Support vector machine based methodology for classification of thermal images pertaining to breast cancer.

Breast cancer has been and continues to be a cause of major health concern for women. It is more prevalent in old age, but its incidence has increased in recent years in groups below 50 years old, as in India. According to the Indian Council of Medical Research (ICMR) 2020, 50% of all the cases are in the age group of 25-50 where the numbers are staggering and constantly rising. The increase in incidence over the years indicates an urging need for innovative approaches to enhance breast cancer detection early. Thermography is non-contact imaging modalities and has potential to detect breast cancer at an early stage. Though thermography has capable of detecting breast cancer early, the challenge lies in the interpretation of the breast thermograms with respect to features and subsequent analysis. The present work discusses image acquisition, image processing related pre-processing, segmentation, and feature extraction. The extracted features were analyzed using ANOVA (Analysis of variance) statistical analysis. Statistical analyses were done in order to find the appropriate feature on the whole and quadrant breast. Statistical analysis results clearly reveal existence of thermal symmetry for the healthy subjects (p value > .05) in both whole and quadrant breast regions. In the case of abnormal subjects, whole breast analyses revealed the significance (p value < .05) for features like mean, variance, standard deviation, kurtosis, skewness, entropy, energy, homogeneity and contrast whereas upper outer quadrant analyses showed significance for all above features except contrast. The well correlated features of upper outer quadrant and whole breast were given as input for the Support Vector Machine - Radial Basis Function (SVM - RBF) classifier with grid search method. The results revealed that whole breast analysis has achieved 92.86% accuracy and upper outer quadrant breast analysis has achieved 85.71% accuracy. The results clearly indicate the involvement of upper outer quadrant and whole breast in early detection of breast cancer using thermal imaging.

Characterisation and identification of antibacterial compound from marine actinobacteria: In vitro and in silico analysis.

OBJECTIVE: The present study was focused on the characterization and in silico analysis of antibacterial compound derived from marine actinobacteria isolated from the sediments of salterns of Ongole, Andhra Pradesh, India. METHODS: The sediment sample was serially diluted and marine actinobacteria were isolated in actinomycetes isolation agar. A total of 9 colonies were recovered and among them, 5 morphologically distinct isolates were selected for further processing. The antibacterial activity of these five isolates was tested against 4 clinical isolates collected from Narayani Hospital, Vellore, Tamil Nadu. RESULTS: The isolate SJP4 showed inhibitory activity against all the test pathogens viz., Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa and Bacillus cereus. The structure of the compounds extracted from SJP4 was identified as 8-diaza-2,9-dibenzoyl-5,6-diphenyl-2,8-decadienedioic acid diethyl ester and [1,2,4]triazol-1-ylethanone through GCMS analysis. Molecular docking studies was done using Autodock software. These two compounds were docked into the binding site of DNA gyrase and found to have binding energy of -6.55(Kcal/mol) and -4.86(Kcal/mol) respectively. The potential actinobacteria isolate was identified as Nocardiopsis dassonvillei SJPB4 strain (Accession no. MG434671) using 16s rRNA sequencing. CONCLUSION: We are concluding that as the compounds were successfully docked on to the active site of DNA gyrase.

Use of eschar for the molecular diagnosis and genotypic characterisation of Orientia tsutsugamushi causing scrub typhus.

Scrub typhus caused by Orientia tsutsugamushi presents as an acute febrile illness with a varied presentation from mild illness to fatal disease in the absence of appropriate antibiotic treatment. Performing polymerase chain reaction (PCR) on eschar sample acts a rapid diagnostic tool in the early stage of scrub typhus when blood is negative. A total of eight patients from whom both whole blood and eschar samples were collected and tested by nested PCR targeting 56 kDa trichostatin A (TSA) gene to detect O. tsutsugamushi DNA. All (100%) eschar samples and three whole blood samples tested positive. Genetic analysis of the 56 kDa TSA gene sequences showed that the majority were related to Karp reference strains, while one clustered with Kawasaki strain. When present, eschar should be favoured as a diagnostic sample over whole blood in the early phase of infection.

