EMG artifact in brain death electroencephalogram, is it a cry of "medullary death"?

The Uniform Determination of Death Act (UDDA) defines death as irreversible cessation of the functions of the entire brain including the brainstem. Many individuals meeting the clinical criteria of brain death can be documented to have some residual sub-cortical and brainstem function on careful testing. Determination of brain death still remains a persistently unresolved issue in health law and bioethics. The determination of brain death is clinical and involves testing for the integrity of brainstem functions. Documentation of irreversible cessation of brainstem functions when the cause of coma is established is usually sufficient to make a diagnosis of brain death. Confirmatory tests like four-vessel angiogram and electroencephalogram (EEG) are required in cases where the clinical testing is inconclusive or unreliable. EEG criteria for electrocerebral silence (ECS) is absence of any detectable cortical activity above 2 microV in a study performed as per the guidelines developed by the American Electroencephalographic Society. EEG studies carried out for ECS are at times contaminated by electromyographic (EMG) artifacts reflecting scalp motor unit activity. A secure EEG diagnosis of ECS cannot be made in such cases. What exactly is the relevance of scalp EMG activity in these clinically brain dead patients? What is the mechanism of generation of this spontaneous scalp EMG activity and how can the diagnosis of brain death be secured in these patients? These issues are explored in this article by highlighting a case.

Ipsilateral hemispheric ischaemic hypoxic changes during central line placement: a video-electroencephalogram correlate.

When venous access is needed for intravenous fluids or antibiotics and a peripheral site is unavailable or not suitable, a central line is placed either in the neck or the groin. Complications have been reported during central line placement including (but not limited to) pneumothorax, haemothorax, arrhythmias, air embolism and introduction of infection. The case history is reported of a patient who developed ipsilateral hemispheric ischaemic hypoxic changes during central line placement. This was represented on the surface electroencephalogram by ipsilateral hemispheric voltage attenuation.

Myoclonic epilepsy masquerading as a tic disorder.

Myoclonic epilepsies comprise a heterogeneous group of epileptic syndromes characterized by myoclonic jerks, generalized tonic-clonic seizures (GTCSs), and sometimes absence seizures (multiplicity of seizure types). JME (Juvenile Myoclonic Epilepsy) is relatively common and usually responds well to treatment with appropriate anticonvulsants. Others like the progressive myoclonic epilepsy syndromes are relentlessly progressive, associated with cognitive decline and respond poorly to anticonvulsants. Myoclonic epilepsy is frequently misdiagnosed until the patient is specifically asked about the leading symptom, i.e., jerky movements occurring in the morning. We present here a patient who had been misdiagnosed as a tic disorder and treated for the past many years before the correct diagnosis of myoclonic epilepsy was made during an admission for Video-EEG monitoring.

Brainstem death: implications in India.

Brainstem death and brain death although practically same with regards to the concept of organ donation, remain technically different. Brain death mandates irreversible cessation of all the functions of the entire brain and brainstem while brainstem death signifies irreversible damage to the brainstem. As per the Indian law, brainstem death is the legal requirement and not brain death.

Megalencephalic leukoencephalopathy with subcortical cysts.

Megalencephalic leukocncephalopathy is rare disorder seen in India in patient belonging to Agarwal community. Many of the patients may have a mild clinical course with gradual worsening of neurological disability. A case is being reported who was followed for 17 years and paradoxically showed radiological and clinical improvement.

Vibrio cholerae diarrhoea in a three-day-old breastfed neonate.

A confirmed case of cholera in a 3-day-old neonate is being reported. Possible source of infection could be by holy water (Chamamrit) given to the baby, which is common ritual in India. Mother's milk has never been reported to transmit cholera, even though mother herself may be suffering from cholera. Contaminated water can transmit the disease as there is no maternally transmitted immunity.

Childbirth spacing in a rural community of Delhi: profile in various marriage cohorts by decades.

Complete retrospective fertility histories of 843 ever married women of two villages in Delhi, obtained through house to house survey, were analysed to study various marriage cohorts by decades for trends of child birth spacing over a period of 60 years from 1921 to 1980. Spacing between consummation of marriage and first child birth gradually declined over the last 6 decades. For all other subsequent livebirths remained constant at an average of nearly 30 months. Irrespective of the reasons for such a trend, much more efforts are required to be put in to increase child spacing.

PIP: From March 1982 to April 1983, researchers from the University College of Medical Sciences in Delhi, India interviewed at least 843 women = or 15 years old and married between 1921-1980 from 2 villages near Delhi about their birth history and year of marriage. There were 3736 live births among the 843 women. 98.8% of the women married between 1921- 1970 had children. Only 182 of the 256 women married between 1971-1980 had already borne children. The spacing between consummation of marriage and the birth of the 1st child (1st birth order) decreased steadily over the 6 decades. For example, the average spacing fell from 44.86 months (1921-1930) to 40.11 (1951-1960) to 28.82 (1971-1980). During this time frame, the mean age at marriage rose gradually, but the mean age for 1st birth did not change. For each decade except 1971- 1980, the spacing for the 1st birth order remained significantly more than most of the other birth orders in that decade. The mean birth interval for all the marriage cohorts stood at 30 months. The average spacing of all births for the 1971-1980 marriage cohort was significantly lower than those of the 5 previous decades (p.05), however. This could be a result of the decline in breast feeding and sexual abstinence in urban areas of India. This trend appears to counteract the efforts of family planning programs. The results of this study indicate that the National Family Welfare Programme must more actively promote child spacing as a means to reduce family size.

Role of migratory population in keeping up endemicity of malaria in metropolitan cities of India.

Urbanisation is rapidly taking place in India. A sizeable number of people migrate to metropolitan cities to take up casual labour jobs and settle in pockets scattered all over the city. They generally pay frequent visits to their native place with a higher malarial endemicity and are believed to be important reservoirs of infection for the native population of metropolis. To investigate this problem, a survey was conducted in 1987-88 to compare the prevalence of chronic malaria in two such pockets of migrant population with that of local population of Delhi from nearby villages. Ninetyone out of 701 (12.84 per cent) immigrants investigated had fever clinically diagnosed as malaria at the time of survey, while in the native population 45 out of 646 (6.97 per cent) had such a history. The difference is statistically significant. Splenomegaly was also significantly higher in migrants (15.41 per cent) than in natives of Delhi villages (3.10 per cent). Migrant population is not covered by active surveillance and live in poor environmental conditions conducive to mosquito breeding and malaria transmission. A special attention needs to be paid to the migratory population in the anti-malaria programme in order to control the transmission of the disease in the cities.