Bone Causing Abdominal Groans.

Gastrointestinal complications secondary to fish bone ingestion are rare, however important to recognize in timely manner to prevent morbidity and mortality. Diagnosis is often challenging in setting of non-specific and variable symptoms and lack of history of fish bone ingestion. Diagnostic imaging particularly computed tomography is crucial for diagnosis. However, emphasis should be given on identifying underlying cause of abdominal complications because fish bone is often missed unless specifically looked for. Identification of fish bone is essential for extraction of the inciting nidus. Emergency physician should be aware of this entity to identify it and triage the patients in timely manner. We describe here cases of sub-capsular liver abscess and acute cholecystitis caused by fish bone ingestion. The fish bone as a cause of these complication was initially missed in emergency.

Posterior Reversible Encephalopathy Syndrome in a Patient of Sepsis-induced Cardiomyopathy, Successfully Managed with Intra-aortic Balloon Pump.

In patients with septic shock refractory to pharmacological agents, mechanical devices have been used successfully, although the reports are scarce. We report a case of septic shock where intra-aortic balloon pump (IABP) initiation leads to drastic improvement and survival from severe septic cardiomyopathy when conventional therapy was not effective. A 19-year-old male patient underwent surgery for adenocarcinoma descending colon. On day 8 he was reoperated for anastomotic leak and developed severe cardiomyopathy associated with septic shock, postoperatively. When he was in a vicious cycle of refractory hypotension, metabolic acidosis and severe cardiomyopathy, IABP was instituted along with other management for septic shock. Over next 3 days patient's hemodynamics improved and IABP was weaned off. While recovering from shock he developed posterior reversible encephalopathy syndrome which was promptly managed. This case report emphasizes on early institution of IABP in case of severe left ventricular dysfunction in septic shock. How to cite this article: Saxena A, Bhargava V, et al. Posterior Reversible Encephalopathy Syndrome in a Patient of Sepsis-induced Cardiomyopathy, Successfully Managed with Intra-aortic Balloon Pump. Indian J Crit Care Med 2019;23(4):188-190.

Some Mushrooms are Hard to Digest: Gastrostomy Tube Exchange.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is an effective and safe mode of enteral nutrition for patients needing chronic enteric nutritional support. Exchanging PEG tubes may result in complications due to inexperience as well as due to lack of protocol. CASE REPORT: We encountered a 73 year-old female with unnoticed, accidently detached portion of the internal bumper of a PEG tube in the gastric lumen after a challenging gastrostomy tube exchange. CONCLUSIONS: This case report discusses the complications associated with gastrostomy tube exchange and proposes a planned protocol for successful gastrostomy tube exchange.

Poland Syndrome with Ipsilateral Hypoplasia of Gluteal Muscles and Contralateral Hidradenitis Suppurativa.

BACKGROUND: Poland syndrome (PS) is a rare congenital anomaly associated with absent or hypoplastic pectoralis major muscle and a wide spectrum of ipsilateral thoracic and upper extremity deformities. Hidradenitis suppurativa (HS) is a recurrent inflammatory follicular disease that commonly affects the apocrine-bearing skin and involves follicular occlusion and hyperkeratosis. CASE REPORT: We report a case of a 46-year-old male with a history of chronic recurrent hidradenitis suppurativa who was incidentally found to have a simple type of Poland syndrome with incidental hypoplasia of ipsilateral gluteal muscles. CONCLUSIONS: Not only can PS present with HS, which we describe for the first time, but it is also associated with a wide variability of symptoms such as previously unknown co-existence of gluteal muscles hypoplasia.

Imaging features of kaposiform lymphangiomatosis.

