Quantitative susceptibility mapping with source separation in normal brain development of newborns.

BACKGROUND AND PURPOSE: Quantitative susceptibility mapping is an emerging method for characterizing tissue composition and studying myelination and iron deposition. However, accurate assessment of myelin and iron content in the newborn brain using this method is challenging because these two susceptibility sources of opposite signs (myelin, negative; iron, positive) occupy the same voxel, with minimal and comparable content in both sources. In this study, susceptibilities were measured in the normal newborn brain using susceptibility source separation. MATERIALS AND METHODS: Sixty-nine healthy newborns without clinical indications were prospectively recruited for MRI. All newborns underwent gradient echo imaging for quantitative susceptibility mapping. Positive (paramagnetic) and negative (diamagnetic) susceptibility sources were separated using additional information from R2* with linear modeling performed for the newborn brain. Average susceptibility maps were generated by normalizing all susceptibility maps to an atlas space. Mean regional susceptibility measurements were obtained in the cortical GM, WM, deep GM, caudate nucleus, putamen, globus pallidus, thalamus, and the four brain lobes. RESULTS: A total of sixty-five healthy newborns (mean postmenstrual age, 42.8 ± 2.3 weeks; 34 females) were studied. The negative susceptibility maps visually demonstrated high signals in the thalamus, brainstem and potentially myelinated WM regions, whereas the positive susceptibility maps depicted high signals in the GM compared to all WM regions, including both myelinated and unmyelinated WM. The WM exhibited significantly lower mean positive susceptibility and significantly higher mean negative susceptibility than cortical GM and deep GM. Within the deep GM, the thalamus showed a significantly lower mean negative susceptibility than the other nuclei, and the putamen and globus pallidus showed significant associations with newborn age in positive and/or negative susceptibility. Among the four brain lobes, the occipital lobe showed a significantly higher mean positive susceptibility and a significantly lower mean negative susceptibility than the frontal lobe. CONCLUSIONS: This study demonstrates regional variations and temporal changes in positive and negative susceptibilities of the newborn brain, potentially associated with myelination and iron deposition patterns in normal brain development. It suggests that quantitative susceptibility mapping with source separation may be used for early identification of delayed myelination or iron deficiency. ABBREVIATIONS: CGM = cortical gray matter; DGM = deep gray matter; PMA = postmenstrual age; QSM = quantitative susceptibility mapping.

Knowledge and Skills in Cardiopulmonary Resuscitation and Effect of Simulation Training on it among Healthcare Workers in a Tertiary Care Center in India.

Aim and background: High-quality cardiopulmonary resuscitation (CPR) is associated with improved patient outcomes, but healthcare workers (HCWs) may be frequently undertrained. This study aimed to assess baseline knowledge and skills among HCWs about basic and advanced life support and the effect of simulation-based training on it. Methods: It was a single-center prospective quasi-interventional study among resident doctors and nurses at a Tertiary Center in New Delhi, India. A questionnaire-based assessment was done to assess baseline knowledge. The participants then underwent simulation-based training followed by questionnaire-based knowledge assessment and skill assessment. A repeat questionnaire-based assessment was done 6 months post-training to assess knowledge retention. Results: A total of 82 HCWs (54 doctors and 28 nurses) were enrolled. The participants scored 22.28 ± 6.06 out of 35 (63.65%) in the pre-training knowledge assessment, with low scores in post-cardiac arrest care, advanced life support, and defibrillation. After the training, there was a significant rise in scores to 28.32 ± 4.08 out of 35 (80.9%) (p < 0.01). The retention of knowledge at 6 months was 68.87% (p < 0.01). The participants scored 92.61 ± 4.75% marks in skill assessment with lower scores in chest compressions and team leadership roles. There was a positive correlation (r = 0.35) between knowledge and skills scores (p < 0.01). Conclusion: There is a progressive decrease in baseline knowledge of HCWs with the further steps in the adult chain of survival. The simulation training program had a positive impact on the knowledge of HCWs. The training programs should focus on defibrillation, advanced life support, post-cardiac arrest care, and leadership roles. How to cite this article: Agarwal A, Baitha U, Ranjan P, Swarnkar NK, Singh GP, Baidya DK, et al. Knowledge and Skills in Cardiopulmonary Resuscitation and Effect of Simulation Training on it among Healthcare Workers in a Tertiary Care Center in India. Indian J Crit Care Med 2024;28(4):336-342.

