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.

Physiological responses to divergent selection for phytate phosphorus bioavailability in a randombred chicken population.

An investigation was conducted to study insulin-like growth factor (IGF)-I, IGF-II, insulin, glucagon, leptin, triiodothyronine (T(3)), and thyroxine (T(4)) levels in a chicken population divergently selected for P bioavailability (PBA). There were differences in growth and feed efficiency between the 2 lines. Concentrations of IGF-I, IGF-II, and T(3) were significantly greater in the high PBA line compared with the low PBA line, whereas the reverse was true for glucagon. There were no correlations between IGF-I and II and PBA in either line, suggesting that the line differences may be the result of factors other than PBA. Glucagon and IGF-I have different relationships with feed conversion ratio in the high PBA line compared with the low PBA line. There was a significant correlation between PBA and T(3) in the low line and between PBA and T(4) in the high PBA line. Thyroid hormone levels may be an indirect indicator of PBA in growing chickens. The genes in the thyroid hormone pathway may be key in the identification of genes associated with PBA.

Zolpidem at supratherapeutic doses can cause drug abuse, dependence and withdrawal seizure.

Zolpidem is a non-benzodiazepine hypnotic drug, acts selectively through omega 1 receptors of GABAA. It is thought to be safer than benzodiazepines but we report a case of zolpidem drug abuse, dependence and withdrawal seizure.

A new familial syndrome characterized by pigmentary retinopathy, hypogonadism, mental retardation, nerve deafness and glucose intolerance.

Three siblings with retinitis pigmentosa, deafness and mental retardation were studied. Physical abnormalities included nystagmus, acanthosis nigricans and multiple keloids. The two male siblings had gynecomastia, small testes and mild subvirilization whereas the only indication of hypogonadism in the female sibling was oligomenorrhea. Testosterone levels in the males, which were in the low to low normal range, were increased by the administration of large doses of chorionic gonadotropin. The two affected males had elevated plasma luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels which were decreased by the administration of testosterone and increased by the administration of clomiphene. One sibling had mild obesity and diabetes mellitus, one had moderate obesity, normal glucose tolerance and hyperinsulinism and the third had abnormal glucose tolerance and hyperinsulinism. This familial syndrome is distinct from either the Laurence-Moon, Bardet-Biedl or Alström disorders and provides further evidence of genetic heterogeneity in this group of autosomal recessive traits.

Persistent proatlantal artery with carotid-vertebral anastomosis. Case report.

The authors describe the occurrence of proatlantal artery as an incidental angiographic observation in a young Indian soldier. This primitive anastomotic channel is seen extending from near the origin of the external carotid artery to the suboccipital region, traversing the foramen magnum and coursing beyond like a vertebral artery. The developmental and roentgenological aspects of carotid-basilar and carotid-vertebral anastomosis are discussed, along with a review of four similar cases reported previously.

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.

Primary antiphospholipid syndrome in stroke in the young.

Antiphospholipid syndrome is an uncommon cause of stroke. A 12 year old girl with this syndrome is reported who presented with thrombotic stroke and high titres of anticardiolipin (aCL) and lupus anticoagulant (LAC). The patient improved subsequently and was put on aspirin. The present report highlights the importance of screening for aCL and LAC in cases of stroke in young patients.

Mathematical modelling and field trials of an inexpensive endoskeletal above-knee prosthesis.

The swing-phase motion of the shank of an above-knee prosthesis has been modelled mathematically. An inexpensive endoskeletal prosthesis was designed using the Jaipur foot and conduit pipes with a hinge joint for the knee. Results of field trials and the modelling indicate that a very simple above-knee prosthesis can give near normal gait at "normal" walking speeds on flat surfaces. The swing of the shank is most sensitive to the timing of toe-off.

Use of John Cunningham virus polymerase chain reaction in the diagnosis of progressive multifocal leucoencephalopathy - a rare presenting manifestation in an HIV-positive patient.

John Cunningham virus infection is an important cause of progressive multifocal leucoencephalopathy (PML) in the context of advanced human immunodeficiency virus infection. Limited data are available regarding the true incidence of PML as a presenting manifestation of HIV. We report one such case and also highlight the effective use of polymerase chain reaction in confirming its diagnosis.