Femoral Access-Site Complications with Tenecteplase versus Alteplase before Mechanical Thrombectomy for Large-Vessel-Occlusion Stroke.

BACKGROUND AND PURPOSE: IV thrombolysis with alteplase before mechanical thrombectomy for emergent large-vessel-occlusion stroke is associated with access-site bleeding complications. However, the incidence of femoral access-site complications with tenecteplase before mechanical thrombectomy requires exploration. Here, femoral access-site complications with tenecteplase versus alteplase before mechanical thrombectomy for large-vessel-occlusion stroke were compared. MATERIALS AND METHODS: All patients receiving IV thrombolytics before mechanical thrombectomy for large-vessel-occlusion stroke who presented from January 2020 to August 2022 were reviewed. In May 2021, our health care system switched from alteplase to tenecteplase as the primary thrombolytic for all patients with stroke, facilitating the comparison of alteplase-versus-tenecteplase femoral access-site complication rates. Major (requiring surgery) and minor (managed conservatively) access-site complications were assessed. RESULTS: One hundred thirty-nine patients underwent transfemoral mechanical thrombectomy for large-vessel-occlusion stroke, of whom 46/139 (33.1%) received tenecteplase and 93/139 (66.9%) received alteplase. In all cases (n = 139), an 8F sheath was inserted without sonographic guidance, and vascular closure was obtained with an Angio-Seal. Baseline demographics, concomitant antithrombotic medications, and periprocedural coagulation lab findings were similar between groups. The incidence of conservatively managed groin hematomas (2.2% versus 4.3%), delayed access-site oozing requiring manual compression (6.5% versus 2.2%), and arterial occlusion requiring surgery (2.2% versus 1.1%) was similar between the tenecteplase and alteplase groups, respectively (P = not significant). No dissection, arteriovenous fistula, or retroperitoneal hematoma was observed. CONCLUSIONS: Tenecteplase compared with alteplase before mechanical thrombectomy for large-vessel-occlusion stroke is not associated with an alteration in femoral access-site complication rates.

Learning Curve for Flow Diversion of Posterior Circulation Aneurysms: A Long-Term International Multicenter Cohort Study.

BACKGROUND AND PURPOSE: Flow diversion has gradually become a standard treatment for intracranial aneurysms of the anterior circulation. Recently, the off-label use of the flow diverters to treat posterior circulation aneurysms has also increased despite initial concerns of rupture and the suboptimal results. This study aimed to explore the change in complication rates and treatment outcomes across time for posterior circulation aneurysms treated using flow diversion and to further evaluate the mechanisms and variables that could potentially explain the change and outcomes. MATERIALS AND METHODS: A retrospective review using a standardized data set at multiple international academic institutions was performed to identify patients with ruptured and unruptured posterior circulation aneurysms treated with flow diversion during a decade spanning January 2011 to January 2020. This period was then categorized into 4 intervals. RESULTS: A total of 378 procedures were performed during the study period. Across time, there was an increasing tendency to treat more vertebral artery and fewer large vertebrobasilar aneurysms (P = .05). Moreover, interventionalists have been increasingly using fewer overlapping flow diverters per aneurysm (P = .07). There was a trend toward a decrease in the rate of thromboembolic complications from 15.8% in 2011-13 to 8.9% in 2018-19 (P = .34). CONCLUSIONS: This multicenter experience revealed a trend toward treating fewer basilar aneurysms, smaller aneurysms, and increased usage of a single flow diverter, leading to a decrease in the rate of thromboembolic and hemorrhagic complications.

Child survivor of rabies in India: a case report.