BACKGROUND: Kaposiform lymphangiomatosis is a rare, aggressive lymphatic disorder. The imaging and presenting features of kaposiform lymphangiomatosis can overlap with those of central conducting lymphatic anomaly and generalized lymphatic anomaly. OBJECTIVE: To analyze the imaging findings of kaposiform lymphangiomatosis disorder and highlight features most suggestive of this diagnosis. MATERIALS AND METHODS: We retrospectively identified and characterized 20 children and young adults with histopathological diagnosis of kaposiform lymphangiomatosis and radiologic imaging referred to the vascular anomalies center between 1995 and 2015. RESULTS: The median age at onset was 6.5 years (range 3 months to 27 years). The most common presenting features were respiratory compromise (dyspnea, cough, chest pain; 55.5%), swelling/mass (25%), bleeding (15%) and fracture (5%). The thoracic cavity was involved in all patients; all patients had mediastinal involvement followed by lung parenchymal disease (90%) and pleural (85%) and pericardial (50%) effusions. The most common extra-thoracic sites of disease were the retroperitoneum (80%), bone (60%), abdominal viscera (55%) and muscles (45%). There was characteristic enhancing and infiltrative soft-tissue thickening in the mediastinum and retroperitoneum extending along the lymphatic distribution. CONCLUSION: Kaposiform lymphangiomatosis has overlapping imaging features with central conducting lymphatic anomaly and generalized lymphatic anomaly. Presence of mediastinal or retroperitoneal enhancing and infiltrative soft-tissue disease along the lymphatic distribution, hemorrhagic effusions and moderate thrombocytopenia (50-100,000/µl) should favor diagnosis of kaposiform lymphangiomatosis.

Impact of Bioactive Compounds in the Management of Various Inflammatory Diseases.

Inflammation is an individual's physiological response to a sequence of physical, chemical, or infectious stressors acting mainly to provide localized protection. Although inflammation is a protective and thus beneficial process, its excess or prolonged action can be harmful to the body. An increasing number of the population worldwide are changing their lifestyles, which leads to a rise in inflammatory diseases, such as atherosclerosis, angina pectoris, myocardial infarction, ulcerative colitis, cancer, and many more. Their treatment is based majorly on the pharmacological approach. However, natural products or bioactive compounds are of great significance in inflammation therapy because they show minimum side effects and maximum bioavailability. Therefore, it is critical to investigate bioactive substances that can modify target functions associated with oxidative stress defense and might be used to achieve various health benefits. This review accentuates the essence of bioactive chemicals used in the treatment of inflammation and other inflammatory illnesses. These bioactive compounds can be of any origin, such as plants, animals, bacteria, fungi, marine invertebrates, etc. Bioactive compounds derived from plant sources, such as glycyrrhizin, lignans, lycopene, resveratrol, indoles, and phenolic and polyphenolic compounds, work mainly by reducing oxidative stress and thereby preventing various inflammatory disorders. A large diversity of these anti-inflammatory bioactive compounds has also been discovered in marine environments, giving rise to an increase in the interest of various scientists in marine invertebrates and microbes. The vast diversity of microbes found in the marine environment represents an enormous supply to extract novel compounds, such as from bacteria, cyanobacteria, fungi, algae, microalgae, tiny invertebrates, etc. In the present review, an attempt has been made to summarize such novel bioactive compounds that help prevent inflammatory responses via different mechanisms of action.

Age-stratified Assessment of Brain Volumetric Segmentation on the Indian Population Using Quantitative Magnetic Resonance Imaging.

BACKGROUND AND PURPOSE: Automated methods for quantifying brain tissue volumes have gained clinical interest for their objective assessment of neurological diseases. This study aimed to establish reference curves for brain volumes and fractions in the Indian population using Synthetic MRI (SyMRI), a quantitative imaging technique providing multiple contrast-weighted images through fast postprocessing. METHODS: The study included a cohort of 314 healthy individuals aged 15-65 years from multiple hospitals/centers across India. The SyMRI-quantified brain volumes and fractions, including brain parenchymal fraction (BPF), gray matter fraction (GMF), white matter fraction (WMF), and myelin. RESULTS: Normative age-stratified quantification curves were created based on the obtained data. The results showed significant differences in brain volumes between the sexes, but not after normalization by intracranial volume. CONCLUSION: The findings provide normative data for the Indian population and can be used for comparative analysis of brain structure values. Furthermore, our data indicate that the use of fractions rather than absolute volumes in normative curves, such as BPF, GMF, and WMF, can mitigate sex and population differences as they account for individual differences in head size or brain volume.