Autologous Reconstruction of Anomalous Origin of a Right Pulmonary Artery From the Aorta.

Anomalous origin of a pulmonary artery branch from the aorta is a rare congenital anomaly in which one of the pulmonary arteries arises from the aorta. These patients require early surgery to prevent development of severe irreversible pulmonary arterial hypertension. Multiple techniques have been described for repair of this condition. In this report, we describe a different technique compared with previously described procedures and discuss its advantages.

[Ga68] DOTATATE PET/MRI-guided radiosurgical treatment planning and response assessment in meningiomas.

BACKGROUND: Our purpose was to determine the utility of [68Ga]-DOTATATE PET/MRI in meningioma response assessment following radiosurgery. METHODS: Patients with meningioma prospectively underwent postoperative DOTATATE PET/MRI. Co-registered PET and gadolinium-enhanced T1-weighted MRI were employed for radiosurgery planning. Follow-up DOTATATE PET/MRI was performed at 6-12 months post-radiosurgery. Maximum absolute standardized uptake value (SUV) and SUV ratio (SUVRSSS) referencing superior sagittal sinus (SSS) blood pool were obtained. Size change was determined by Response Assessment in Neuro-Oncology (RANO) criteria. Association of SUVRSSS change magnitude and progression-free survival (PFS) was evaluated using Cox regression. RESULTS: Twenty-seven patients with 64 tumors (26% World Health Organization [WHO]-1, 41% WHO-2, 26% WHO-3, and 7% WHO-unknown) were prospectively followed post stereotactic radiosurgery (SRS) or stereotactic body radiotherapy (SBRT; mean dose: 30 Gy, modal dose 35 Gy, mean of 5 fractions). Post-irradiation SUV and SUVRSSS decreased by 37.4% and 44.4%, respectively (P < .0001). Size product decreased by 8.9%, thus failing to reach the 25% significance threshold as determined by RANO guidelines. Mean follow-up time was 26 months (range: 6-44). Overall mean PFS was 83% and 100%/100%/54% in WHO-1/-2/-3 subcohorts, respectively, at 34 months. At maximum follow-up (42-44 months), PFS was 100%/83%/54% in WHO-1/-2/-3 subcohorts, respectively. Cox regression analyses revealed a hazard ratio of 0.48 for 10-unit reduction in SUVRSSS in the SRS cohort. CONCLUSIONS: DOTATATE PET SUV and SUVRSSS demonstrated marked, significant decrease post-radiosurgery. Lesion size decrease was statistically significant; however, it was not clinically significant by RANO criteria. DOTATATE PET/MR thus represents a promising imaging biomarker for response assessment in meningiomas treated with radiosurgery. CLINICALTRIALS.GOV IDENTIFIER: NCT04081701.

Cyclotron vs generator-produced 68Ga PSMA: a single-institution, prospective clinical trial.

