Deep neck abscess after intubation trauma: a case report.

Significant injuries from endotracheal intubation are exceedingly rare but can lead to life-threatening complications, such as pharyngeal perforation. This type of perforation can result in abscess formation and airway compromise. Risks for this complication include operator skill and intubation in emergent situations. This case report details a 59-year-old male who underwent elective septoplasty with bilateral nasal turbinate reduction. The procedure required general anesthesia induction and endotracheal intubation. He developed a gradually enlarging right-sided neck mass with associated fevers, neck pain, odynophagia, and dysphonia. He presented to the emergency department on postoperative day 5 and was diagnosed with a right-sided, prevertebral space abscess with airway mass effect secondary to pharyngeal perforation. He was admitted for operative management, intravenous antibiotics, and was successfully treated. While significant injury from endotracheal intubation is rare, it can result in infection and threaten airway patency. Emergency physicians must recognize pharyngeal perforation as a potential source of infection following instrumentation of the pharynx. This case has been reported to increase awareness of the potential for such injury.

Practicality and cost-effectiveness of using MRI compatible EEG system in the critical care setting.

BACKGROUND: Continuous video-EEG (cvEEG) monitoring is a vastly utilized tool for monitoring critically ill patients in the intensive care unit. Our study investigates the clinical utility and cost-effectiveness of using MRI Compatible EEG electrode system for patients being monitored in the intensive care unit. METHODS: This retrospective study included 14 critically ill patients who underwent cvEEG between March 2019 to March 2020. They were classified into 2 subgroups: Group 1- 'MRI-compatible EEG' (mean age: 56.00 ± 19.99 years; M:F = 2:5; N = 7), Group 2 - 'Conventional EEG' (mean age: 49.14 ± 24.76 years; M:F = 4:3; N = 7). The EEG monitoring times as well as cost-effectiveness of cvEEG between the groups were compared using Mann-Whitney Test (p ≤ 0.05). We also compared the MRI quality between the groups using Chi-squared test (p ≤ 0.05). RESULTS: The EEG non-monitored time in Group 2 (7.62 ± 6.45 h) was significantly higher than Group 1 (2.71 ± 2.34 h)] (p = 0.025). The average daily cost for cvEEG in Group 1 ($2098.53 ± 493.58) and Group 2 ($2230.58 ± 142.73) was comparable (p = 0.896). The quality of MRI scans between Group 1 (6/7) and 2 (6/7) were also comparable (p = 1.000). CONCLUSIONS: The monitoring time lost in patients with MRI Compatible EEG electrodes was significantly lower than the patients with Conventional EEG electrodes. The daily cost of monitoring and the quality of MRI scans were comparable between the 2 groups. We conclude that the use of MRI Compatible EEG electrodes is a practical and cost-effective method to improve the quality of monitoring in critically ill patients.

Sleep profile and Polysomnography in patients with drug-resistant temporal lobe epilepsy (TLE) due to hippocampal sclerosis (HS) and the effect of epilepsy surgery on sleep-a prospective cohort study.

OBJECTIVES: We analyzed changes in sleep profile and architecture of patients with drug-resistant TLE-HS using three validated sleep questionnaires- Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), NIMHANS Comprehensive Sleep Disorders, and polysomnography (PSG). We studied the effect of epilepsy surgery in a subset of patients. METHODS: In this prospective observational cohort study, sleep profile of 40 patients with drug-resistant TLE-HS was compared to 40 healthy matched controls. Sleep architecture of 22 patients was studied by overnight PSG and compared to 22 matched controls. Sleep profile was reassessed in 20 patients after a minimum period of three months after epilepsy surgery. RESULTS: The mean PSQI was higher among patients compared to controls(P=0.0004) while mean ESS showed no difference. NCSDQ showed fewer patients feeling refreshed after a night's sleep compared to controls (p=0.006). PSG revealed a higher time in bed (p=0.0001), longer total sleep time (p=0.006) and more time spent in NREM stage 1 (p=0.001) and stage 2 (p=0.005) while spending less time in stage 3 (p=0.039) among TLE patients. Sleep efficiency was worse in patients on ≥3 ASMs compared to those on 2 ASMs (p-0.044). There was no change in mean ESS (p=0.48) or PSQI (p=0.105) after surgery. CONCLUSIONS: Patients with drug-resistant TLE-HS have an altered sleep profile and architecture. Patients on ≥3 ASMs have a lower sleep efficiency. Reassessment at short intervals after epilepsy surgery did not reveal significant changes in sleep profile.