Nurse educators' professional practice attributes and its determinants.

BACKGROUND: Professional practice attributes of nurses help to promote nursing as a profession and advance nursing education. Nursing professionals need to demonstrate a high level of professional commitment to their practices and must be professionally competent to perform their roles. MATERIAL AND METHODS: Descriptive survey was conducted at the nursing educational institutes affiliated with the Indian Nursing Council and situated in the selected Northern Indian states. The sample included 343 nurse educators who were selected using simple random sampling. The self-reported method was adopted to collect data where three questionnaires including socio-demographic information, organizational characteristics of current place of work, and professional practice attributes assessment criteria were used. Descriptive and inferential statistics were used for data analysis. RESULTS: Overall, the study's participants scored poorly on professional practice attributes (Mean, SD: 1.98, 2.03), which were linked to their personal (age and gender), professional (educational background, professional qualification, current designation), and organizational (duration of organization's establishment, courses provided, college management) characteristics. CONCLUSION: The findings highlighted the need for nurse educators to be more competent and dedicated in their respective fields. The study also suggests that in order to raise the standard of nursing education, nursing regulatory bodies like nursing councils, universities, and governments must take the necessary steps to foster the professional development of nurse educators.

Early-infantile developmental and epileptic encephalopathy: the aetiologies, phenotypic differences and outcomes-a prospective observational study.

In this study, we have evaluated the underlying aetiologies, yield of genetic testing and long-term outcomes in patients with early-infantile developmental and epileptic encephalopathies. We have prospectively studied patients with seizure onset before 3 months of age. Based on the clinical details, neuroimaging, metabolic testing and comprehensive genetic evaluation, patients were classified into different aetiological groups. The phenotypic differences between genetic/unknown groups and remaining aetiologies were compared. Factors that could affect seizure control were also assessed. A total of 80 children (M:F ratio-1.5:1) were recruited. The median seizure onset age was 28 days (range, 1-90 days). The aetiologies were confirmed in 66 patients (83%). The patients were further classified into four aetiological groups: genetic (50%), structural (19%), metabolic (14%; all were vitamin responsive) and unknown (17%). On comparing for the phenotypic differences between the groups, children in the 'genetic/unknown' groups were more frequently observed to have severe developmental delay (Odds Ratio = 57; P < 0.0001), autistic behaviours (Odds Ratio = 37; P < 0.0001), tone abnormalities (Odds Ratio = 9; P = 0.0006) and movement disorder (Odds Ratio = 19; P < 0.0001). Clonic seizures were more common in the vitamin responsive/structural groups (Risk Ratio = 1.36; P = 0.05) as compared to patients with 'genetic/unknown' aetiologies. On the contrary, vitamin responsive/structural aetiology patients were less likely to have tonic seizures (Risk Ratio = 0.66; P = 0.04). Metabolic testing was diagnostic in three out of 41 patients tested (all three had biotinidase deficiency). MRI was abnormal in 35/80 patients (malformation observed in 16/35; 19/35 had non-specific changes that did not contribute to underlying aetiology). A molecular diagnosis was achieved in 53 out of 77 patients tested (69%). Next-generation sequencing had a yield of 51%, while microarray had a yield of 14%. STXBP1 was the most common (five patients) single-gene defect identified. There were 24 novel variants. The mean follow-up period was 30 months (range, 4-72 months). On multivariate logistic regression for the important factors that could affect seizure control (seizure onset age, time lag of first visit to paediatric neurologist and aetiologies), only vitamin responsive aetiology had a statistically significant positive effect on seizure control (P = 0.02). Genetic aetiologies are the most common cause of early-infantile developmental and epileptic encephalopathies. Patients in the genetic/unknown groups had a more severe phenotype. Patients with vitamin responsive epilepsies had the best probability of seizure control.

Two cases of lead poisoning associated with occupational exposure presented as intestinal obstruction: a case report.