Advances in the Management of Pediatric Septic Shock: Old Questions, New Answers.

Septic shock in children is associated with high mortality, especially in developing countries. Management includes early recognition, timely antibiotics, aggressive fluid resuscitation, and appropriate vasoactive therapy, to achieve the therapeutic end points. The evidence at each step in management has evolved over the past decade with a paradigm shift in emphasis from a 'protocolized care' to an 'individualized physiology-based care'. This shift mirrors the general trend one observes in critical care with respect to various treatment modalities i.e. moving away from a liberal to a more conservative approach be it fluids, ventilation, transfusion, antibiotics or insulin. The age-old questions of how much fluid to give, what inotropes to start, when to administer antibiotics, are steroids indicated and when to consider extracorporeal therapies in refractory shock are finding new answers from the recent spate of evidence. It is therefore imperative for all of us to be aware of the recent changes in management, to enable us to adopt an evidenced based approach while managing children with septic shock. In this review, we have tried to summarize the key changes in evidence that have occurred over the past decade at various steps in the management of pediatric septic shock.

A randomized controlled trial of one bag vs. two bag system of fluid delivery in children with diabetic ketoacidosis: Experience from a developing country.

PURPOSE: To compare one vs. two bag system with respect to blood glucose variability (BGV), time for resolution of acidosis and incidence of hypoglycemia, hypokalemia, and cerebral edema in children with diabetic ketoacidosis (DKA). MATERIAL AND METHODS: In an open labelled randomized controlled trial, thirty consecutive patients ≤12years with DKA were randomized to either one (n=15) or two bag (n=15) system of intravenous fluid delivery. The two bags had similar electrolyte but differing dextrose concentration (none vs. 12.5%) and changing the rate of fluid, delivered different dextrose concentrations. BGV was primary outcome while hypoglycemia (blood glucose, BG<50mg/dL), hypokalemia (serum potassium<3.5mEq/L), time to resolution of acidosis and cerebral edema were secondary outcomes. RESULTS: The one and two bag systems had similar BGV parameters; median hourly absolute BG change (mg/dL) [44 (30-74.5) vs. 36 (31-49); p=0.54], mean of standard deviation of BG measurements [65.1 (25.1) vs. 65.5 (26.8); p=0.96] and median number of undesirable events (hourly blood sugar change ≥50mg/dL) [4.5 (1.75-6.0) vs. 5.0 (3.0-8.0); p=0.31]. The incidence of hypoglycemia [42.9% (n=6) vs. 26.7% (n=4); p=0.45] and hypokalemia [64% (n=9) vs. 67% (n=10); p=0.23], and mean (SD) time to resolution of acidosis [20.3 (14.8) and 20.3 (7.0); p=0.59] were similar in both the groups. None had cerebral edema. CONCLUSIONS: The one and two bag systems were similar to each other with respect to BGV, incidence of complications and time to resolution of acidosis.

Hypoalbuminemia in critically sick children.

CONTEXT: There is a paucity of data evaluating serum albumin levels and outcome of critically ill-children admitted to intensive care unit (ICU). AIMS: The aim was to study frequency of hypoalbuminemia and examine association between hypoalbuminemia and outcome in critically ill-children. SETTINGS AND DESIGN: Retrospective review of medical records of 435 patients admitted to 12 bedded pediatric ICU (PICU). MATERIALS AND METHODS: Patients with hypoalbuminemia on admission or any time during PICU stay were compared with normoalbuminemic patients for demographic and clinical profile. Effect of albumin infusion was also examined. Odds ratio and 95% confidence interval were calculated using SPSS 16. RESULTS: Hypoalbuminemia was present on admission in 21% (92 of 435) patients that increased to 34% at the end of 1(st) week and to 37% (164 of 435) during rest of the stay in PICU. Hypoalbuminemic patients had higher Pediatric Risk of Mortality scores (12.9 vs. 7.5, P < 0.001) and prolonged PICU stay (13.8 vs. 6.7 days, P < 0.001); higher likelihood of respiratory failure requiring mechanical ventilaton (84.8% vs. 28.8%, P < 0.001), prolonged ventilatory support, progression to multiorgan dysfunction syndrome (87.8% vs. 16.2%) and risk of mortality (25.6% vs. 17.7%). Though, the survivors among recipients of albumin infusion had significantly higher increase in serum albumin level (0.76 g/dL, standard deviation [SD] 0.54) compared with nonsurvivors (0.46 g/dL, SD 0.44; P = 0.016), albumin infusion did not reduce the risk of mortality. CONCLUSIONS: Hypoalbuminemia is a significant indicator of mortality and morbidity in critically sick children. More studies are needed to define role of albumin infusion in treatment of such patients.