Neurovascular networks in epilepsy: Correlating ictal blood perfusion with intracranial electrophysiology.

Perfusion patterns observed in Subtraction Ictal SPECT Co-registered to MRI (SISCOM) assist in focus localization and surgical planning for patients with medically intractable focal epilepsy. While the localizing value of SISCOM has been widely investigated, its relationship to the underlying electrophysiology has not been extensively studied and is therefore not well understood. In the present study, we set to investigate this relationship in a cohort of 70 consecutive patients who underwent ictal and interictal SPECT studies and subsequent stereo-electroencephalography (SEEG) monitoring for localization of the epileptogenic focus and surgical intervention. Seizures recorded during SEEG evaluation (SEEG seizures) were matched to semiologically-similar seizures during the preoperative ictal SPECT evaluation (SPECT seizures) by comparing the semiological changes in the course of each seizure. The spectral changes of the ictal SEEG with respect to interictal ones over 7 traditional frequency bands (0.1 to 150Hz) were analyzed at each SEEG site. Neurovascular (SEEG/SPECT) relations were assessed by comparing the estimated spectral power density changes of the SEEG at each site with the perfusion changes (SISCOM z-scores) estimated from the acquired SISCOM map at that site. Across patients, a significant correlation (p<0.05) was observed between spectral changes during the SEEG seizure and SISCOM perfusion z-scores. Brain sites with high perfusion z-score exhibited higher increased SEEG power in theta to ripple frequency bands with concurrent suppression in delta and theta frequency bands compared to regions with lower perfusion z-score. The dynamics of the correlation of SISCOM perfusion and SEEG spectral power from ictal onset to seizure end and immediate postictal period were also derived. Forty-six (46) of the 70 patients underwent resective epilepsy surgery. SISCOM z-score and power increase in beta to ripple frequency bands were significantly higher in resected than non-resected sites in the patients who were seizure-free following surgery. This study provides for the first time concrete evidence that both hyper-perfusion and hypo-perfusion patterns observed in SISCOM maps have strong electrophysiological underpinnings, and that integration of the information from SISCOM and SEEG can shed light on the location and dynamics of the underlying epileptic brain networks, and thus advance our anatomo-electro-clinical understanding and approaches to targeted diagnostic and therapeutic interventions.

Cutaneous Carcinosarcoma: A Small Case Series and Review of the Literature of a Rare Skin Tumor.

Carcinosarcomas are composed of epithelial and mesenchymal elements and primarily present within visceral organs. Despite being potentially aggressive, they are a rare diagnosis in the skin, and few manifestations have been reported to date. In this report, we describe two separate cases of carcinosarcoma presenting as nonhealing scalp wounds. Patient A: a 57-year-old male with a nonhealing skin lesion of ten years successfully treated with wide-local excision and local ortichochea flap reconstruction. Patient B: a 75-year-old female that presented with a painless, slow-growing hemorrhagic mass of 7 years invading the skull and dura ultimately requiring craniectomy and free-tissue transfer with anterolateral thigh flap. Cutaneous carcinosarcomas have more favorable outcomes due to low metastatic rates likely due to earlier detection, but delayed presentation can be fatal. Histopathological analysis is critical for determining diagnosis and prognosis. Adequate reconstruction after wide base excision varies and follows the reconstructive ladder/elevator ranging from primary closure up through free-tissue transfer. With cutaneous manifestations of carcinosarcoma seldom reported in the literature, it is our hope that reporting unusual instances such as this will raise awareness and allow for earlier diagnoses, treatments, and reconstructions.

Almost Perfect Metals in One Dimension.

