Prevalence and Risk Factors of Cerebral Microbleeds in Community-Dwelling Adults in Urban Delhi.

BACKGROUND: Several observational studies have reported the prevalence of cerebral microbleeds (CMBs) and their risk factors in an elderly population. Any information in this regard is currently lacking from India. Aim of this study was to estimate the prevalence, risk factors of CMBs, and association with cognition in an Indian urban population aged 50 years and above. METHODS: Household surveys were conducted as part of ongoing Longitudinal Cognition and Aging Research on Population of the National Capital Region (LoCARPoN) study in areas of urban Delhi. Magnetic resonance imaging of the brain was performed in 2599 participants. Using standard neuropsychological battery, mean Z-scores for each domain (memory, executive, information) were derived. Binary and stepwise logistic regression models were used to determine associated risk factors for the presence of CMB and its association with cognitive domains. RESULTS: The prevalence of CMBs was 14.42% (95% confidence interval [CI]: 13.06-15.73). Of these, 203 (7.81%) participants had single CMBs and 172 (6.61%) had multiple microbleeds (≥2). Higher prevalence was observed in older age (60-70 years: odds ratio [OR]: 1.25 [95% CI: 0.93-1.67]; 70-80 years: OR: 2.05 [95% CI: 1.48-2.84]; ≥80 years: OR: 3.27 [95% CI: 1.97-5.44]) compared to individuals in the age group 50-60 years. History of stroke (OR: 2.97 [95% CI: 1.56-5.66]), hypertension (OR: 1.36 [95% CI: 1.05-1.75]), and smoking (OR: 1.43 [95% CI: 1.11-1.85]) was associated with at least one CMB. Multiple CMBs were associated with worse scores in memory and executive domains. CONCLUSION: Older age, hypertension, history of stroke, and history of smoking emerged as important risk factors for the presence of multiple CMBs. Follow-up study is required to determine implications of CMBs.

Orientia tsutsugamushi: An Unusual Intracellular Bacteria-Adaptation Strategies, Available Antibiotics, and Alternatives for Treatment.

During evolution Orientia tsutsugamushi became a smarter obligate bacterium to establish as intracellular pathogens. O. tsutsugamushi is a human pathogenic bacterium responsible for 1 billion infections of scrub typhus. Several novel mechanisms make this bacterium unique (cell wall, genetic constitutions, secretion system, etc.). In 2007, O. tsutsugamushi Boryong was pioneer strain for whole-genome sequencing. But the fundamental biology of this bacterial cell is a mystery till date. The unusual biology makes this organism as model for host cell interaction. Only a few antibiotics are effective against this intracellular pathogen but emergence of less susceptibility toward antibiotics make the situation alarming. The review was captivated to highlight the unusual aspects of adaptation, antibiotics, and drugs beyond antibiotics.

Profile of diseases prevalent in Datia District of Madhya Pradesh, India.

Background and objectives: Exploring the disease profile in a defined area helps policymakers to understand local health issues. It is essential to collect such information in countries, like India, which have a wide range of socioeconomic, geographic, and cultural diversity. Madhya Pradesh is the second largest state of India and has diversified populations living in urban, rural, and tribal areas. In this study, we performed a hospital record-based analysis to find out the status of different diseases in various outpatient departments (OPDs) of the District Hospital where patients from both rural and urban areas are treated. Materials and methods: The retrospective data was collected from medical records available for the period September 2018 to September 2020. These datasets were analyzed to determine the most common presentations among patients. Results and conclusions: A total of 138,756 records of patients were available for this study, whose department-wise analysis revealed that most records were related to respiratory tract infection, superficial dermatophytosis, anemia among women, suppurative otitis media, and pneumonia. This study provides a broad overview of the overall health issues of people living in rural and urban areas of Datia. However, a major limitation of the study was that other correlations with age and gender were not established due to the absence of such information. Nonetheless, these findings will help policymakers and researchers to set the agenda for interventions and set goals for achieving better health for all people including those living in rural and tribal regions.

Point-of-care blood clotting test and its correlation with fibrinogen level: Potential in goal-directed transfusion in postpartum hemorrhage.

