred in over half of them (53%) and every second child faced emotional abuse, mostly by parents (83%). In this presentation, we will be sharing the experience of managing two cases of battered baby syndrome, reported at a tertiary health care centre in India.

A cadaveric microanatomical study of the fascicular topography of the brachial plexus

OBJECT

Mapping of the fascicular anatomy of the brachial plexus could provide the nerve surgeon with knowledge of fascicular orientation in spinal nerves of the brachial plexus. This knowledge might improve the surgical outcome of nerve grafting in brachial plexus injuries by anastomosing related fascicles and avoiding possible axonal misrouting. The objective of this study was to map the fascicular topography in the spinal nerves of the brachial plexus.

METHODS

The entire right-sided brachial plexus of 25 adult male cadavers was dissected, including all 5 spinal nerves (C5–T1), from approximately 5 mm distal to their exit from the intervertebral foramina, to proximal 1 cm of distal branches. All spinal nerves were tagged on the cranial aspect of their circumference using 10-0 nylon suture for orientation. The fascicular dissection of the C5–T1 spinal nerves was performed under microscopic magnification. The area occupied by different nerve fascicles was then expressed as a percentage of the total cross-sectional area of a spinal nerve.

RESULTS

The localization of fascicular groups was fairly consistent in all spinal nerves. Overall, 4% of the plexus supplies the suprascapular nerve, 31% supplies the medial cord (comprising the ulnar nerve and medial root of the median nerve [MN]), 27.2% supplies the lateral cord (comprising the musculocutaneous nerve and lateral root of the MN), and 37.8% supplies the posterior cord (comprising the axillary and radial nerves).

CONCLUSIONS

The fascicular dissection and definitive anatomical localization of fascicular groups is feasible in plexal spinal nerves. The knowledge of exact fascicular location might be translatable to the operating room and can be used to anastomose related fascicles in brachial plexus surgery, thereby avoiding the possibility of axonal misrouting and improving the results of plexal reconstruction.

Endoscopic management of post-liver transplant billiary complications: A prospective study from tertiary centre in India

BACKGROUND

Liver transplantation has become common in India over the last decade and biliary strictures after the procedure cause a significant morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) is a safe and effective treatment modality for post-transplant biliary strictures so we decided to evaluate prospectively the outcomes of endoscopic treatment in post-living donor liver transplantation (LDLT) biliary strictures.

METHODS

We studied ten consecutive patients who had developed biliary strictures (out of 312 who had undergone liver transplantation between June 2009 and June 2013) and had been referred to the Department of Gastroenterology for management. All patients underwent liver function tests, ultrasound of the abdomen, magnetic resonance cholangiography and liver biopsy, if this was indicated.

RESULTS

Of these 312 patients who underwent liver transplantation, 305 had living donors (LDLT) and 7 deceased donors (DDLT). Ten patients in the LDLT group (3.3%) developed biliary strictures. There were seven males and three females who had median age of 52 years (range 4-60 years). The biliary anastomosis was duct-to-duct in all patients with one patient having an additional duct-to-jejunum anastomosis. The mode of presentation was cholangitis in four patients (40%), asymptomatic elevation of liver enzymes in four (40%) and jaundice in two patients (20%). The median time from transplantation to the detection of the stricture was 12 months (2-42.5 months). ERCP was attempted as initial therapy in all patients: seven were managed entirely by endoscopic therapy, and three required a combined percutaneous and endoscopic approach. Cholangiography demonstrated anastomotic stricture in all patients. A total of 32 sessions of ERCP were done with mean of 3.2 (2-5) endoscopic sessions and 3.4 (1-6) stents required to resolve the stricture. The median time from the first intervention to stricture resolution was 4 months (range 2-12 months). In four patients, the stents were removed after one session and in two patients each after two, three and four sessions. In six patients more than one stent was placed and all of them required dilatation of stricture. Seven patients completed treatment and are off stents at a median follow up period of 9.5 months (7-11 months). Two patients developed recurrence of their stricture after 7.5 months. Both had long strictures and required a combined endoscopic and percutaneous approach. There was one mortality due to sepsis secondary to cholangitis.

CONCLUSIONS

Post-LDLT biliary strictures can be successfully treated with ERCP, and most patients remain well on follow up (median 9.5 months). A combined endoscopic and percutaneous approach is useful when ERCP alone fails.