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In the mammalian cerebral cortex, the hippocampal primordium (Hcp) occupies a discrete position in the dorsal telencephalic neuroepithelium adjacent to the neocortical primordium (Ncp). We examined transcriptomic and chromatin-level features that distinguish the Hcp from the Ncp in the mouse during the early neurogenic period, embryonic day (E)12.5. ATAC-seq revealed that the Hcp was more accessible than the Ncp at this stage. Motif analysis of the differentially accessible loci in these tissues revealed LHX2 as a candidate transcription factor for modulating gene regulatory networks (GRNs). We analyzed LHX2 occupancy profiles and compared these with transcriptomic data from control and Lhx2 mutant Hcp and Ncp at E12.5. Our results revealed that LHX2 directly regulates distinct genes in the Hcp and Ncp within a set of common pathways that control fundamental aspects of development namely pluripotency, axon pathfinding, Wnt, and Hippo signaling. Loss of Lhx2 caused a decrease in accessibility, specifically in hippocampal chromatin, suggesting that this factor may play a unique role in hippocampal development. We identified 14 genes that were preferentially enriched in the Hcp, for which LHX2 regulates both chromatin accessibility and mRNA expression, which have not thus far been examined in hippocampal development. Together, these results provide mechanistic insight into how LHX2 function in the Hcp may contribute to the process by which the hippocampus acquires features distinct from the neocortex.

The cerebrospinal fluid-secreting choroid plexus needs a balanced level of canonical Wnt signaling. Here the authors show that if this signaling is over-activated, the choroid plexus loses its properties and function, and transforms to a neuronal identity.

Background and Aims: Neurosurgery involves a high level of expertise coupled with enduring and long duration of working hours. There is a paucity of published literature about the experience with a speciality-specific checklist in neurosurgery. We conducted a cross-sectional observational study to identify the adherence to various elements of the Modified World Health Organization Surgical Safety Checklist (WHO SSC) for neurosurgery by the operating room (OR) team. Methods: We implemented an intra-operative Modified WHO SSC consisting of 40 tools for neurosurgery, in 200 consecutive elective cases. Trained anaesthesiologists assumed the role of checklist co-ordinator. The checklist divided the surgery into 5 phases, each corresponding to a specific time-period. The adherence rates to various tools were evaluated and areas where the checklist prompted a corrective measure were analysed. Results: A total of 131 cases undergoing craniotomy and 69 cases undergoing spine surgery were studied. With the 40-point modified SSC applied in 200 cases, we analysed a total of 8000 observations. The modified checklist prompted the OR team to adhere to speciality-specific safety practices about application of compression stockings (9.5%); airway precautions in unstable cervical spine (2.5%); precautions for treatment of raised intracranial pressure (10.5%); and intraoperative neuro-monitoring (5%). Conclusion: The implementation of Modified WHO SSC for Neurosurgery, by a designated checklist co-ordinator, can rectify anaesthetic and surgical facets promptly, without increasing the OR time. The anaesthesiologist as SSC coordinator can effectively implement an intraoperative checklist ensuring excellent participation of operating room team members.

COVID-19 which emerged in Wuhan, China has rapidly spread all over the globe and the World Health Organisation has declared it a pandemic. COVID-19 disease severity shows variation depending on demographic characteristics like age, history of chronic illnesses such as cardio-vascular/renal/respiratory disease; pregnancy; immune-suppression; angiotensin converting enzyme inhibitor medication use; NSAID use etc but the pattern of disease spread is uniform – human to human through contact, droplets and fomites. Up to 3.5% of health care workers treating COVID-19 contact an infection themselves with 14.8% of these infections severe and 0.3% fatal. The situation has spread panic even among health care professionals and the cry for safe patient care practices are resonated world-wide. Surgeons, anesthesiologists and intensivists who very frequently perform endotracheal intubation, tracheostomy, non-invasive ventilation and manual ventilation before intubation are at a higher odds ratio of 6.6, 4.2, 3.1 and 2.8 respectively of contacting an infection themselves. Elective surgery is almost always deferred in fever/infection scenarios. A surgeon and an anesthesiologist can anytime encounter a situation where in a COVID-19 patient requires an emergency surgery. COVID-19 cases requiring surgery predispose anesthesiologists and surgeons to cross-infection threats. This paper discusses, the COVID-19 precautionary outlines which has to be followed in the operating room; personal protective strategies available at present; methods to raise psychological preparedness of medical professionals during a pandemic; conduct of anesthesia in COVID-19 cases/suspect cases; methods of decontamination after conducting a surgery for COVID-19 case in the operating room; and post-exposure prophylaxis for medical professionals.