A 4-year-old boy was admitted with an acute onset fever for 4 days and drowsiness for 3 days, followed by progressive flaccid weakness of both lower limbs and encephalopathy soon after admission. He had sustained a WHO Class III stray dog bite 2 weeks previously and had received three doses of post-exposure rabies vaccination with purified vero cell vaccine but not rabies immunoglobulin. He was diagnosed with rabies based on the presence of rabies virus neutralising antibody in CSF (Day 1 1:128 and Day 26 1:2048) and typical findings on neuro-imaging. Rabies viral RNA was not detected in CSF, in saliva or on nuchal skin. The child survived with supportive treatment alone but he has extensive neurological sequelae. This report demonstrates the detailed clinico-investigative profile of a child who survived rabies following inadequate post-exposure prophylaxis and adds to the sparse knowledge of this usually fatal condition. ABBREVIATIONS: ADEM, acute disseminated encephalomyelitis; CBNAAT, cartridge-based nucleic acid amplification test; CSF, cerebrospinal fluid; EEG, electroencephalogram; GCS, Glasgow coma scale; EVM, eye opening, best verbal response, best motor response; IM, intramuscular; IVIg, intravenous immunoglobulin; MRC, Medical Research Council; MRI/FLAIR, magnetic resonance imaging/fluid attenuation inversion recovery; PCR, polymerase chain reaction; RFFIT, rapid fluorescent focus inhibition test; RIg, rabies immunoglobulin; RNA, ribonucleic acid; WBC, white blood cells; WHO, World Health Organization.

Point prevalence & risk factor assessment for hospital-acquired infections in a tertiary care hospital in Pune, India.

BACKGROUND & OBJECTIVES: Hospital-acquired infections (HAIs) are a major challenge to patient safety and have serious public health implications by changing the quality of life of patients and sometimes causing disability or even death. The true burden of HAI remains unknown, particularly in developing countries. The objective of this study was to estimate point prevalence of HAI and study the associated risk factors in a tertiary care hospital in Pune, India. METHODS: A series of four cross-sectional point prevalence surveys were carried out between March and August 2014. Data of each patient admitted were collected using a structured data entry form. Centers for Disease Control and Prevention guidelines were used to identify and diagnose patients with HAI. RESULTS: Overall prevalence of HAI was 3.76 per cent. Surgical Intensive Care Unit (ICU) (25%), medical ICU (20%), burns ward (20%) and paediatric ward (12.17%) were identified to have significant association with HAI. Prolonged hospital stay [odds ratio (OR=2.81), mechanical ventilation (OR=18.57), use of urinary catheter (OR=7.89) and exposure to central air-conditioning (OR=8.59) had higher odds of acquiring HAI (P<0.05). INTERPRETATION & CONCLUSIONS: HAI prevalence showed a progressive reduction over successive rounds of survey. Conscious effort needs to be taken by all concerned to reduce the duration of hospital stay. Use of medical devices should be minimized and used judiciously. Healthcare infection control should be a priority of every healthcare provider. Such surveys should be done in different healthcare settings to plan a response to reducing HAI.

Emotional and behavioral disturbances in school going HIV positive children attending HIV clinic.

BACKGROUND: To study the emotional and behavioral disturbances (EBD) in school going HIV positive children attending HIV center in a tertiary care hospital. METHOD: This cross-sectional study was conducted on 258 HIV infected children between 6 and 16 years of age, 200 were on Anti-retroviral therapy (ART) and 58 were not on ART. They were evaluated for EBD by using Pictorial Pediatric Symptom Checklist (PPSC) screening tool. A cut-off score of 28 was taken as significant for detecting early EBD. RESULTS: The prevalence of EBD in our study is 11.2%. Demographic and disease related profile were assessed for correlation with EBD. Type of family (p = 0.023), school attendance (p = 0.034), school performance (p = 0.045), and CD4 count (p = 0.015) were detected to have significant association with early manifestation of EBD in the study group. CONCLUSIONS: HIV positive children who have low CD4 count, poor school attendance, and performance are at a higher risk of being detected with EBD. Screening with PPSC to identify EBD in HIV positive children attending HIV clinic in a hospital setting could help in early diagnosis and management.

To publish and perish: A Faustian bargain or a Hobson's choice.

As a matter of career choice, doctors have to choose between becoming an 'academic' or a 'practitioner.' To conduct research and publish articles in scientific journals is compulsory for the academic professional and mostly optional for the latter. The Medical Council of India has revised the eligibility qualifications for medical teachers over the past decade, and has now come out with regulations for streamlining the process of promotion by focusing on scientific papers, apart from clarifying on required experience and qualifications. 'Predatory publishers' are proliferating across the world, exploiting the reach of the Internet, and are enticing naïve professionals to publish their research work with them. The pitfalls of paid publishing in such journals may tarnish upcoming careers if doctors are not cautious. For a price, there are many publishers who will process articles without even rudimentary peer review; and for the sake of padding up of the resume, this Faustian bargain may eventually prove detrimental to authors, and thus with their professional credibility at stake, may prove to be a Hobson's choice. It is suggested for authors to make a wise choice and a correct decision when selecting a journal to submit their manuscripts.