We show that a one-dimensional quantum wire with as few as two channels of interacting fermions can host metallic states of matter that are stable against all perturbations up to qth order in fermion creation or annihilation operators for any fixed finite q. Thus, the leading relevant perturbations are complicated operators that are expected to modify the physics only at very low energies, below accessible temperatures. The stability of these non-Fermi liquid fixed points is due to strong interactions between the channels, which can (but need not) be chosen to be purely repulsive. Our results might enable elementary physical realizations of these phases.

Enhanced stability of C-phycocyanin colorant by extrusion encapsulation.

C-phycocyanin (C-PC) a blue color phycobiliproteins used as a food colorant, therapeutics, medicines, health food and biomarkers. In the present study, morphological property of encapsulated C-PC and its stability under various conditions like temperature, pH conditions are discussed. Microencapsulated droplets formed by extrusion found to be spherical with average size 1.2 ± 0.1 mm. SEM micrographs of freeze dried encapsulate confirmed the spherical shape. The effect of droplet formation with varying alginate percentage (1.5%, 2.0% and 2.5% w/v) was studied. In the stability test at 70 °C and 80 °C relative concentration (CR  %) was found to be 86.89 and 88.19%, respectively. The encapsulated C-PC showed a slow degradation at higher temperature compared to without encapsulated C-PC which was confirmed by UV-visible absorbance. At 45 °C and 55 °C temperatures the stability was studied at various pH conditions (pH 4.5, 5.5, 6.5, and 7.0) and reported. Aggregation of C-PC protein will not change during encapsulation was confirmed by SDS-PAGE. FTIR analysis of encapsulate and the alginate depicted similar characteristics of the compound compared to that of native C-phycocyanin colorant. Microencapsulation improves the stability and increases the shelf life of colorant.

Observation of the 4π-periodic Josephson effect in indium arsenide nanowires.

Quantum computation by non-Abelian Majorana zero modes (MZMs) offers an approach to achieve fault tolerance by encoding quantum information in the non-local charge parity states of semiconductor nanowire networks in the topological superconductor regime. Thus far, experimental studies of MZMs chiefly relied on single electron tunneling measurements, which lead to the decoherence of the quantum information stored in the MZM. As a next step towards topological quantum computation, charge parity conserving experiments based on the Josephson effect are required, which can also help exclude suggested non-topological origins of the zero bias conductance anomaly. Here we report the direct measurement of the Josephson radiation frequency in indium arsenide nanowires with epitaxial aluminium shells. We observe the 4π-periodic Josephson effect above a magnetic field of ≈200 mT, consistent with the estimated and measured topological phase transition of similar devices.

Topological Exciton Fermi Surfaces in Two-Component Fractional Quantized Hall Insulators.

A wide variety of two-dimensional electron systems allow for independent control of the total and relative charge density of two-component fractional quantum Hall (FQH) states. In particular, a recent experiment on bilayer graphene (BLG) observed a continuous transition between a compressible and incompressible phase at total filling ν_{T}=1/2 as charge is transferred between the layers, with the remarkable property that the incompressible phase has a finite interlayer polarizability. We argue that this occurs because the topological order of ν_{T}=1/2 systems supports a novel type of interlayer exciton that carries Fermi statistics. If the fermionic excitons are lower in energy than the conventional bosonic excitons (i.e., electron-hole pairs), they can form an emergent neutral Fermi surface, providing a possible explanation of an incompressible yet polarizable state at ν_{T}=1/2. We perform exact diagonalization studies that demonstrate that fermionic excitons are indeed lower in energy than bosonic excitons. This suggests that a "topological exciton metal" hidden inside a FQH insulator may have been realized experimentally in BLG. We discuss several detection schemes by which the topological exciton metal can be experimentally probed.

NREM Sleep and Antiepileptic Medications Modulate Epileptiform Activity by Altering Cortical Synchrony.