Enhanced electrical activity, ventricular arrhythmia (VA), and cardiac instability due to increased sympathetic tone may be refractory to standard medical treatment and ablation procedures. Stellate ganglion block (SGB) has been used to treat refractory VA; however, there is insufficient information in the literature on its long-term outcome. Herein, we described three patients that were successfully treated with ultrasound-guided left SGB (LSGB) and chemical neurolysis. Ultrasound-guided LSGB may be considered as rescue or bridge therapy for stabilizing ventricular rhythm before a definitive procedure is planned.

Background: Post-herpetic neuralgia (PHN) is usually a constant or intermittent burning, stabbing, or sharp shooting pain with hyperalgesia or allodynia, persisting beyond the healing of herpetic skin lesions. This review was carried out in concordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We used PICOS (Population, Intervention, Control, and Outcome Study) design for inclusion of potential studies into this review. Online literature available in PubMed, Cochrane, and Embase was searched for studies from January 1995 till March 2020, which evaluated interventional treatments in PHN by an independent reviewer, using the relevant medical subject heading (MeSH) terms. We analyzed the following outcome parameters with regard to each intervention—pain status at predefined fixed intervals after the intervention, quality of sleep using any of the reported questionnaires, analgesic consumption, functional evaluation, and quality of life assessment after the intervention. Conclusion: Interventional pain management options provide effective and long-lasting pain relief to patients not responding to medical management. The choice of intervention will depend on the region involved, cost, and invasiveness. Simple procedures such as intercostal nerve blocks/neurolysis, stellate ganglion blocks, paravertebral neurolysis, epidural steroid injections, and dorsal root ganglion–radiofrequency ablation are effective interventions, and if they fail, spinal cord stimulators could be effective in the hands of experienced pain physicians.

Introduction: Hemodynamic stability and fluid responsiveness (FR) assume importance in perioperative management of patients undergoing major surgery. Passive leg raising (PLR) is validated in assessing FR in intensive care unit patients. Very few studies have examined FR to PLR in intraoperative scenario. We prospectively studied FR to PLR using transesophageal echocardiography (TEE), in patients with no coronary artery disease (CAD) undergoing major neurosurgery and those with CAD undergoing coronary artery bypass grafting (CABG). Methods: We enrolled 29 adult consenting patients undergoing major neurosurgery with TEE monitoring and 25 patients undergoing CABG. After induction of anesthesia, baseline hemodynamic parameters were obtained which was followed by PLR using automated adjustment of the operating table. Clinical and TEE-derived hemodynamic parameters were recorded at 1 and 10 min after PLR following which patients were returned to supine position. Results: A total of 162 TEE and clinical examinations were done across baseline, 1 and 10 min after PLR; and paired comparison was done at data intervals of baseline versus 1 min PLR, baseline versus 10 min PLR, and 1 min versus 10 min PLR. There was no significant change in hemodynamic variables at any of the paired comparison intervals in patients undergoing neurosurgery. CABG cases had significant hemodynamic improvement 1 min after PLR, partially sustained at 10 min. Conclusion: Patients undergoing CABG had significant hemodynamic response to PLR, whereas non-CAD patients undergoing neurosurgery did not. A blood pressure–left ventricular end-diastolic volume combination represented strong correlation in response prediction (Pearson's coefficient 0.641; P < 0.01).

