3D Capsule Networks for Brain Image Segmentation.

BACKGROUND AND PURPOSE: Current autosegmentation models such as UNets and nnUNets have limitations, including the inability to segment images that are not represented during training and lack of computational efficiency. 3D capsule networks have the potential to address these limitations. MATERIALS AND METHODS: We used 3430 brain MRIs, acquired in a multi-institutional study, to train and validate our models. We compared our capsule network with standard alternatives, UNets and nnUNets, on the basis of segmentation efficacy (Dice scores), segmentation performance when the image is not well-represented in the training data, performance when the training data are limited, and computational efficiency including required memory and computational speed. RESULTS: The capsule network segmented the third ventricle, thalamus, and hippocampus with Dice scores of 95%, 94%, and 92%, respectively, which were within 1% of the Dice scores of UNets and nnUNets. The capsule network significantly outperformed UNets in segmenting images that were not well-represented in the training data, with Dice scores 30% higher. The computational memory required for the capsule network is less than one-tenth of the memory required for UNets or nnUNets. The capsule network is also >25% faster to train compared with UNet and nnUNet. CONCLUSIONS: We developed and validated a capsule network that is effective in segmenting brain images, can segment images that are not well-represented in the training data, and is computationally efficient compared with alternatives.

Safety and Efficacy of Low-osmolarity ORS vs. Modified Rehydration Solution for Malnourished Children for Treatment of Children with Severe Acute Malnutrition and Diarrhea: A Randomized Controlled Trial.

World Health Organization-recommended rehydration solution for malnourished children (ReSoMal) for rehydrating severe acute malnourished children is not available in India. In present study, 110 consecutive children aged 6-59 months with severely acute malnourishment and acute diarrhea were randomized to low-osmolarity oral rehydration solution (ORS) (osmolarity: 245, sodium: 75) with added potassium (20 mmol/l) or modified ReSoMal (osmolarity: 300, sodium: 45). In all, 15.4% of modified ReSoMal group developed hyponatremia as compared with 1.9% in low-osmolarity ORS, but none developed severe hyponatremia or hypernatremia. Both groups had equal number of successful rehydration (52 each). Both types of ORS were effective in correcting hypokalemia and dehydration, but rehydration was achieved in shorter duration with modified ReSoMal.

Antigen sequence typing of outer membrane protein (fetA) gene of Neisseria meningitidis serogroup A from Delhi & adjoining areas.

BACKGROUND & OBJECTIVES: Meningitis caused by Neisseria meningitidis is a fatal disease. Meningococcal meningitis is an endemic disease in Delhi and irregular pattern of outbreaks has been reported in India. All these outbreaks were associated with serogroup A. Detailed molecular characterization of N. meningitidis is required for the management of this fatal disease. In this study, we characterized antigenic diversity of surface exposed outer membrane protein (OMP) FetA antigen of N. meningitidis serogroup A isolates obtained from cases of invasive meningococcal meningitis in Delhi, India. METHODS: Eight isolates of N. meningitidis were collected from cerebrospinal fluid during October 2008 to May 2011 from occasional cases of meningococcal meningitis. Seven isolates were from outbreaks of meningococcal meningitis in 2005-2006 in Delhi and its adjoining areas. These were subjected to molecular typing of fetA gene, an outer membrane protein gene. RESULTS: All 15 N. meningitides isolates studied were serogroup A. This surface exposed porin is putatively under immune pressure. Hence as a part of molecular characterization, genotyping was carried out to find out the diversity in outer membrane protein (FetA) gene among the circulating isolates of N. meningitidis. All 15 isolates proved to be of the same existing allele type of FetA variable region (VR) when matched with global database. The allele found was F3-1 for all the isolates. INTERPRETATION & CONCLUSIONS: There was no diversity reported in the outer membrane protein FetA in the present study and hence this protein appeared to be a stable molecule. More studies on molecular characterization of FetA antigen are required from different serogroups circulating in different parts of the world.

A randomized prospective study of desflurane versus isoflurane in minimal flow anesthesia using "equilibration time" as the change-over point to minimal flow.