INTRODUCTION: The activating role of non-rapid eye movement (NREM) sleep on epileptic cortex and conversely, the seizure remission brought about by antiepileptic medications, has been attributed to their effects on neuronal synchrony. This study aims to understand the role of neural synchrony of NREM sleep in promoting interictal epileptiform discharges (IEDs) in patients with epilepsy (PWE) by assessing the peri-IED phase synchrony during awake and sleep states. It also studies the role played by antiepileptic drugs (AEDs) on EEG desynchronization in the above cohort. METHODS: A total of 120 PWE divided into 3 groups (each n = 40; juvenile myoclonic epilepsy [JME], temporal lobe epilepsy [TLE]. and extratemporal lobe epilepsy [Ex-TLE]) were subjected to overnight polysomnography. Each patient group was subdivided into drug-naive and on treatment (Each n = 20). EEG phase synchronization analysis was performed to compare peri-IED phase synchronization indices (SI) during awake and sleep stages and between drug naïve and on treatment groups in 4 frequency bands, namely delta, theta, alpha, and beta. The mean ± SD of peri-IED SI among various subgroups was compared employing a multilevel mixed effects modeling approach. RESULTS: Patients with JME had increased peri-IED cortical synchrony in N3 sleep stage, whereas patients with partial epilepsy had increased IED cortical synchrony in N1 sleep stage. On the other hand, peri-IED synchrony was lower during wake and REM sleep. We also found that peri-IED synchronization in patients with JME was higher in drug-naive patients compared with those on sodium valproate monotherapy in theta, alpha, and beta bands. CONCLUSION: The findings of this study suggest that sleep stages can alter cortical synchrony in patients with JME and focal epilepsy, with NREM IEDs being more synchronized and wake/REM IEDs being less synchronized. Furthermore, it also suggests that AEDs alleviate seizures in PWE by inhibiting cortical synchrony.

Heightened Background Cortical Synchrony in Patients With Epilepsy: EEG Phase Synchrony Analysis During Awake and Sleep Stages Using Novel Ensemble Measure.

INTRODUCTION: Excessive cortical synchrony within neural ensembles has been implicated as an important mechanism driving epileptiform activity. The current study measures and compares background electroencephalographic (EEG) phase synchronization in patients having various types of epilepsies and healthy controls during awake and sleep stages. METHODS: A total of 120 patients with epilepsy (PWE) subdivided into 3 groups (juvenile myoclonic epilepsy [JME], temporal lobe epilepsy [TLE], and extra-temporal lobe epilepsy [Ex-TLE]; n = 40 in each group) and 40 healthy controls were subjected to overnight polysomnography. EEG phase synchronization (SI) between the 8 EEG channels was assessed for delta, theta, alpha, sigma, and high beta frequency bands using ensemble measure on 10-second representative time windows and compared between patients and controls and also between awake and sleep stages. Mean ± SD of SI was compared using 2-way analysis of variance followed by pairwise comparison ( P ≤ .05). RESULTS: In both delta and theta bands, the SI was significantly higher in patients with JME, TLE, and Ex-TLE compared with controls, whereas in alpha, sigma, and high beta bands, SI was comparable between the groups. On comparison of SI between sleep stages, delta band: progressive increase in SI from wake ⇒ N1 ⇒ N2 ⇒ N3, whereas REM (rapid eye movement) was comparable to wake; theta band: decreased SI during N2 and increase during N3; alpha band: SI was highest in wake and lower in N1, N2, N3, and REM; and sigma and high beta bands: progressive increase in SI from wake ⇒ N1 ⇒ N2 ⇒ N3; however, sigma band showed lower SI during REM. CONCLUSION: This study found an increased background cortical synchronization in PWE compared with healthy controls in delta and theta bands during wake and sleep. This background hypersynchrony may be an important property of epileptogenic brain circuitry in PWE, which enables them to effortlessly generate a paroxysmal EEG depolarization shift.

Connectivity in ictal single photon emission computed tomography perfusion: a cortico-cortical evoked potential study.