Probiotic use and prevalence of candidemia and candiduria in a PICU.

OBJECTIVES: To compare the prevalence of candidemia and candiduria before and after the introduction of routine use of probiotics in children who received broad-spectrum antibiotics in a PICU. DESIGN: Retrospective "before and after" study. SETTING: A 12-bed PICU of a teaching hospital in India. PATIENTS: Children 3 months to 12 years old, admitted to the PICU over two 9 months' time periods, who received broad-spectrum antibiotics for more than 48 hours. INTERVENTIONS: Three hundred forty-four patients enrolled between November 2008 and July 2009 after the introduction of routine use of probiotics served as the "probiotic group"; they had received one sachet twice a day of a probiotic mix (EUGI [Wallace Pharma, Goa, India] containing Lactobacillus acidophillus, Lactobacillus rhamnosum, Bifidobacterium longum, Bifidobacterium bifidum, Saccharomyces boulardii, and Streptococcus thermophilus) for 7 days. Three hundred seventy-six children enrolled between February 2007 and October 2007 served as "controls." Blood was sent for bacterial and fungal cultures if clinically indicated and urine catheter/bag specimen was submitted for bacterial and fungal culture twice a week as per unit's protocol. MEASUREMENTS AND MAIN RESULTS: Primary outcome was growth of Candida in blood (candidemia), and secondary outcomes were growth of Candida in urine (candiduria), nosocomial bloodstream infections, and urinary tract infections. Data were retrieved from the case records. Candidemia was seen in four of 344 patients (1.2%) in the probiotic group and in 14 of 376 (3.7%) in the control group (relative risk, 0.31; 95% CI, 0.10-0.94; p = 0.03). Candiduria was noted in 37 of 344 patients (10.7%) in the probiotic group and 83 of 376 (22%) in the control group (relative risk, 0.48; 95% CI, 0.34-0.7; p = 0.0001). The prevalence of nosocomial bloodstream infection and urinary tract infection in the probiotic and control groups was 20.3% and 26% (p = 0.07) and 14.2% and 19.1% (p = 0.08), respectively. CONCLUSIONS: Routine use of a mix of probiotics in patients who receive broad-spectrum antibiotics could be a useful strategy to reduce the prevalence of candidemia and candiduria in the PICU.

Vitamin D levels during and after resolution of ketoacidosis in children with new onset Type 1 diabetes.

AIM: To study the effect of ketoacidosis on measured 25-hydroxyvitamin D3 in children with new onset Type 1 diabetes. METHODS: Measurement of pH and bicarbonate levels was carried out in children with newly diagnosed Type 1 diabetes at presentation with ketoacidosis. 25-hydroxyvitamin D3 estimation was carried out at presentation (timepoint 1) and 1 month later (timepoint 2). There was no significant difference in the mean (±sd) 25-hydroxyvitamin D3 levels [35.39 (±25.79) vs 39.63 (±48.03) nmol/L; P = 0.661) at the two timepoints in the study. RESULTS: Correlation analysis revealed a positive correlation between bicarbonate levels and timepoint 1, i.e. the lower the bicarbonate levels, the lower were the timepoint 1 levels and vice versa (correlation coefficient 0.538, P = 0.001). Timepoint 2 levels also showed a positive correlation with serum bicarbonate levels with a correlation coefficient of 0.379 (P = 0.032). None of the variables other than bicarbonate,.(age, gender, BMI, pH or time), was found to have the predictive ability for timepoint1 levels. Similarly for predicting timepoint 2 levels, BMI was found to have independent predictive ability in addition to bicarbonate. CONCLUSIONS: Severe ketoacidosis, as judged by bicarbonate but not pH, may transiently lower 25-hydroxyvitamin D3 levels in children with new onset Type 1 diabetes. Persistence of low 25-hydroxyvitamin D3 levels after resolution of ketoacidosis suggests a state of permanent vitamin D deficiency in our patient population.