OBJECTIVE: To study the correlation of conventional point-of-care clotting test (POCCT) of whole blood with laboratory fibrinogen levels in women with primary major postpartum hemorrhage (PPH) to generate evidence regarding its potential in rationalizing transfusion of blood components for supplementing fibrinogen. METHODS: A total of 68 samples were studied: 40 from women with primary major PPH, 20 from women without PPH, and eight samples of Fresh Frozen Plasma (FFP). POCCT was performed in the PPH and non-PPH groups and at the same time, sample for laboratory fibrinogen was sent. Values were correlated using Pearson's correlation coefficient (r). Depending upon the laboratory fibrinogen values, POCCT in the PPH group was divided into three subgroups of less than 7, 7-11, and more than >11 min as subgroups 1, 2, and 3, respectively. RESULTS: Women in the PPH group (n = 40) had a mean fibrinogen level of 346.15 ± 143.37 mg% with a significant negative correlation with POCCT (r = -0.69, P < 0.001). Mean fibrinogen levels of non-PPH group and FFP samples were 602.1 ± 169.72 and 286.75 ± 103.42 mg%, respectively. PPH subgroups 1, 2, and 3 had mean fibrinogen of 452.2 ± 141.8, 332.58 ± 138.51, and 158.71 ± 145 mg%, respectively. These values may potentially guide FFP transfusions. CONCLUSION: POCCT is easy, costs nothing and has a potential role in rationalizing FFP transfusion in low- and middle-income countries.

Evolution of reduced minimum critical size as a response to selection for rapid pre-adult development in Drosophila melanogaster.

Adult body size in holometabolus insects is directly proportional to the time spent during the larval period. The larval duration can be divided into two parts: (i) pre-critical duration-time required to attain a critical size/critical weight that would result in successful completion of development and metamorphosis even under non-availability of nutrition beyond the time of attainment of critical size, and (ii) post-critical duration-the time duration from the attainment of critical size till pupation. It is of interest to decipher the relative contribution of the two larval growth phases (from the hatching of the egg to the attainment of critical size, and from the attainment of critical size to pupation) to the final adult size. Many studies using Drosophila melanogaster have shown that selecting populations for faster development results in the emergence of small adults. Some of these studies have indirectly reported the evolution of smaller critical size. Using two kinds of D. melanogaster populations, one of which is selected for faster/accelerated pre-adult development and the other their ancestral control, we demonstrate that the final adult size is determined by the time spent as larvae post the attainment of critical size despite having increased growth rate during the second larval instar. Our populations under selection for faster pre-adult development are exhibiting adaptive bailout due to intrinsic food limitation as against extrinsic food limitation in the yellow dung fly.

Efficacy and Feasibility of Chhattisgarh Balloon and Conventional Condom Balloon Tamponade: A 2-Year Prospective Study.

OBJECTIVE: To evaluate the clinical efficacy of two types of condom uterine balloon tamponade systems, namely Chhattisgarh condom balloon device "CG balloon (CGB)" having a central drainage channel as well as indigenous tying system to fasten condom to the catheter and conventional condom uterine balloon device (C-UBT) as a second-line intervention in post-partum haemorrhage (PPH). MATERIALS AND METHODS: The present non-randomised prospective case series was carried out from December 2014 to September 2016 and included 60 women having PPH which was refractory to first-line management and who were treated with either of the two condom balloon tamponade devices prepared on spot. Women with allergy to latex, retained placenta, uterine rupture, anomaly, genital infection and/or malignancy were excluded. Case report forms were filled for all participants and analysed. Primary outcome was arrest of haemorrhage, and one of the secondary outcomes was cost and consistency of the devices. RESULTS: CGB was used in 46 and C-UBT in 14 women. The overall success rate was 98.33%. The mean blood loss was 1417 mL. Women of C-UBT group had greater blood loss, higher inflation volume and delays due to technical issues (OR 7.6). CGB was cheaper and more consistent than C-UBT by omitting the use of suture material. CONCLUSION: CGB and conventional condom balloon tamponade both are easy to use, feasible and efficacious for control of PPH, but CGB condom balloon device has the advantage of a central drainage lumen for real-time assessment of blood loss and therefore early corrective action.

Role of intravenous tranexamic acid in reducing blood loss during caesarean section: Study at tribal-dominated area hospital in Chhattisgarh, India.