Unusual Case of Left Bronchial Compression by Aneurysmal Pulmonary Arteries in a Child With Atrial Septal Defect.

We report an uncommon case of large ostium secundum atrial septal defect (ASD) with severe pulmonary arterial hypertension, with associated aneurysmal dilatation of the pulmonary arteries (PAs) leading to compression of the left main bronchus and collapse of the entire left lung in a 15-month-old female child. The patient was managed by surgical closure of the ASD, translocation of the right PA anterior to the aorta with PA aneurysmorrhaphy. Left bronchial compression was relieved with complete lung expansion on the third postoperative day.

Antimicrobial use and antimicrobial resistance in nosocomial pathogens at a tertiary care hospital in Pune.

BACKGROUND: Resistance to antimicrobial agents is emerging in wide variety of nosocomial and community acquired pathogens. Widespread and often inappropriate use of broad spectrum antimicrobial agents is recognized as a significant contributing factor to the development and spread of bacterial resistance. This study was conducted to gain insight into the prevalent antimicrobial prescribing practices, and antimicrobial resistance pattern in nosocomial pathogens at a tertiary care hospital in Pune, India. METHODS: Series of one day cross sectional point prevalence surveys were carried out on four days between March and August 2014. All eligible in patients were included in the study. A structured data entry form was used to collect the data for each patient. Relevant samples were collected for microbiological examination from all the clinically identified hospital acquired infection cases. RESULTS: 41.73% of the eligible patients (95% CI: 39.52-43.97) had been prescribed at least one antimicrobial during their stay in the hospital. Beta-lactams (38%) were the most prescribed antimicrobials, followed by Protein synthesis inhibitors (24%). Majority of the organisms isolated from Hospital acquired infection (HAI cases) were found to be resistant to the commonly used antimicrobials viz: Cefotaxime, Ceftriaxone, Amikacin, Gentamicin and Monobactams. CONCLUSION: There is need to have regular antimicrobial susceptibility surveillance and dissemination of this information to the clinicians. In addition, emphasis on the rational use of antimicrobials, antimicrobial rotation and strict adherence to the standard treatment guidelines is very essential.

An Interesting Observation of PDA Closure with Oral Paracetamol in Preterm Neonates.

Patent ductus arteriosus (PDA), in which there is a persistent communication between the descending thoracic aorta and the pulmonary artery that results from failure of normal physiologic closure of the fetal ductus, is one of the more common congenital heart defects in preterm neonates. The closure of PDA can be done with either Indomethacin or Brufen which are cyclooxygenase 1, 2 inhibitor; however these drugs are associated with side effects. We report an interesting findings of ductal closure in 10 preterm neonates (gestational age 27-33 wks) presenting with significant large PDA who had failed or had absolute contraindication with Brufen. These preterm neonates were treated with oral paracetamol in the dose of 15 mg/kg 8 hourly. The PDA closure was achieved within 48 h and there was no complication.

The role of time-resolved 3D contrast-enhanced MR angiography in the assessment and grading of cerebral arteriovenous malformations.

PURPOSE: To assess the role of three-dimensional (3D) contrast-enhanced, time-resolved MR angiography (CE TR MRA) in patients with intracranial arteriovenous malformations (AVMs). METHODS: We studied 12 patient with intracranial AVMs on a 3.0T MR imaging system (Magentom TIM Trio, Siemens Medical Solutions, Erlangen, Germany) using 3D CE TR MRA with autocalibrating partially parallel acquisitions and echo sharing schemes, which provided temporal resolution of 0.58 or 1.7s and near isotropic voxels. We qualitatively assessed image quality of the 3D CE TR MRA and compared the grading of the AVMs based on modified Spetzler-Martin system for 3D CE TR MRA and catheter digital subtraction angiography (DSA). RESULTS: CE TR MRA provided good quality images in the 3 standard orthogonal planes, and good arterial-venous separation in all cases. All AVMs were correctly graded by CE TR MRA when compared with DSA. 3D CE TR MRA provides a non-invasive alternative to DSA for the evaluation of cerebral AVMs.