Arrhythmogenic right ventricular dysplasia / cardiomyopathy (ARVD / C) is a rare genetic cardiomyopathy characterized by fibro-fatty replacement primarily of the right ventricular myocytes,and can present as any of 'concealed' disease, 'overt arrhythmia' followed by sudden cardiac death, isolated right heart failure or biventricular failure: mimicking dilated cardiomyopathy. We present the successful management of a 65 year old male patient with ARVD/C presenting to us with trauma and Cardiogenic shock for limb saving emergency surgery.

Background and Aims: Glasgow Coma scale (GCS), the most widely used tool for evaluation of the level of consciousness has various limitations. The Full Outline of UnResponsiveness (FOUR) score is a possible alternative. The present study was designed to examine the inter-rater reliability and outcome predictability of these scores in the Intensive Care Unit (ICU). Methods: The GCS and FOUR scores of 111 adult patients with altered sensorium, admitted to the ICU, were assessed as early as possible after admission by the Senior Resident (SR), Junior Resident (JR) and Staff Nurse (SN) of ICU. The outcomes measured survival and modified Rankin Scale (mRS) and Glasgow outcome scale (GOS) of the patients at discharge. Results: The inter-observer agreement was measured using the kappa ('k') statistic. For GCS it was higher (k = 0.472 to 0.555) than FOUR score (k = 0.352 to 0.448). A higher 'k' score in either score was recorded between SR and JR. Linear regression analysis showed no significant association of either score with the duration of ICU stay or mechanical ventilation. Survival in ICU was correlated with both GCS and FOUR scores on logistic regression. GOS and mRS were correlated with either GCS or FOUR scores on ordinal regression. Conclusion: The inter-observer agreement with FOUR score was not superior to GCS in this study, possibly due to lack of familiarity with the FOUR score. Both the scores were statistically correlated with the rate of survival.

Insulinomas are rare neuroendocrine tumours of pancreas arising from the Islets of Langerhans cells with an incidence estimated at 1 to 4 new cases per million persons per year. Patients with insulinomas usually develop neuroglycopenic symptoms presenting as recurrent headache, lethargy, diplopia, and blurred vision, particularly with exercise or fasting. We report a case of young female patient presenting with unwitnessed cardiac arrest later diagnosed as Insulinoma.

Background: Yoga the spiritual union of mind with the divine intelligence of the universe aims to liberate a human being from conflicts of body–mind duality. Beneficial cardiovascular and pulmonary effects of yoga are in par with aerobic exercise, even amounting to replace the exercise model. We conducted an interventional study in healthy volunteers, to analyze the impact of short-term yoga training on cardiovascular, pulmonary, autonomic function tests, lipid profile, and thyroid function tests. Materials and Methods: A sample of fifty new recruits attending the district yoga center was subject to 75 min yoga practice a day for 41 days. Basal values of cardiovascular, pulmonary, autonomic function tests, lipid profile, and thyroid function tests were recorded before yoga training and were reassessed for postyoga changes after 41 days. Results: After yoga practice there was a significant reduction in the resting heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure of the participants. Effects on autonomic function tests were variable and inconclusive. There was a significant increase in forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow rate after yoga. A significant reduction in body mass index was observed. Effects on metabolic parameters were promising with a significant reduction in fasting blood sugar level, serum total cholesterol, serum triglycerides serum low-density lipoprotein levels, and significant increase in high-density lipoprotein. There was no significant change in thyroid function tests after yoga. Conclusion: Short-term yoga practice has no effect on thyroid functions. Yoga practice was found beneficial in maintaining physiological milieu pertaining to cardiovascular and other metabolic parameters.