AIM: To evaluate the effect of low dose (1 g) of intravenous tranexamic acid (TXA) before caesarean delivery upon the mean blood loss during and after surgery as well side effects of the drug and to compare these effects with those who did not receive this medication in a referral hospital situated at the tribal terrain of Chhattisgarh. METHODS: Total 100 women fulfilling inclusion criteria and shifted for caesarean section were studied. Fifty women comprising the study group were given one gram TXA (10 mL) intravenously over 10-20 min before skin incision whereas the other 50 women did not receive the drug (control group). Active Management of the Third Stage of Labor was done in all using 10 units of oxytocin intramuscularly within one minute of delivery of baby. The blood loss was quantified by the combination of gravimetric and direct measurement. RESULTS: The mean blood loss (intra as well as postoperative) was 436.5 ± 118.07 mL in the study group in comparison to 616.5 ± 153.34 mL in the control group (P ≤ 0.05), only two (4%) women had a blood loss >500 mL during surgery versus nine (18%) (P ≤ 0.05), none versus three (6%) had PPH and postoperative mean change in the hemoglobin was 0.494 ± 0.12 g % versus 0.594 ± 0.16 g % (P ≤ 0.05) in the study and control groups, respectively. No adverse effects were reported in women or neonates. CONCLUSION: TXA is a cheap, easily available antifibrinolytic drug that significantly reduces the intra and postoperative blood loss in caesarean section and is very useful for low resource settings.

Decision Delivery Interval in Emergency and Urgent Caesarean Sections: Need to Reconsider the Recommendations?

Introduction: The timeline between a decision made and delivery of the baby is termed decision delivery interval (DDI). According to current recommendations, an emergency caesarean section must be performed within 30 min of the decision. The present study was conducted with an objective to assess DDI in a busy obstetric unit in India and its impact on obstetric outcome. Material and Method: A total of 480 women with indications of category I (emergency): Immediate threat to life of woman or foetus (n = 66), and category II (urgent): Maternal or foetal compromise but not immediately life-threatening (n = 414), were studied in the context of DDI and composite adverse perinatal outcomes including fresh stillbirth, 5-min Apgar score <7 and NICU admission. Result: Recommended DDI of <30 min could be achieved in 30% cases of emergency CS only. Sixty-three per cent with prolapsed cord could be delivered within 30 min. The composite neonatal outcomes were not significantly increased up to DDI of 60 min for category I (emergency) (except in prolapsed cord) and up to 90 min in category II (urgent) caesarean sections. Conclusion: Authors propose reconsideration of the present recommendations of DDI in categories I and II, while Crash CS (cord prolapse or catastrophic antepartum haemorrhage) should be a separate group with recommended DDI of 30 min. For the remaining cases in the present emergency CS group, the suggested DDI of 60 and, for urgent group, 90 min may be made following further studies to prevent this DDI yardstick from becoming a rod at our back.

Diffusion tensor imaging tractography study in bipolar disorder patients compared to first-degree relatives and healthy controls.

AIM: We aimed to compare white matter structural changes in specific tracts by diffusion tensor imaging (DTI) tractography in patients with bipolar disorder (BD) I, non-ill first-degree relatives (FDR) of the patients, and healthy controls (HC). METHODS: In a cross-sectional study, we studied right-handed subjects consisting of 16 euthymic BD I patients, 15 FDR, and 15 HC. The anterior thalamic radiation, uncinate fasciculus, corpus callosum, and cingulum bundle were reconstructed by DTI tractography. Mean fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were compared for group differences followed by post-hoc analysis. RESULTS: The three groups did not differ in terms of sociodemographic variables. There were significant group differences in the FA values among the BD I patients, their FDR, and the HC for the corpus callosum, the dorsal part of the right cingulum bundle, the hippocampal part of the cingulum bundle bilaterally, and the uncinate fasciculus (P < 0.001). The FA values in the patients were significantly lower than in controls, and FDR also showed similar differences; however, they were smaller than those in patients. No significant difference was found between the groups for FA values of the dorsal part of the left cingulum bundle and anterior thalamic radiation. Significant differences were present for ADC values among the groups for the corpus callosum, the dorsal and hippocampal parts of the cingulum, anterior thalamic radiation, and uncinate fasciculus bilaterally (P < 0.01). The FA and ADC values did not correlate significantly with age or any clinical variables. CONCLUSION: These findings suggest that BD patients and their FDR show alterations in microstructural integrity of white matter tracts, compared to the healthy population.

Vein of Galen aneurysmal malformation-clinical and angiographic spectrum with management perspective: an institutional experience.