Subtraction ictal and interictal single photon emission computed tomography can demonstrate complex ictal perfusion patterns. Regions with ictal hyperperfusion are suggested to reflect seizure onset and propagation pathways. The significance of ictal hypoperfusion is not well understood. The aim of this study was to verify whether ictal perfusion changes, both hyper- and hypoperfusion, correspond to electrically connected brain networks. A total of 36 subtraction ictal and interictal perfusion studies were analysed in 31 consecutive medically refractory focal epilepsy patients, evaluated by stereo-electroencephalography that demonstrated a single focal onset. Cortico-cortical evoked potential studies were performed after repetitive electrical stimulation of the ictal onset zone. Evoked responses at electrode contacts outside the stimulation site were used as a measure of connectivity. The evoked responses at these electrodes were compared to ictal perfusion values noted at these locations. In 67% of studies, evoked responses were significantly larger in hyperperfused compared to baseline-perfused areas. The majority of hyperperfused contacts also had significantly increased evoked responses relative to pre-stimulus electroencephalogram. In contrast, baseline-perfused and hypoperfused contacts mainly demonstrated non-significant evoked responses. Finally, positive significant correlations (P < 0.05) were found between perfusion scores and evoked responses in 61% of studies. When the stimulated ictal onset area was hyperperfused, 82% of studies demonstrated positive significant correlations. Following stimulation of hyperperfused areas outside seizure onset, positive significant correlations between perfusion changes and evoked responses could be seen, suggesting bidirectional connectivity. We conclude that strong connectivity was demonstrated between the ictal onset zone and hyperperfused regions, while connectivity was weaker in the direction of baseline-perfused or hypoperfused areas. In trying to understand a patient's epilepsy, one should consider the contribution of all hyperperfused regions, as these are likely not random, but represent an electrically connected epileptic network.

Comparing sleep profiles between patients with juvenile myoclonic epilepsy and symptomatic partial epilepsy: Sleep questionnaire-based study.

OBJECTIVES: Patients with epilepsy commonly report excessive daytime sleepiness and daytime fatigue, which may be attributed to the direct effect of seizures, a side effect of antiepileptic drugs or a combination of the two. The aim of the study was to compare sleep profiles in patients with juvenile myoclonic epilepsy (JME) and symptomatic partial epilepsy (PE) in drug naïve and treated patients using standardized sleep questionnaires. METHODS: Three study groups: - 1) juvenile myoclonic epilepsy (N=40) [drug naïve (N=20); On sodium valproate (SVA) (N=20)]; 2) symptomatic partial epilepsy (N=40) [drug naïve (N=20); On carbamazepine (CBZ) (N=20)]; 3) healthy controls (N=40) completed 3 standardized sleep questionnaires - Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and NIMHANS Comprehensive Sleep Disorders Questionnaire. Scores were compared using t-test and Chi-squared tests (P≤0.005). RESULTS: The mean PSQI scores as well as the proportion of subjects with abnormal PSQI scores were higher in patients with JME and PE compared to controls. Although the mean ESS scores were comparable between patients with epilepsy and controls, the percentage of patients with partial epilepsy having abnormal ESS scores was higher. No significant differences were present between drug naïve and treatment monotherapy groups. Excessive daytime somnolence was reported more often by patients with JME compared to patients with partial epilepsy and controls. CONCLUSION: This study found that patients with epilepsy have a higher prevalence of poor sleep quality compared to controls. Moreover, a significantly higher percentage of patients with partial epilepsy had higher ESS scores compared to healthy controls. However, there was no difference between ESS and PSQI scores between drug naïve and treated patients with JME or PE. SIGNIFICANCE: Poor sleep quality is more prevalent in patients with epilepsy irrespective of the use of antiepileptic medications. Excessive daytime somnolence is more commonly seen in patients with partial epilepsy when compared to the general population.

Phase Synchronization Analysis of Natural Wake and Sleep States in Healthy Individuals Using a Novel Ensemble Phase Synchronization Measure.