Lead exposure in India is common in industries that may present with nonspecific signs and symptoms or symptoms of toxicity, depending on the amount of lead absorbed. We are presenting two case reports of occupational lead exposure in a lead-based battery manufacturing unit, which were presented as intestinal obstruction. Both the patients aged 28 and 24-year old presented with complaints of pain in the abdomen with blood lead levels of 61.1 and 85 µg/dl, respectively. The diagnosis was made clinically before any other radiological investigation or intervention. Both the patients were treated conservatively with D-Penicillamine, following which, both the patients improved symptomatically and the blood lead level also decreased. The importance of a detailed history of occupation & clinically diagnosing such patient will avoid unnecessary investigation and intervention. This will help to reach the correct diagnosis in such cases.

Tunneled and routine peripherally inserted central catheters placement in adult and pediatric population: review, technical feasibility, and troubleshooting.

Vascular access procedures are crucial for the management of various critically ill pediatric and adult patients. Venous access is commonly performed in the form routine as well as tunneled peripherally inserted central catheters (PICC). These venous accesses are commonly used in emergency, surgical as well as ICU settings, for various infusions, total parenteral nutrition, long term intravenous antibiotics, frequent blood draws, etc. PICC insertion is guided using ultrasound and fluoroscopic guidance, which decreases the risk of complications that are otherwise seen with central venous accesses like triple lumen catheters, etc. PICC insertion and care is very simple and can be performed by specially trained PICC nurses and that helps in decreasing the overall cost of healthcare. This review article is written with educational intent for the readers to discuss indications, contraindications, procedure techniques, imaging, care of routine as well as tunneled PICC.

Clinical and imaging features of idiopathic granulomatous mastitis - The diagnostic challenges and a brief review.

Idiopathic granulomatous mastitis (IGM), or granulomatous lobular mastitis is a rare, benign, inflammatory condition of the breast, without an identifiable underlying etiology. The clinical and imaging diagnosis of this entity is challenging with the presentation frequently mimicking inflammatory breast carcinoma (IBC). Mammography and breast ultrasound (US) have an important role in its detection, however, biopsy is imperative for histopathological confirmation. We present three cases of biopsy proven IGM, highlighting the variability of the clinical and imaging features,brieflyreview the relevant literature and discuss the challenges associated with its diagnosis and management.

An Interesting Case of Congenital Intrahepatic Porto-hepatic Shunt as a Cause of Unexplained Encephalopathy.

Congenital portosystemic shunts can be divided into two types: intrahepatic shunts in which there is an abnormal connection between the branches of the portal vein and either the inferior vena cava or the hepatic veins and less commonly the extrahepatic type in which the portal system is connected to one of the branches of the mesenteric veins. Here we describe a 73-year-old woman who was admitted to the hospital with clinical evidence of encephalopathy and was found to have hyperammonemia. Abdominal computed tomography angiography was performed and revealed a dilated portal vein measuring up to 1.8 cm at the porta-hepatis along with dilated superior mesenteric and splenic veins. Multiple dilated vascular channels were identified within the right hepatic lobe. An intrahepatic portosystemic shunt between an enlarged middle hepatic vein and two separate branches of the right portal vein was demonstrated. A liver biopsy showed normal architecture with no evidence of inflammation or fibrosis. Portosystemic shunts are rare and often detected in adulthood but should be considered as an important cause of unexplained encephalopathy in the absence of cirrhotic liver disease or hepatic trauma. Given that the size of such shunts increases with age, older persons are more prone to the effect of toxic metabolites.This age-associated increase in shunt size may help explain why some patients remain asymptomatic until later in their life which may account for the late presentation in our patient.

Infantile spasms: Etiology, lead time and treatment response in a resource limited setting.