BACKGROUND AND PURPOSE: Vein of Galen aneurysmal malformation (VGAM) is a rare developmental intracranial vascular malformation. We analyzed the clinical presentations, imaging findings, angioarchitecture, management options, and outcome in a demographically heterogeneous set of VGAM patients. METHODS: We retrospectively analyzed cases of VGAM from our departmental archive collected between 1988 and January 2015. Demographic, clinical, therapeutic, and follow-up details were obtained for each patient from the available records. RESULTS: We identified 36 patients with VGAM including 6 neonates, 18 infants, 7 children aged 2-10 years, and 5 adults. Macrocrania was the commonest presenting feature. Type of fistulae was mural in 14 and choroidal in 18 patients while 4 had a thrombosed sac at presentation. In 3 cases the dilated venous sac had connection with the deep venous system. Bilateral jugular atresia and stenosis were seen in 9 and 6 patients, respectively. Giant venous sac (>4 cm) was significantly correlated with mural type (p=0.0001). Dural arterial recruitment was seen in 4 patients including 3 adults. Among the 23 patients treated by endovascular means, 14 had a good outcome, 5 had a poor outcome, and 4 died. A significant correlation was noted between jugular atresia and poor outcome (p=0.003). CONCLUSIONS: We encountered a wide range of demographic, clinical, and angiographic features in VGAM. Mural type malformations were associated with giant venous sacs. Good outcome after embolization was seen in selected neonates and in most of the infants, children, and adults. Jugular atresia was significantly associated with poor outcome.

Study of Abnormal Liver Function Test during Pregnancy in a Tertiary Care Hospital in Chhattisgarh.

INTRODUCTION: Abnormal liver function tests (LFTs) in pregnancy require proper interpretation in order to avoid pitfalls in the diagnosis. The underlying disorder can have a significant effect on the outcome of both mother and foetus. The present study was done with the objective to study the clinical profile, incidence and possible causes of derangements of liver function tests. MATERIAL AND METHOD: Eighty pregnant women with abnormal liver dysfunction were studied prospectively. Women with chronic liver disease and drug-induced abnormal liver function test were excluded. All available LFTs including LDH were studied along with some more definitive tests to aid identification of underlying cause. Foetomaternal outcome was noted in all. RESULT: The incidence of abnormal LFT was 0.9 %. 13/80 (16.75 %) women had liver disorder not specific to pregnancy, whereas 67/80 (83.25 %) women had pregnancy-specific liver dysfunction. Of these, 65(81.25 %) women with liver dysfunction had pre-eclampsia including 11 (13.75 %) with HELLP and six women with eclampsia. 48/65 (60 %) women had pre-eclampsia in the absence of HELLP syndrome or eclampsia. The mean value for bilirubin (mg %) in hypertensive disorders of pregnancy ranged from 1.64 to 3.8, between 5 and 10 for ICP and AFLP and >10 in infective hepatitis. Transaminases were highest in infective hepatitis, whereas alkaline phosphate was highest in ICP. Total 27 (33.75 %) women suffered from adverse outcome with four (5 %) maternal deaths and 23 (28.75 %) major maternal morbidities. 33/80 (41.25 %) women had intrauterine death. 26.25 % babies were small for date. CONCLUSION: Pregnancy-specific disorders are the leading cause of abnormal liver function test during pregnant state particularly in the third trimester. Pre-eclampsia-related disorder is the commonest. Gestational age of pregnancy and relative values of various liver function tests in different pregnancy-specific and pregnancy nonspecific disorders appear to be the best guide to clinch the diagnosis.

Free Antropyloric Valve Flap for End-Stage Fecal Incontinence as a Substitute to Permanent Colostomy.

BACKGROUND: Surgical removal of the anal canal and sphincter for carcinoma results in end-stage fecal incontinence (ESFI) and requires a permanent colostomy resulting in significant impact on quality of life. Presently, there are limited options for EFSI. The successful use of pedicled antropyloric valve (APV) based on left gastroepiploic artery as an alternative to permanent colostomy has previously been described. It is based on a long omental pedicle which at times is risky and is difficult to perform. A free APV flap could be the only solution in such cases. We assessed the vascular anatomy for the technical feasibility of a free APV flap, and report the first ever clinical application of free APV flap. METHODS: Bench dissection of 10 pancreaticoduodenectomy specimens was done to delineate the vessels of APV flap. It showed the consistent presence of right gastroepiploic and infrapyloric vessels in all specimens with sufficient diameters. After the technical feasibility, a free APV Flap transposition to perineum was done in a patient, where pedicled transposition was not feasible. RESULTS: The free APV flap with vagus nerve branch was harvested without extensive dissection along the greater curvature of stomach. A tension free anastomosis was achieved between the epiploic and left colic vessels. The flap survived well and had a definite tone on digital examination. It was evaluated by radiological and manometric methods. CONCLUSIONS: APV flap for EFSI can be done as a free flap with distinct advantages and it has the potential of becoming popular options for EFSI.

