Case Record

DIAGNOSTIC CLARIFICATION: He presented with a 2 months history of multiple episodes of unconscious spells followed by possession of his body by spirits which he claimed to be that of his father and grandmother, who were no more. The episodes would last for 1 to 2 hours. During the episodes he would speak like his father and grandmother. He also describes that during these episodes he could clearly hear his father talking to him and advising him, following which he would reply to the voices. The illness apparently started after a quarrel with his mother over his multiple relationships with several girls in his school and locality. He had not been going to school during these days. There was a significant deterioration in his academic performance in the last 2 years. His sleep was decreased and appetite was also decreased. There was no history of delusions, manic symptoms, or of substance use. CONCLUSION: He was prone to exhibit maladaptive behaviour under stressful situation. His disregard to social norms was also evident. The difficulty in decision-making and problem-solving justify his dissatisfaction with life. The environment was perceived threatening and insecure. Poor interpersonal relations can be the cause of his psychopathology. Rorschach revealed no pathognomonic signs of psychosis or mood disorder. PERSONALITY ASSESSMENT: The patient was described to be a highly reserved and introvert person with less number of friends. He was apparently normal till he reached 10th standard when he noticed to have decreased energy in doing work, poor concentration and easy fatiquability. His academic performance also started deteriorating. He attributes the cause of illness to loss of semen when he masturbates. He expresses guilt regarding masturbation. He would have episodes of anxiety, sweating and palpitation when he think about masturbation. He is worried that this might affect his marital life adversely. There was no history suggestive of first rank symptoms. There was no history of any abnormal perception. There was no history of depressive symptoms. There was no history of mania or hypomania. There was no history of phobia or panic attacks. There was no history suggestive of organicity or seizures. CONCLUSION: The Tests revealed his personality traits viz. emotionally less stable, and anxious. It also indicated that he is less intelligent in thinking, and usually adapts concrete way of thinking. Tests also found that he is slow tempered, unenthusiastic, reserved & uninquiring. He is also in less need of stimulation, resistant & slow to engage in new activities and conventional. Blaming the outside for his failures were also evident. Rapport was established with the patient. Dothiepin was started to lessen his anxiety. He was asked to keep a cognitive diary. During interviews the negative automatic thoughts and possible alternative thoughts are discussed. Improvements in his anxiety and positive world view have noticed over a period of time. He was adviced a regular OP follow up visits. DIAGNOSTIC CLARIFICATION: From early childhood onwards, Ms.GK was reported to be adamant. She had poor frustration tolerance that even for trivial incidents at school or at home she will be angry and sometimes agitated. But significant changes were noticed since she was studying in 10th standard. She was noticed to have multiple episodes of loss of consciousness. The episode would last for 5 to 10 minutes. Usually the episodes are preceded by a problem at home or in school. After regaining the consciousness she would resume her routine activities. There was no history of injury, incontinence of urine or bowel during the episodes. For the last 3 to 4 years she also started complaining that she could hear nonexistent voices talking to her. She could hear multiple voices, both male and female, talking to her and talking to each other. She also express the fear that, she feels that somebody is catching her neck from behind and trying to kill her, when nobody is around. There was no history of depressive syndrome or mania or hypomania. There was no history of phobia or panic attacks. There was no history suggestive of organicity or seizures. CONCLUSION: The tests revealed her personality traits viz. avoidant, emotional dysregulation, sensitivity to stressors. She was prone to exhibit maladaptive behaviour under stressful situation. No psychosis was evident in the tests conducted. The difficulty in decision-making and problem-solving justify her dissatisfaction with life. The defense mechanisms were mostly mature and neurotic. The significant conflicts were support vs. independence, affiliation vs. rejection, autonomy vs. compliance, helpless vs. autonomy. Sex vs. morality. She was found to be vulnerable to social rejection. There was also tendency to loss self-sufficiency. Both finally may culminate in somatisation with secondary gain. Rapport was established with the patient. Patients mother was educated about illness and she was taught to cut down the secondary gains by not giving attention to her symptoms. Principles of differential reinforcement and daily activity scheduling were also used to control the symptoms. Social skills training with focus on helping her to deal with heavy responsibilities and stress was also undertaken. Specific techniques as self-instruction, feedback, and reinforcement of positive interactions were used. She was taught relaxation techniques and coping skills. She had four dissociative episodes in the hospital and was symptom free at the time of discharge. NEUROPSYCHOLOGICAL ASSESSMENT: Patient was apparently normal till 10 years back when he suffered from multiple episodes of vomiting, falls, tremors of extremities and loss of consciousness. He was taken to a hospital in Chennai and was diagnosed as hydrocephalus and tectal mass lesion. Ventriculo-peritonial shunt was done. Later he was referred to CMC, Vellore as shunt block was noticed and VP shunt was again done in CMC. Following the surgery, vomiting, falls and episodes of loss of consciousness had subsided. However the patient was noticed to have poor Academic performance in school, repeated failures, frequent change of school since then. For the last 2 years a significant change is noticed in patient’s behaviour. He had started abusing and assaulting family members and noticed to have a negative attitude towards everything, and accusing others for his problems. He had become more irritable and adamant. He would demand unreasonanbly. He had forgotten his lessons at school and had difficulty in pursuing his academic work. Reading and writing skills had deteriorated. His sleep was also reduced. There was no history of seizures, mood syndrome, anxiety or psychosis. CONCLUSION: Neuropsychological assessment reveals bilateral temporal and right parietal involvement with moderate deficits in prefrontal cortex INTELLIGENCE QUOTIENT ASSESSMENT: The patient was born out of a non consanguineous union. It was a preterm (32 weeks) normal delivery in the hospital. There were no perinatal complications. Parents noticed a delay in motor milestones after the age of 1 year. He attained head control at the age of 4 months, turning at 6months, sitting with support at 11 months, standing at 18 months and walking with support at 2 years of age. Likewise his language development was also delayed. He started cooing at 1 year, babbling by 2 years of age and thereafter no language development was noticed. He started recognizing his mother by 6 months of age and social smile was noticed by around 8 months of age. He was noticed to have hearing impairment and was evaluated by an ENT specialist who confirmed the same