Approach to a child with upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) is a potentially life threatening medical emergency requiring an appropriate diagnostic and therapeutic approach. Therefore, the primary focus in a child with UGIB is resuscitation and stabilization followed by a diagnostic evaluation. The differential diagnosis of UGIB in children is determined by age and severity of bleed. In infants and toddlers mucosal bleed (gastritis and stress ulcers) is a common cause. In children above 2 y variceal bleeding due to Extra-Hepatic Portal Venous Obstruction (EHPVO) is the commonest cause of significant UGIB in developing countries as against peptic ulcer in the developed countries. Upper gastrointestinal endoscopy is the most accurate and useful diagnostic tool to evaluate UGIB in children. Parenteral vitamin K (infants, 1-2 mg/dose; children, 5-10 mg) and parenteral Proton Pump Inhibitors (PPI's), should be administered empirically in case of a major UGIB. Octreotide infusion is useful in control of significant UGIB due to variceal hemorrhage. A temporarily placed, Sengstaken-Blakemore tube can be life saving if pharmacologic/ endoscopic methods fail to control variceal bleeding. Therapy in patients having mucosal bleed is directed at neutralization and/or prevention of gastric acid release; High dose Proton Pump Inhibitors (PPIs, Pantoprazole) are more efficacious than H2 receptor antagonists for this purpose.

Management of a child with vomiting.

Vomiting is a protective reflex that results in forceful ejection of stomach contents up to and out of the mouth. It is a common complaint and may be the presenting symptom of several life-threatening conditions. It can be caused by a variety of organic and nonorganic disorders; gastrointestinal (GI) or outside of GI. Acute gastritis and gastroenteritis (AGE) are the leading cause of acute vomiting in children. Important life threatening causes in infancy include congenital intestinal obstruction, atresia, malrotation with volvulus, necrotizing enterocolitis, pyloric stenosis, intussusception, shaken baby syndrome, hydrocephalus, inborn errors of metabolism, congenital adrenal hypoplasia, obstructive uropathy, sepsis, meningitis and encephalitis, and severe gastroenteritis, and in older children appendicitis, intracranial mass lesion, diabetic ketoacidosis, Reye's syndrome, toxic ingestions, uremia, and meningitis. Initial evaluation is directed at assessment of airway, breathing and circulation, assessment of hydration status and red flag signs (bilious or bloody vomiting, altered sensorium, toxic/septic/apprehensive look, inconsolable cry or excessive irritability, severe dehydration, concern for symptomatic hypoglycemia, severe wasting, Bent-over posture). The history and physical examination guides the approach in an individual patient. The diverse nature of causes of vomiting makes a "routine" laboratory or radiologic screen impossible. Investigations (Serum electrolytes and blood gases,renal and liver functions and radiological studies) are required in any child with dehydration or red flag signs, to diagnose surgical causes. Management priorities include treatment of dehydration, stoppage of oral fluids/feeds and decompression of the stomach with nasogastric tube in patients with bilious vomiting. Antiemetic ondansetron(0.2 mg/kg oral; parenteral 0.15 mg/kg; maximum 4 mg) is indicated in children unable to take orally due to persistent vomiting, post-operative vomiting, chemotherapy induced vomiting, cyclic vomiting syndrome and acute mountain sickness.