BACKGROUND: In the administration of minimal flow anesthesia, traditionally a fixed time period of high flow has been used before changing over to minimal flow. However, newer studies have used "equilibration time" of a volatile anesthetic agent as the change-over point. MATERIALS AND METHODS: A randomized prospective study was conducted on 60 patients, who were divided into two groups of 30 patients each. Two volatile inhalational anesthetic agents were compared. Group I received desflurane (n = 30) and group II isoflurane (n = 30). Both the groups received an initial high flow till equilibration between inspired (Fi) and expired (Fe) agent concentration were achieved, which was defined as Fe/Fi = 0.8. The mean (SD) equilibration time was obtained for both the agent. Then, a drift in end-tidal agent concentration during the minimal flow anesthesia and recovery profile was noted. RESULTS: The mean equilibration time obtained for desflurane and isoflurane were 4.96 ± 1.60 and 16.96 ± 9.64 min (P < 0.001). The drift in end-tidal agent concentration over time was minimal in the desflurane group (P = 0.065). Recovery time was 5.70 ± 2.78 min in the desflurane group and 8.06 ± 31 min in the isoflurane group (P = 0.004). CONCLUSION: Use of equilibration time of the volatile anesthetic agent as a change-over point, from high flow to minimal flow, can help us use minimal flow anesthesia, in a more efficient way.

The impact of county-level radiation oncologist density on prostate cancer mortality in the United States.

BACKGROUND: The distribution of radiation oncologists across the United States varies significantly among geographic regions. Accompanying these variations exist geographic variations in prostate cancer mortality. Prostate cancer outcomes have been linked to variations in urologist density, however, the impact of geographic variation in the radiation oncologist workforce and prostate cancer mortality has yet to be investigated. The goal of this study was to determine the effect of increasing radiation oncologist density on regional prostate cancer mortality. METHODS: Using county-level prostate cancer mortality data from the National Cancer Institute and Centers for Disease Control as well as physician workforce and health system data from the Area Resource File a regression model was built for prostate cancer mortality controlling for categorized radiation oncologist density, urologist density, county socioeconomic factors and pre-existing health system infrastructure. RESULTS: There was statistically significant reduction in prostate cancer mortality (3.91-5.45% reduction in mortality) in counties with at least 1 radiation oncologist compared with counties lacking radiation oncologists. However, increasing the density of radiation oncologists beyond 1 per 100 000 residents did not yield statistically significant incremental reductions in prostate cancer mortality. CONCLUSION: The presence of at least one radiation oncologist is associated with significant reductions in prostate cancer mortality within that county. However, the incremental benefit of increasing radiation oncologist density exhibits a plateau effect providing marginal benefit. In order to optimize outcomes a geographically aware policy, which addresses the size and distribution of the workforce, must be in place in order prevent geographic disparities in prostate cancer mortality.

Clinical course of children with HIV associated thrombocytopenia.

OBJECTIVES: To study the clinical profile of HIV associated thrombocytopenia, co-relation between thrombocytopenia and immune status and the effect of the anti-retroviral therapy (ART) on platelet count. METHODS: In this cross sectional retrospective analytical study, records of all children up to 15 y, enrolled at a Pediatric ART Centre during the period 30 Nov. 2006 to 31st Dec. 2009 were reviewed for presence of thrombocytopenia. Clinical course, outcome and their immunological status were analyzed. RESULTS: 34 children (19.6%) out of 173 were found to have thrombocytopenia. After excluding three who had pancytopenia associated thrombocytopenia, records of 31 children (28 M, 3 F) were further studied. Six children (19.4%) presented with bleeding manifestations. The platelet counts ranged between 4x10(9)/L to 140x10(9)/L. No specific co-relation could be made out between platelet count and CD4 counts. The mortality was higher in thrombocytopenic children on ART as compared to children on ART with normal platelet count (p- < 0.001). Amongst the live children, the platelet counts normalized within 3 mo of ART in 11 (64.7%) while it took 18 mo in three and 30 mo in one case respectively. Twelve children with thrombocytopenia as an incidental finding have shown a good platelet response to ART. Six symptomatic children with thrombocytopenia showed a varied platelet response to ART despite showing a significant increase in the CD4 counts. CONCLUSIONS: Thrombocytopenia in HIV infected may be an incidental finding in some children. Thrombocytopenia was found to be a poor prognostic factor and no specific co-relation to immune status was seen.

Paradoxical amniotic fluid embolism presenting before caesarean section in a woman with an atrial septal defect.

We present a case of presumed amniotic fluid embolism in a 33-year-old parturient at 30 weeks of gestation, which occurred just before she was due to receive spinal anaesthesia for urgent caesarean section. While sitting, the woman suddenly lost consciousness, started having convulsions and finally suffered cardiorespiratory collapse. She was resuscitated and a live baby was delivered by emergency caesarean section. An echocardiogram performed postoperatively showed a large atrial septal defect and severe right ventricular dysfunction with moderate pulmonary hypertension. Paradoxical amniotic fluid embolism was diagnosed. After extubation she was aphasic and had a right hemiparesis. She made a good recovery and was discharged from hospital 24 days later, at which time she had a slight weakness on her right side. Three months later she had a normal gait with no obvious neurological deficit.