Limb splinting for intravenous cannulae in neonates: a randomised controlled trial.

OBJECTIVE: To evaluate the efficacy of peripheral intravenous (IV) cannula site joint immobilisation by splint application on functional duration of peripheral IV cannula in neonates. DESIGN: Randomised controlled trial. SETTING: Neonatal intensive care unit of a tertiary care hospital. PARTICIPANTS: Neonates requiring continuous IV infusion for an expected duration of more than or equal to 72 hours. INTERVENTION: Eligible cannulations were randomised to either "splint" or "no-splint" group. In the splint group, a cardboard splint was used to immobilise the joint at peripheral IV cannula site. No attempt was made to immobilise the limb in the no-splint group. OUTCOME MEASURE: Functional duration of a peripheral IV cannula measured as interval from time of insertion to the development of predefined sign of removal (extravasation, blockage, inflammation). RESULTS: A total of 69 peripheral IV cannulations in 54 neonates were randomised to either the splint (n = 33) or no-splint group (n = 36). Both groups were comparable in birth weight, gestation, site of cannulation and nature of fluids administered. Mean functional duration of cannula was lesser in the splint group compared to the no-splint group (h; 23.5 (SD15.9) vs 26.9 (SD15.5), mean difference: -3.3 h, 95% CI -11.02 to 4.3 h) although the difference was not statistically significant (p = 0.38). Extravasation at cannula site was found be the commonest indication for cannula removal in both the groups (84% vs 76.5%). CONCLUSION: Joint immobilisation with splint at cannula site did not improve the functional duration of peripheral IV cannula.

Performance of prewhitening beamforming in MEG dual experimental conditions.

This paper presents an analysis on the performance of the prewhitening beamformer when applied to magnetoencephalography (MEG) experiments involving dual (task and control) conditions. We first analyze the method's robustness to two types of violations of the prerequisites for the prewhitening method that may arise in real-life two-condition experiments. In one type of violation, some sources exist only in the control condition but not in the task condition. In the other type of violation, some signal sources exist both in the control and the task conditions, and that they change intensity between the two conditions. Our analysis shows that the prewhitening method is very robust to these nonideal conditions. In this paper, we also present a theoretical analysis showing that the prewhitening method is considerably insensitive to overestimation of the signal-subspace dimensionality. Therefore, the prewhitening beamformer does not require accurate estimation of the signal subspace dimension. Results of our theoretical analyses are validated in numerical experiments and in experiments using a real MEG data set obtained during self-paced hand movements.

High gamma power is phase-locked to theta oscillations in human neocortex.

We observed robust coupling between the high- and low-frequency bands of ongoing electrical activity in the human brain. In particular, the phase of the low-frequency theta (4 to 8 hertz) rhythm modulates power in the high gamma (80 to 150 hertz) band of the electrocorticogram, with stronger modulation occurring at higher theta amplitudes. Furthermore, different behavioral tasks evoke distinct patterns of theta/high gamma coupling across the cortex. The results indicate that transient coupling between low- and high-frequency brain rhythms coordinates activity in distributed cortical areas, providing a mechanism for effective communication during cognitive processing in humans.

NUTMEG: a neuromagnetic source reconstruction toolbox.

We have developed an analysis toolbox called NUTMEG (Neurodynamic Utility Toolbox for Magnetoencephalography) for reconstructing the spatiotemporal dynamics of neural activations and overlaying them onto structural MR images. The toolbox runs under MATLAB in conjunction with SPM2 and can be used with the Linux/UNIX, Mac OS X, and even Windows platforms. Currently, evoked magnetic field data from 4-D Neuroimaging, CTF, and KIT systems can be imported to the toolbox for analysis. NUTMEG uses an eigenspace vector beamforming algorithm to generate a tomographic reconstruction of spatiotemporal magnetic source activity over selected time intervals and spatial regions. The MEG coordinate frame is coregistered with an anatomical MR image using fiducial locations and, optionally, head shape information. This allows the reconstruction to be superimposed onto an MRI to provide a convenient visual correspondence to neuroanatomy. Navigating through the MR volume automatically updates the displayed time series of activation for the selected voxel. Animations can also be generated to view the evolution of neural activity over time. Since NUTMEG displays activations using SPM2's engine, certain SPM functions such as brain rendering and spatial normalization may be applied as well. Finally, as a MATLAB package, the end user can easily add customized functions. Source code is available at http://bil.ucsf.edu/ and distributed under a BSD-style license.