Management of acute diarrhea in emergency room.

Acute diarrhea is the second leading cause of under-five mortality in India. It is defined as the passage of frequent watery stools (>3/24 h). Recent change in consistency of stools is more important than frequency. Acute diarrhea is caused by variety of viral, bacterial and parasitic agents. The common ones are: Rotavirus, E. coli, Shigella, Cholera, and Salmonella. Campylobacter jejuni, Giardia and E. histolytica are also not uncommon. The most important concern in management of acute diarrhea in Emergency room (ER) is fluid and electrolyte imbalances and treatment of underlying infection, wherever applicable. It includes, initial stabilization (identification and treatment of shock), assessment of hydration and rehydration therapy, recognition and treatment of electrolyte imbalance, and use of appropriate antimicrobials wherever indicated. For assessment of hydration clinical signs are generally reliable; however, in severely malnourished children sunken eyes and skin turgor are unreliable. Oral Rehydration Therapy is the cornerstone of management of dehydration. Intravenous fluids are not routinely recommended except in cases of persistent vomiting and/or shock. Majority of cases can be managed in ER and at home. Hospitalization is indicated in infants <3 mo, children with severe dehydration, severe malnutrition, toxic look, persistent vomiting and suspected surgical abdomen. Supplementations with zinc and probiotics have been shown to reduce severity and duration of diarrhea; however evidence does not support the use of antisecretary, antimotility and binding agents. Education of parents about hand hygiene, safe weaning and safe drinking water etc., can help in reducing incidence of this important health problem in the country.

A prospective observational study of the outcome of central venous catheterization in 100 patients.

CONTEXT: To Study the outcome following central vein catheterization in patients receiving chemotherapy. AIMS: To Study the outcome of central venous catheterization in terms of difficulty during insertion, duration, incidence of infections and other complications and reasons for removal. SETTINGS AND DESIGNS: Prospective observational study conducted in 100 patients attending to Gujarat Cancer and Research Institute. MATERIALS AND METHODS: Both onco-medical and onco-surgical patients who required insertion of central venous catheters were enrolled after ethical approval from June 2008 to November 2010. The study comprised 100 patients. STATISTICAL ANALYSIS USED: Mean and percentage. RESULTS: Mean duration of the indwelling catheter was 109 days for Hickman catheter, 39 days for cavafix and 59 days for certofix. Difficulty in insertion and arrhythmias were common complications. There were no incidences of major life threatening complications. Catheter related infection was 30%. The commonest reason for catheter removal was treatment completion 72%. The next frequent cause was catheter infection 14% and patient death 6%. CONCLUSIONS: Even though central venous catheterization is associated with acceptable complications, they serve a useful aid in management of patients on chemotherapy.

Nutritional status and complications in children with diabetic ketoacidosis.