This study explores the etiology and lead time to treatment for infantile spasm (IS) patients and their effect on treatment responsiveness, in a limited resource setting. Patients with IS onset age ≤12 months', seen over 3 years were recruited retrospectively. Clinical information, neuroimaging and genetic results retrieved. Patients categorized into three primary etiological groups: Structural (including Structural Genetic), Genetic, and Unknown. The effect of etiology and lead time from IS onset to initiating appropriate treatment on spasm resolution, evaluated. Total 113 patients were eligible. Mean IS onset age was 6.86(±4.25) months (M: F 3.3:1). Patients were grouped into: Structural 85, Genetic 11 and Unknown 17. Etiology was ascertained in 94/113 (83.1%) with neonatal hypoglycemic brain injury (NHBI) being the most common (40/113, 36%). A genetic etiology identified in 17 (including 6 Structural Genetic, of which five had Tuberous Sclerosis). Structural group was less likely to be treatment resistant (p = 0.013, OR 0.30 [0.12-0.76]). Median treatment lead time - 60 days. Longer lead time to treatment was significantly associated with resistant spasms (χ2 for trend = 10.0, p = 0.0015). NHBI was the commonest underlying cause of IS. There was significant time lag to initiating appropriate treatment, affecting treatment responsiveness.

Radioprotective effects of Aloe vera leaf extract on Swiss albino mice against whole-body gamma irradiation.

The skin, being a cell-renewal system, is one of the first organs to be affected in total-body irradiation during radiotherapy. An attempt has been made in the present study to explore radiation-induced biochemical alterations caused by whole-body gamma irradiation and their modulation in Swiss albino mice by Aloe vera leaf extract (AVE). Mice were selected for this study from an inbreed colony and divided into four different groups: I (double-distilled water-treated group): considered as normal; II (Aloe vera-treated group): the animals were administered 1 g/kg body-wt/day Aloe vera leaf extract; III (radiation-treated group): the animals were exposed to 6 Gy gamma radiation at the dose rate of 0.96 Gy/min; and IV (combination group): animals were administered Aloe vera leaf extract continuously for 15 consecutive days, and on the 15th day they were irradiated to 6 Gy gamma radiation after 30 minutes of extract administration. The animals from the above groups were autopsied after 6 hours, 24 hours, and at 3, 7, 14, and 21 days of radiation. Biochemical estimations of DNA, lipid peroxidation, glutathione, catalase, and superoxide-dismutase were made. Total DNA, catalase, superoxide dismutase (SOD) activity in the skin, and glutathione (GSH) in the liver and blood significantly decreased compared to normal, but lipid peroxidation (LPO) in the liver and blood increased in the irradiated control group. In contrast, in experimental animals, DNA, catalase, and SOD in the skin and GSH in the liver and blood increased significantly, whereas LPO in the liver and blood decreased in comparison to irradiated control animals. Thus, Aloe vera leaf extract is found to have damage-resistant properties against radiation-induced biochemical alterations in Swiss albino mice.

Bordetella bronchiseptica pneumonia a thread in the diagnosis of human immunodeficiency virus infection.

Bordetella (B.) bronchiseptica is primarily a zoonotic pathogen, which is often found in upper respiratory tract of various domestic and wild animals. Human infections are rarely reported in immunocompromised patients and are associated with a wide spectrum of presentation ranging from mild cough, tracheobronchitis to sepsis and death. Here, we describe a case of B. bronchiseptica pneumonia that led to the diagnosis of human immunodeficiency virus infection. The diagnosis of B. bronchiseptica infection can be challenging, as there are no distinctive imaging features. This infection mimics Pneumocystis jiroveci infection and unless a detailed evaluation of an unusual presentation is done it may be missed, resulting in increased morbidity and mortality. This case emphasizes the importance of a systematic detailed investigation of patients with unusual pneumonia presentations.

Dilated Appendix: Is There More to It? Case Report and Brief Review of Literature with Radiologic-Pathological Correlation.

Mucocele of the appendix is rare and represents only the tip of the iceberg of underlying benign and malignant pathological processes. Intraoperative diagnosis is also tricky because the inflammation of the appendix often hides the tumor. The preoperative diagnosis is essential to differentiate appendiceal mucocele from acute appendicitis as the treatment varies from open surgical versus laparoscopic surgical approach and for decreasing intraoperative and postoperative morbidity and mortality rate. We present three cases of appendiceal mucocele. The purpose of this paper is to make the physicians aware of the entity, its associations and the effect on management. This review will provide radiologic and pathologic correlation for the preoperative diagnosis of benign and malignant causative processes and differential diagnostic considerations.