Cardiac biomarkers in acute coronary syndromes

Cardiac biomarkers play a significant role in the diagnosis, risk assessment, and management of patients with acute coronary syndromes (ACS). Several biomarkers identify different components of the pathophysiology of ACS: troponins are markers of myocyte necrosis, natriuretic peptides reflect neurohormonal activation and myocardial dysfunction, and C-reactive protein reflects various inflammatory processes. Whilst there are a number of established and novel biomarkers to assess ischemia, necrosis and myocardial dysfunction in coronary artery disease, it is probable that no single biomarker will emerge that provides appropriate information for all clinical settings of ACS. This suggests that ongoing efforts in plasma-based biomarker research should concentrate on the use of a multimarker approach to enhance our diagnosis, prognostic assessment, and management of patients with suspected ACS, as compared with using individual markers alone. It is recommended that current practice involve the selective use of biomarkers in patients in whom a more complete assessment of risk is desired. At present, routine biomarker measurement is not advocated until further data become available, which will support the benefit of specific therapeutic interventions

SUM SIGNED GRAPHS – II

In this paper, the study of sum signed graphs is continued. The balancing and switching nature of the graphs are analyzed. The concept of  $rna$ number is revisited and an important relation between the number and its complement is established

Comment on "Exposed-Key Weakness of Alpha-Eta" [Phys. Lett. A 370 (2007) 131]

We show that the insecurity claim of the AlphaEta cryptosystem made by C. Ahn and K. Birnbaum in Phys. Lett. A 370 (2007) 131-135 under heterodyne attack is based on invalid extrapolations of Shannon's random cipher analysis and on an invalid statistical independence assumption. We show, both for standard ciphers and AlphaEta, that expressions of the kind given by Ahn and Birnbaum can at best be interpreted as security lower bounds.Comment: Published versio

Flow characteristics of hydraulically fractured granite rocks under high temperature

Hydraulic fracturing technique, which is widely used to enhance the permeability of tight geological formations, has been employed to stimulate unconventional geothermal systems. However, these reservoirs are accompanied by high in-situ stresses and large geothermal gradients. Therefore, it is important to understand the hydraulic fracturing process and the respective permeability enhancement under extreme temperature and pressure conditions. Therefore, the aim of the present study is to understand the effect of flow performance of hydraulically fractured granite under high temperature and pressure conditions. A series of flow-through experiments were conducted on granite specimens which were hydraulically fractured under 60 MPa confining pressure and two temperature conditions: room temperature and 300 °C. Corresponding influence on rock microstructure was studied using high- resolution CT imaging with the IMBL facility of Australian Synchrotron. Based on the experimental results, it was found that one single fracture is induced at room temperature. However, a perforated zone with multiple inter-crystalline cracks is induced in the wellbore zone under the high-temperature fracturing process. Therefore, the measured permeability was almost one order higher in the sample hydraulically fractured under high temperature up to 20 MPa confining pressure. Further, it was identified that the fracture permeability and the fluid discharge were strongly stressed dependent

Clinical and laboratory profile of children admitted with measles in a tertiary care teaching hospital

Background: Measles is a vaccine-preventable viral illness associated with substantial childhood morbidity and mortality. Recently, changing trends in the occurrence of measles are noted like incidence in younger infants and in those who have received measles vaccine. Objectives: The objective was to study the clinical profile of children with measles and to study the usefulness of polymerase chain reaction (PCR) in diagnosing measles and to study the measles-specific immunoglobulin M (IgM) response in children with measles. Materials and Methods: This study was done in the Pediatrics Department of a Tertiary Care Center, and the study population was children up to 12 years of age admitted in the setting with a clinical diagnosis of measles during the study period and who were laboratory confirmed by PCR/IgM ELISA or both. Results: Of 173 clinically diagnosed cases, 149 laboratory confirmed cases were taken for analysis and studied. Of these, 47% of cases were below 9 months. Newborns constituted 2.01% of the total cases. The mean age was 13 months and the male:female ratio was 1.13:1. A total of 24.8% children were unimmunized, 16.77% had a single dose, and 8.72% had 2 doses of measles vaccine. Overall mortality was 0.67% and bronchopneumonia was the major complication (76.5%). Among immunized children with measles confirmed by PCR, measles-specific IgM response was reactive in 36.4% of cases. In the early phase of measles (within 3 days) confirmed by PCR, IgM response was inconclusive in 60% of cases. Conclusion: In our study, 47% of the cases of measles were below 9 months; therefore, the age of measles vaccination may be reconsidered. Among eligible cases (>9 months), 24.83% were not immunized for measles which indicates that measles immunization coverage should be increased. Among the measles cases, 25% had measles vaccination which highlights the need to check for the determinants of vaccine failure. In our study, the RT-PCR was found to be useful for early diagnosis of measles and for diagnosis in immunized children