OBJECTIVE: Diabetic ketoacidosis in children continues to be an important cause of morbidity and mortality, especially in developing economies as a result of malnutrition, a high rate of infections, and delay in seeking timely medical care. Malnutrition also increases the risk of diabetic ketoacidosis-related complications. The objective of this study was to assess the nutritional status of patients presenting with diabetic ketoacidosis and correlate it with the incidence of complications at presentation and those encountered during the course of illness. DESIGN: Prospective study. SETTING: Pediatric emergency and intensive care units, Advanced Pediatrics Centre, PGIMER, Chandigarh, India. PATIENTS: Thirty-three children between 1 month and 12 yrs of age presenting with diabetic ketoacidosis between July 2008 and June 2009 were enrolled consecutively and assessed for nutritional status by anthropometric parameters (body weight, crown-heel length/height, mid-upper arm circumference, triceps and subscapular skin fold thicknesses), biochemical parameters (serum albumin, zinc, magnesium, vitamin A levels), and preillness dietary history (by pretested Food Frequency Questionnaire). Patients were classified as malnourished or normally nourished based on the weight for age criteria matched for Indian standards. The incidence of complications (electrolyte imbalances, hypoglycemia, sepsis, cerebral edema, etc.) and outcome in terms of survival or death in both the groups were compared with Student's t-test for parametric data, Mann-Whitney U test for nonparametric data, and chi-square test for categorical variables. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Anthropometric assessment showed that 11 of 33 (33.3%) were malnourished. Preillness dietary history revealed that 16 (48.5%) were calorie- and protein-deficient (known diabetic n = 7; new onset n = 9), whereas 11 (33.3%) were only calorie-deficient (known diabetic n = 2). Hypoalbuminemia was seen in 21 (63.6%), hypovitaminosis A in eight (24.2%), and low zinc levels in three (9%). The malnourished and normally nourished groups were similar with respect to demographics, precipitating factors, severity of diabetic ketoacidosis, treatment received, and outcome. However, the incidence and severity of therapy-related hypokalemia (100% vs. 72.7%; p = .05) and hypoglycemia (63.6 vs. 13.6%; p = .004) were significantly higher in the former as compared with the latter. The mean ± SD admission serum potassium levels were similar in both the groups (3.4 ± 0.8 mEq/L in the malnourished vs. 3.5 ± 0.7 mEq/L in the normally nourished) with the malnourished group showing a significant fall at 6 hrs after start the of diabetic ketoacidosis protocol (2.8 ± 0.8 mEq/L vs. 3.6 ± 0.7 mEq/L; p = .033), although the mean rate and dose of insulin infusion were similar. The fall in blood glucose (mean ± SD mg/dL) at 12, 24, and 36 hrs after onset of the diabetic ketoacidosis protocol was also significantly greater in the malnourished group as compared with the normally nourished diabetic ketoacidosis (195 ± 69.1 and 272.61 ± 96.3, p = .02; 171 ± 58.5 and 257 ± 96.3, p = .05; and 153.75 ± 49.6 and 241.71 ± 76.3, p = .04, respectively). The incidence of hypophosphatemia, hypomagnesemia, cerebral edema, renal failure, sepsis, and septic shock was similar in both the groups. There were two deaths, both resulting from complicating cerebral edema and renal failure and unrelated to the nutritional status of the patients. CONCLUSIONS: The incidence and severity of therapy-related hypokalemia and hypoglycemia were significantly higher in the malnourished as compared to the normally nourished diabetic ketoacidosis. Other diabetic ketoacidosis-related complications and outcome were similar in both the groups.

Pediatric cardiopulmonary resuscitation and stabilization.

Cardiopulmonary arrest refers to cessation of clinically detectable cardiac activity. In children, it usually results from progression of shock, respiratory failure or cardiac dysrhythmia. Early recognition and timely interventions in above group of patients is the key to prevent progression to cardiac arrest. The goal of resuscitation is to urgently re-establish oxygenation of vital organs by attention to Airway, Breathing and Circulation. Measures to restore airway patency include positioning, suctioning, continuous positive airway pressure, relieving a foreign-body airway obstruction and, endotracheal intubation, tracheotomy or laryngeal mask airway. Breathing is supported with O(2) and if needed, bag-mask ventilation, or endotracheal intubation and ventilation. Patients with absent or feeble central pulse are given cardiac compressions (CPR) at a rate of 100/ min synchronized with ventilation. In sudden witnessed collapse, immediate defibrillation is warranted, followed by CPR and administration of drugs. In unwitnessed collapse, CPR is performed for five cycles or 2 min before defibrillation. In patients with shock, a venous or an intraosseous access is rapidly established to administer 20 ml/kg saline bolus. Supraventricular tachycardia is treated with vagal maneuvers and adenosine, if the patient is stable and with synchronized cardioversion, if unstable. Ventricular tachycardia is treated with amiodarone or lidocaine, if stable, and cardioversion if unstable or if drugs fail. Ventricular fibrillation needs defibrillation. Aggressive supportive care is needed during the post-resuscitation phase. There is no definite marker to determine futility of CPR. Short duration of arrest, early initiation of CPR, hypothermia as the cause of arrest, and in-hospital arrest have better prognosis.