Spinal cord involvement and contrast enhancement in posterior reversible encephalopathy syndrome.

Although posterior reversible encephalopathy syndrome (PRES) is a widely encountered clinicoradiological entity, spinal cord involvement on MRI is very rarely reported. We found only eight cases that have been reported so far. Reports of post-contrast meningeal or parenchymal enhancement in PRES are even rarer. Herein we report a case of PRES with extensive spinal cord signal abnormality with contrast enhancement. Familiarity with this rare imaging finding of PRES, in the appropriate clinical setting, will avoid unnecessary investigations and inappropriate treatment.

3D Rotational Angiography in Follow-Up of Clipped Intracranial Aneurysms.

Introduction. 3D Rotational Angiography (RA) is indispensable for evaluation of intracranial aneurysms, providing infinite viewing angles and defining the aneurysm morphology. Its role in follow-up of clipped aneurysms remains unclear. We aimed to compare the aneurysm residue/recurrence detection rate of 3D RA with 2D digital subtraction angiography (DSA). Methods. 47 patients harboring 54 clipped aneurysms underwent both 2D DSA and 3D RA. The residual/recurrent aneurysms were classified into five grades and the images of both modalities were compared. Results. The residual/recurrent aneurysm detection rate was 53.70% (29/54 aneurysms) with 2D DSA and 66.67% (36/54 aneurysms) with 3D RA (P = 0.05). In 12 aneurysms, 3D RA upgraded the residue/recurrence among which nine had been completely not detected on 2D DSA and were found to have grade one or two residual necks on the 3D RA, and, in three cases, a small neck on 2D DSA turned out to be aneurysm sac on 3D RA. In a total of 5 aneurysms, the classification was downgraded by 3D RA. Conclusion. 3D RA picks up more aneurysm residue/recurrence; hence, both 2D DSA and 3D RA should be performed in follow-up evaluation of clipped aneurysms.

Peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a rare type of cardiomyopathy of unknown aetiology associated with significant mortality and morbidity and characterized by heart failure in late pregnancy or puerperium. Recently PPCM workshop committee has recommended inclusion of echocardiographic features of LV dysfunction to redefine PPCM. Subsequent pregnancies are associated with a very high mortality in these patients and hence should be avoided. Women with PPCM continue to have significant mortality despite the use of conventional drugs for managing heart failure. Use of newer drugs such as immunoglobulin, pentoxifylline, bromocriptine, and cabergoline along with newer interventions such as plasmapheresis, immunoadsorption, ventricular assist devices and last but not the least the heart transplantation hold promise for future.

Autologous intravenous bone marrow mononuclear cell therapy for patients with subacute ischaemic stroke: a pilot study.

BACKGROUND & OBJECTIVES: Bone marrow mononuclear cell therapy has emerged as one of the option for the treatment of Stroke. Several preclinical studies have shown that the treatment with mononuclear cell (MNCs) can reduce the infarct size and improve the functional outcome. We evaluated the feasibility, safety and clinical outcome of administering bone marrow mononuclear cell (MNCs) intravenously to patients with subacute ischaemic stroke. METHODS: In a non-randomized phase-I clinical study, 11 consecutive, eligible and consenting patients, aged 30-70 yr with ischaemic stroke involving anterior circulation within 7 to 30 days of onset of stroke were included. Bone marrow was aspirated from iliac crest and the harvested mononuclear cells were infused into antecubital vein. Outcomes measured for safety included immediate reactions after cell infusion and evidence of tumour formation at one year in whole body PET scan. Patients were followed at week 1, 4-6, 24 and 52 to determine clinical progress using National Institute of Health Stroke Scale (NIHSS), Barthel Index (BI), modified Rankin Scale (mRS), MRI, EEG and PET. Feasibility outcomes included target-dose feasibility. Favourable clinical outcome was defined as mRS score of 2 or less or BI score of 75 to 100 at six months after stem cell therapy. RESULTS: Between September 2006 and April 2007, 11 patients were infused with bone-marrow mononuclear cells (mean 80 million with CD-34 + mean 0.92 million). Protocol was target-dose feasible in 9 patients (82%). FDG-PET scan at 24 and 52 wk in nine patients did not reveal evidence of tumour formation. Seven patients had favourable clinical outcome. INTERPRETATION & CONCLUSIONS: Intravenous bone marrow mononuclear cell therapy appears feasible and safe in patients with subacute ischaemic stroke. Further, a randomized controlled trial to examine its efficacy is being conducted.