The clinical utility of gallium 68 (68Ga)-PSMA PET for the diagnosis and management of prostate cancer is driven in part by radioisotope availability and production costs. This study evaluates the equivalence between the two manufacturing processes for 68Ga-PSMA: 68Ga-PSMA-cyclotron (from a solid target) and 68Ga-PSMA-generator. A prospective, single-arm, single-institution non-randomized study was conducted where 16 patients with prostate adenocarcinoma underwent PET/CTs consecutively within 12 to 48 hours with each type of manufactured 68Ga-PSMA between December 2020 and June 2021. The intraclass correlation coefficients suggested acceptable reliability in all lesion parameters (ICC > 0.70). Bland-Altman analysis demonstrated acceptable bias levels for all lesion parameters. Thereby 68Ga-cyclotron (solid target) and 68Ga-generator production methods tagged to the same PSMA ligand resulted in scans which were deemed to be equivalent in detecting PSMA+ lesions in our study. As cyclotron-produced, solid- target 68Ga can be made in large (Ci) quantities, it is a promising tool for future application in 68Ga-PSMA PET scans with the potential to decrease radiotracer production costs and increase isotope availability.

Left pulmonary artery reconstruction using cryopreserved pulmonary homograft.

In patients with univentricular heart, the Fontan procedure is the final palliation. This is usually staged. A systemic-to-pulmonary artery shunt is performed in the presence of episodes of cyanotic spells in the neonatal period or in some patients in infancy; a bidirectional superior cardiopulmonary anastomosis is preferred early in life. This is followed by the final Fontan palliation on an elective basis later. For an effective bidirectional superior cavopulmonary anastomosis and Fontan palliation, good-sized confluent pulmonary arteries (PAs) are mandatory in addition to favorable hemodynamic data. Patients with discontinuous PAs that are small in size present a surgical challenge at initial palliation as the one described in this report.

An alternate technique of performing total cavopulmonary connection without cardiopulmonary bypass.

Total cavopulmonary connection (Fontan) without using cardiopulmonary bypass (CPB) may be superior to Fontan on CPB. In the experience of many, a Fontan operation without CPB may be associated with a reduced need for inotropic support, improved outcomes in the postoperative phase including faster time to termination of mechanical ventilatory support, reduced intensive care unit stay, lower volume of pleural and peritoneal effusions, and decreased hospital stay, thereby rendering it more cost-effective. However, the operation is technically more difficult to perform than Fontan on CPB and requires significant modifications of surgical technique and alteration in overall management strategy. In this article, an alternative technique of performing total cavopulmonary connection without CPB is described. Its advantages are briefly discussed.

Effect of change in tidal volume on left to right shunt across ventricular septal defect in children - A pilot study.

BACKGROUND: Pulmonary vascular resistance, an important determinant of shunting across ventricular septal defects (VSD), rises at both extremes of lung volume. AIMS: We sought to determine the effect of changes in tidal volumes (VT) on pulmonary blood flow (Qp), systemic blood flow (Qs), and shunt (Qp/Qs) in children with VSD. SETTING: Single-center teaching hospital. DESIGN: Prospective observational study. METHODS: Thirty children with a mean age of 11.8 ± 5 months undergoing surgical closure of VSD were studied. Hemodynamics and shunt-related parameters were assessed using transthoracic echocardiography measured at three different VT i.e. 10, 8, and 6-ml/kg keeping the minute ventilation constant. RESULTS: Reduction in VT from 10 to 8 to 6 ml/kg led to a reduction in gradient across VSD measuring 23.5, 20 and 13 mmHg respectively (P < 0.001). Similarly, right ventricluar outflow tract (RVOT) diameter, RVOT velocity time integral, Qp (57.3 ± 18.1, 50.6 ± 16.9, 39.9 ± 14.7 mL; P < 0.001), Qs (24.1 ± 10.4, 20.0 ± 8.7, 15.3 ± 6.9 mL; P < 0.001) and peak airway pressure (17.2 ± 1.5, 15.8 ± 1.3, 14.5 ± 1.2 cmHg; P < 0.001) showed progressive decline with decreasing VT from 10 to 8 to 6 ml/kg, respectively. However, Qp/Qs (2.4 ± 0.4, 2.6 ± 0.4, 2.6 ± 0.4) demonstrated a minor increasing trend. CONCLUSION: Lower VT reduces the gradient across VSD, the pulmonary blood flow, and the peak airway pressure. Hence, ventilation with lower VT and higher respiratory rate maintaining adequate minute ventilation might be preferable in children with VSD. Further studies are required to confirm the findings of this pilot study.