Background and Aims: Tertiary care teaching hospitals remain referral centres for victims of trauma and mass casualty. Often specialists from various disciplines manage these crowded casualty areas. These age old casualty areas are being replaced, throughout the country by Emergency Medicine Departments (EMDs), presumed to be better planned to confront a crisis. We aimed to gather basic data contributive in setting up of an EMD at a tertiary care teaching hospital from the lessons learned from functioning existent systems. Methods: This is primarily a questionnaire-based descriptive study at tertiary care referral centres across the country, which was purposively selected.The study models included one from a hospital without designated EMD and the other four from hospitals with established EMDs. Direct observation and focus group meetings with experienced informants at these hospitals contributed to the data. In the absence of a validated hospital preparedness assessment scale, comparison was done with regard to quantitative, qualitative and corroborative parameters using descriptive analysis. Results: The EMDs at best practice models were headed by specialist in Emergency Medicine assisted by organised staff, had protocols for managing mass casualty incident (MCI), separate trauma teams, ergonomic use of infrastructure and public education programmes. In this regard, these hospitals seemed well organised to manage MCIs and disasters. Conclusion: The observation may provide a preliminary data useful in setting up an EMD. In the absence of published Indian literature, this may facilitate further research in this direction. Anaesthesiologists, presently an approved Faculty in Emergency Medicine training can provide creative input with regard to its initial organisation and functioning, thus widening our horizons in a country where there is a severe dearth of trained emergency physicians.

Celiac plexus block (CPB) for chronic upper abdominal pain, particularly cancer pain, can be given in both supine and prone positions, using anterior and posterior approaches, respectively. Both approaches suffer from their own demerits. In ultrasonography (USG)-guided anterior approach, the needle has to pass through the liver, intestine, stomach, pancreas, and vessels, exposing the patient to the risk of infection, hemorrhage, and fistula formation. Moreover, in the presence of ascites and large lymph nodes, retroperitoneal area cannot be visualized clearly using USG. In the posterior approach, the patient lies prone with a pillow underneath the abdomen to alleviate lumbar lordosis, and the block is given under fluoroscopic or computed tomography (CT) guidance. Terminally ill patients have difficulty in tolerating prone position because of pain and discomfort due to abdominal distension. To the best of my knowledge, no position other than the supine, prone and rarely lateral, have been described for giving CPB in patients. We present three cases with carcinoma head of pancreas, where CPB was given under fluoroscopic guidance. As all three patients could not tolerate the prone position because of pain and ascites, we modified the position to a knee-chest position [Figure 1]. The patients found the position comfortable to maintain, and they were cooperative during the block. We encountered no problems in imaging the vertebral bodies in anteroposterior (AP) and lateral view. No pillow was required, as the lumbar lordosis was already abolished in this position. In each patient, bilateral block was given using 15-20 mL of 50% alcohol in 0.25% bupivacaine, on either side using a 15-cm Chiba needle. Subsequent follow-up showed successful blockade in all three patients. The use of a modified knee-chest position has not been described earlier for this procedure, but may be a suitable, convenient, and comfortable alternative for terminally ill patients who are unable to lie prone.

Cell-free DNA (cfDNA) has significant potential in the diagnosis and monitoring of clinical conditions but accurately and easily distinguishing the relative proportion of DNA molecules in a mixture derived from two different sources (i.e. donor and recipient tissues after transplantation) is challenging. In human cellular transplantation there is currently no useable method to detect in vivo engraftment and blood-based non-invasive tests for allograft rejection in solid organ transplantation are either non-specific (e.g. creatinine in kidney transplantation, liver enzymes in hepatic transplantation) or absent (i.e. heart transplantation). Elevated levels of donor cfDNA have been shown to correlate with solid organ rejection but complex methodology limits implementation of this promising biomarker. We describe a cost-effective method to quantify donor cfDNA in recipient plasma using a panel of high-frequency single nucleotide polymorphisms, next-generation (semiconductor) sequencing and a novel mixture model algorithm. In vitro, our method accurately and rapidly determined donor/recipient DNA admixture. For in vivo testing, donor cfDNA was serially quantified in an infant with a urea cycle disorder after receiving six daily infusions of donor liver cells. Donor cfDNA isolated from 1-2 ml of recipient plasma was detected as late as 24 weeks after infusion suggesting engraftment. The percentage of circulating donor cfDNA was also assessed in pediatric and adult heart transplant recipients undergoing routine endomyocardial biopsy with levels observed to be stable over time and generally measuring