Analgesic Effect of Oral Glucose in Neonates.

The International Association for the Study of Pain, has defined pain as "an unpleasant sensory and emotional experience connected with actual or potential tissue damage or described in terms of such damage". It was thought that the newborn baby does not experience pain because of incompletely developed nervous system. However, it has been shown that neurological system known to be associated with pain transmission and modulation, is intact and functional. A study was conducted in our center to study the analgesic effect of administration of oral glucose in various concentrations, in neonates undergoing heel punctures, for collection of blood for investigations. This was compared with the analgesic effects of breast milk (which contains lactose). 125 full term normal neonates with no history of birth asphyxia or underlying neurological abnormality, requiring heel punctures for collection of blood for various investigations were selected for the study. They were matched for gestational age, birth weight and sex distribution and divided into 5 groups of 25 each. One group comprised control subjects and was administered sterile water. 3 groups were administered 1 ml of varying strengths of glucose solutions i.e. 10%, 25% and 50% respectively. The last group was given 1 ml of expressed breast milk (EBM). Prior to heel pricks, state of arousal, baseline heart rate (HR) and transcutaneous oxygen saturation (SpO2) were recorded by pulse oximeter in each neonate. Autolet, a mechanical device for capillary sampling, was used for heel pricks to give equal strength of painful stimulus in each procedure. Audio tape recorder was used to record the cry. The oral solution was administered slowly over 30 seconds by means of a syringe placed in the mouth. Heel puncture was done after 2 minutes, taking all aseptic precautions. HR and SpO2 were monitored using pulse oximeter. Pain response was assessed, by recording duration of crying, change in HR, change in SpO2 and facial action score after the procedure. Mean duration of cry and total cry over 5 minutes was significantly less in groups given 25% and 50% glucose solutions as compared to the control group and babies given EBM. Difference in mean increase in HR, fall in SpO2 were statistically significant between control group, EBM group and neonates given 25% and 50% glucose solutions respectively. Compared to control group, all other administered solutions (10%, 25%, 50% glucose and EBM) were found to reduce physiological and behavioral responses in neonates undergoing heel punctures. 25% and 50% glucose solutions were found to have maximal analgesic effect and both were found to be equally effective. EBM and 10% glucose solution have an equal analgesic effect but less than 25% or 50% glucose. This simple, cheap and safe method of oral analgesia can be easily used in neonates undergoing heel prick procedures during routine neonatal care.

Human collagenase (matrix metalloproteinase-1) expression in the lungs of patients with emphysema.

Pulmonary emphysema is believed to result from an imbalance between proteolytic enzymes and their inhibitors. Multiple studies have examined the presence of various proteases within the bronchoalveolar lavage fluid from patients with chronic obstructive pulmonary disease (COPD). However, to date extensive examination of the lung parenchyma for the expression of destructive enzymes has not yet been determined. The following study examines the lung parenchyma of 23 patients with emphysema and 8 normal control samples for the expression of matrix matalloproteinase-1 (MMP-1), MMP-12, and MMP-9. We report here that interstitial collagenase (MMP-1) RNA, protein, and activity are present in the lung parenchyma of patients with emphysema and not in the lung of normal control subjects. In contrast, metalloelastase (MMP-12) expression is absent in these samples. Immunohistochemistry studies localized MMP-1 to the Type II pneumocyte in patients with emphysema and not normal control subjects or smokers without emphysema. This observation demonstrates that the lung is altered in emphysema such that the Type II pneumocyte secretes MMP-1 and suggests that MMP-1 may be an important enzyme involved in the destruction of the lung in the human disease. In addition, the induction of a proteolytic enzyme within the Type II pneumocyte suggests that the cells within the lung itself are capable of producing degradative enzymes in this disease process.