Erector spinae plane block: An effective analgesic technique for pleurodesis after senning operation.

Pain emanating from pleurodesis is significantly distressing and presents an important management concern. Despite encouraging evidence on the application of fascial plane blocks for cardiothoracic surgery, the literature on the use of erector spinae block for pleurodesis remains scarce. We describe a case of bilateral recurrent pleural effusion following congenital heart surgery where erector spinae block was employed as an analgesic technique for pleurodesis. Finally, we discuss its regional analgesic effects in comparison to the conventional intravenous/systemic analgesia in a cross over fashion.

Erector spinae plane block using clonidine as an adjuvant for excision of chest wall tumor in a pediatric patient.

Erector spinae plane block has been described to manage post-thoracotomy pain. It is a simple block and shown to be provide effective analgesia. In single shot blocks opioid supplementation may be required to manage pain after the effect of local anesthetic wears off. In this case, we describe a case of chest wall tumor excision in a child who received clonidine in addition to local anesthetic for the erector spinae plane block. This provided long lasting and effective postoperative analgesia and may be considered to prolong the analgesia achieved with erector spinae plane block.

Management of ruptured sinus of valsalva for device closure in a patient with haemophilia.

The association of Hemophilia A and ruptured aneurysm of sinus of valsalva (RSOV) has never been reported to the best of our knowledge. We report the case of a 29-year-old male patient with Hemophilia type A who presented with a RSOV into right atrium (RA). The patient underwent device closure off the RSOV and received Factor VIII infusions to decrease blood loss. The peri-procedural management is being presented in this case report.

Transesophageal Echocardiographic Estimation of Coronary Sinus Blood Flow for Predicting Favorable Postoperative Transit Time Coronary Graft Flow Measurements: A Pilot Study.

BACKGROUND: Augmentation of coronary artery flow by surgical grafting increases coronary sinus blood flow (CSBF), which can be quantified on transesophageal echocardiography (TEE). However, transit time flowmetry (TTF) technology remains the most used intraoperative technique for coronary artery graft assessment. The purpose of the present pilot study was to evaluate the predictive value of TEE-based CSBF estimation for identifying favorable TTF graft measurements. DESIGN: Prospective observational study. SETTING: Single university hospital. PATIENTS: Forty patients undergoing triple vessel coronary artery bypass grafting. MEASUREMENTS AND MAIN RESULTS: CSBF was assessed on TEE examination before and after revascularization, estimating the percentage increase in CSBF (∆CSBF). Postoperative TTF graft measurements were averaged to compute mean diastolic filling (DF) and pulsatility index (PI). Subjects were grouped based on favorable (PI ≤ 3, DF ≥ 50%) and unfavorable (PI > 3, DF < 50%) parameters. The group with PI ≤ 3 (n = 32) had significantly higher ∆CSBF compared with the group with PI > 3 (n = 8) (38.22% ± 12.05%, 13.75% ± 3.37%, p < 0.001). ∆CSBF was higher in the DF ≥ 50% group (n = 35) (36.40 ± 12.99) in contrast to DF < 50% group (n = 5) (11.80 ± 2.59%). A strong negative and significantly positive correlation was observed between ∆CSBF with PI, DF (r = -0.903, 0.571, respectively, p < 0.001). A ∆CSBF ≥15.5% was found to predict a mean PI ≤ 3 and DF ≥ 50% with sensitivity and specificity of 100% and 62.5% for PI and 100% and 100% for DF. A ∆CSBF ≥19% demonstrated a sensitivity and specificity of 100% and 100%, 100% and 91.4% for prediction of PI ≤ 3 and DF ≥ 50%, respectively. CONCLUSION: TEE-based demonstration of an augmented CSBF can ensure favorable TTF graft parameters, guiding the adequacy of surgical revascularization.