PURPOSE: Electrical activity in the brain is presumed to arise from a combination of tonic asynchronous neuronal firing during wake and a synchronized, burst-pause firing of large number of neurons during sleep. This study aims to compare the phase synchronization index (SI) across multiple channels during wake and various sleep stages on scalp electroencephalographic recordings. METHODS: Forty healthy subjects were subjected to overnight polysomnography using 8-channel electroencephalography. Electroencephalographic phase synchronization during awake, non-rapid eye movement (N1, N2, N3), and rapid eye movement sleep states was studied using ensemble measure (multichannel measure across all the eight channels based on Hilbert transformation between any two pairs). RESULTS: With the progression of states of wakefulness to non-rapid eye movement sleep, there was progressive increase in phase SI in delta band while SI decreased in alpha band (P < 0.001). The SI in delta band during rapid eye movement was comparable with that of awake state (P < 0.001). In theta band, SI tends to decrease in N2 and increase in N3 (P < 0.001). In beta band, there was progressive increase in SI from awake to non-rapid eye movement stages that decreased in rapid eye movement stage (P < 0.001). CONCLUSIONS: This is the first study that has used an ensemble measure to assess the long-range cortical phase synchronization during awake and various sleep stages. The findings support the previous view of increased delta synchrony during non-rapid eye movement sleep and alpha synchrony during wakefulness. Rapid eye movement stage was characterized by marked desynchrony in all frequency bands. These findings suggest the possible role of cortical synchronization in influencing the occurrence of epileptic activity during sleep and awake states.

Effect of carbamazepine on the sleep microstructure of temporal lobe epilepsy patients: a cyclic alternating pattern-based study.

BACKGROUND: Studies looking at the effect of anti-epileptic drugs on the sleep microstructure of patients with epilepsy are scarce. The aim of this study was to compare the sleep microstructural characteristics of drug-naive temporal lobe epilepsy (TLE) patients and those on carbamazepine (CBZ) monotherapy. METHODS: Three age-matched (p = 0.286) and sex-matched (p = 0.398) groups were studied: drug-naive TLE (n = 20); TLE on CBZ (n = 20); and healthy controls (n = 40). All groups underwent overnight polysomnography. Scoring and analysis of arousals and cyclic alternating pattern (CAP) parameters were performed. Comparison of arousal parameters and CAP parameters was performed using either one-way analysis of variance or the Kruskal-Wallis test, followed by pairwise comparisons (p ≤ 0.05). RESULTS: Rapid eye movement (REM) arousal indices and overall CAP rates were higher in patients with TLE (group 1, p < 0.001; group 2, p < 0.001) compared to controls. Furthermore, the overall CAP rate was higher in patients on CBZ. The CAP cycle/sequences indices (group 1, p < 0.001; group 2, p < 0.001) were higher, and conversely, the average duration of CAP cycles/sequences (group 1, p = 0.018; group 2, p = 0.003) was lower in patients with TLE. Finally, an increase in A2 percentage was noted in patients with TLE (group 1, p = 0.011; group 2, p = 0.011). CONCLUSION: We found significant alterations in REM arousal indices and CAP parameters in patients with TLE as compared to controls. Moreover, many of these CAP alterations were greater in patients on CBZ. These findings suggest that anti-epileptic drugs such as CBZ may augment arousal instability in patients with TLE, and hence worsen sleep quality and continuity.

Floquet Time Crystals.

We define what it means for time translation symmetry to be spontaneously broken in a quantum system and show with analytical arguments and numerical simulations that this occurs in a large class of many-body-localized driven systems with discrete time-translation symmetry.

Complications and oncologic outcomes following elective neck dissection with salvage laryngectomy for the N0 neck.

PURPOSE: To investigate the difference in survival and complication outcomes between patients with a clinically and radiologically N0 neck who received an elective neck dissection at the time of salvage total laryngectomy compared to those who had salvage total laryngectomy alone. MATERIALS AND METHODS: A retrospective chart review was performed on 125 salvage total laryngectomy patients who were clinically and radiologically N0 preoperatively. Performance of an elective neck dissection and other factors were tested for associations with various postoperative complications, disease-free survival, and overall survival. RESULTS: Ninety-eight patients underwent elective neck dissection, of which ten had positive nodal pathology. Elective neck dissection was not significantly associated with complications or survival outcomes. Positive nodal disease was associated with worse disease-free and overall survival on multivariate analysis. CONCLUSIONS: In patients with clinically and radiologically N0 necks undergoing salvage total laryngectomy, an elective neck dissection can provide prognostic information but does not appear to be significantly associated with increased complications or improved survival.