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Despite the best possible pharmacotherapy, 30% of persons with epilepsy will remain drug resistant. Drug resistant Epilepsy (DRE) has many different presentations and causes; hence evaluation may help to understand and manage appropriately. To study a cohort of adult patients with refractory focal epilepsy, focusing on clinical semiology, risk factors, imaging and video EEG findings. This is a prospective observational study done in adult neurology department of tertiary care hospital, from 2013 to 2016. The primary inclusion criteria were patients with drug refractory focal seizure (as per ILAE definition 2010), with age more than 12 years. Detailed clinical data, long term EEG monitoring, MRI and minimum follow up of 6 months were collected. Of 120 patients of DRE, 72% were in the age group of 12-30 yrs. Febrile seizure (26%) and head injury (17%) were the most significant antecedent history. Focal seizures with dyscognitive features were present in 87%. 16 patients had abnormal neurological examination. The most common radiological finding was mesial temporal sclerosis and gliosis. After complete evaluations, 30% of the patients were found to have pseudo-resistance. The evaluation led to modification of treatment in more than three-fourth of the patients. Early age of onset, history of febrile seizures, past history of head injury, focal dyscognitive type of seizures and structural lesion on imaging are common factors in patients with DRE. Pseudo- resistance due to wrong diagnosis and inadequate AEDs were responsible for one third of cases.

Bleeding haemorrhoids present commonly to surgical outpatient departments (OPDs) and sometimes in emergency. Most often conservative management suffices but infrequently the patients can land up in emergency operation theatre for uncontrolled bleeding. Some haematological disorders can also present with rectal bleeding and amongst them Chronic myeloid leukaemia (CML), a haematological malignancy, presenting as bleeding per rectum has been not been reported so far, though instances of CML with gingival bleed, epistaxis have been reported. CML per se is known to be asymptomatic (40% cases) and bleeding is rarely seen. Here we present an interesting case of an emergency hemorrhoidal bleed that was subsequently diagnosed as CML. The patient after failed conservative management for bleeding haemorrhoids was taken up for emergency haemorrhoidectomy and again a relook under general anaesthesia in the post-operative period as he continued to ooze. The total leucocyte counts which were initially high continued to rise further and the bone marrow examination was reported as chronic myeloproliferative neoplasm and the excised mass was consistent with haemorrhoids. Rectal bleeding associated with CML is so far unreported even though bleeding is seen due to platelet dysfunction from gums and nose in chronic phases of the disease. A high index of suspicion is needed particularly with deranged haematological parameters for considering a diagnosis of these rare presentations. and anaesthesia.

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