Hypovitaminosis d and hypocalcemic seizures in infancy.

BACKGROUND: Hypocalcemia accounts for a majority of seizures in infants reporting to the emergency ward of our hospital. OBJECTIVE: To evaluate the role of Vitamin D deficiency in the etiology of hypocalcemic seizures in infancy. DESIGN AND SETTING: Cross sectional hospital based study, from April 2006-March 2007. SUBJECTS: 60 infants with hypocalcemic seizures and their mothers (study group) and 60 healthy breastfed infants with their lactating mothers (control group). MEASUREMENTS: Vitamin D [25(OH) D] and intact para-thormone levels. RESULTS: High prevalence of hypovitaminosis D [25(OH)D levels <10 ng/mL] was observed in study mothers (85%), control mothers (50%), study infants (90%), and control infants (41.7%). Mean serum 25(OH) D values in study mothers and their infants (6.54 +/- 5.32 ng/mL and 4.92 +/- 4.62 ng/mL) were significantly lower than those of mother-infant pairs (9.06 +/- 4.78 ng/mL and 9.03 +/- 4.63 ng/mL) in the control group (P<0.001). A strong positive correlation of 25(OH) D levels between mothers and their infants was seen in both the study and control populations (P<0.001). Of the 54 study infants who had 25(OH)D levels <10 ng/mL, 48 (89%) were born to mothers who also had 25(OH) D levels <10 ng/mL. CONCLUSIONS: Vitamin D deficiency is a major cause of hypocalcemic seizures in infants. Infants born to vitamin D deficient mothers are at a significantly higher risk to develop hypocalcemic seizures.

Vitamin D nutritional status of exclusively breast fed infants and their mothers.

BACKGROUND: Vitamin D nutrition has a profound effect on the development of an infant. Vitamin D status of mothers and their infants are closely correlated. While hypovitaminosis D has emerged as a significant public health problem across all age groups, there is limited information of this condition in lactating mothers and their breast fed infants. AIM: To evaluate the vitamin D status of lactating mothers and their breast fed infants. SUBJECTS AND METHODS: 180 healthy lactating mothers and exclusively breast fed infants, 2-24 weeks old, were recruited for the study. The mother-infant pairs underwent concurrent clinical, biochemical and hormonal evaluation for calcium-vitamin D-PTH axis. RESULTS: The mean serum 25(OH)D values in lactating mothers was 27.2 +/- 14.6 nmol/l (10.9 +/- 5.8 ng/ml), while that of their infants was 28.9 +/- 20.8 nmol/l (11.6 +/- 8.3 ng/ml). Serum 25(OH)D levels <25 nmol/l (10 ng/ml) were found in 47.8% of the mothers and 43.2% of the infants. Among these, elevated PTH levels (>54 pg/ml) were seen in 59.3% of the mothers and 69.6% of the infants. A highly significant negative correlation was found between serum 25(OH)D and PTH in mothers (r = -0.480, p = 0.01) and their infants (r = -0.431, p = 0.01). A strong positive correlation was seen of 25(OH)D levels in mother-infant pairs (r = 0.324, p = 0.001). CONCLUSIONS: A high prevalence of vitamin D deficiency was found in lactating mothers and their exclusively breast fed infants. Infants born to mothers with hypovitaminosis D had 3.8 times higher risk of developing hypovitaminosis D as compared to those born to mothers with normal vitamin D levels.

Rare serotype non-typhoidal Salmonella sepsis.

An 11-month female with a poor socio-economic status presented to a tertiary care paediatric hospital with complaints of fever of 4-5 days and diarrhoea of 20 days duration. The patient didn't respond to the prescribed antimicrobials namely--Norfloxacin and metronidazole. On admission she was diagnosed as persistent diarrhea with PEM grade III with sepsis. Stool examination and culture were negative for any pathogens, however blood culture yielded growth of Salmonella Virchow which was susceptible to most common antimicrobial agents excepting Trimethoprim Sulfamethoxazole. Salmonella Virchow is a common non-typhoidal Salmonellae causing bacteremia in the west, however this is the first report of bacteremia by S. virchow from India.

Berardinelli-Seip congenital lipodystrophy.

Berardinelli-Seip congenital lipodystrophy (BSCL) is a very rare genetic disorder characterized by lipoatrophy, hypertriglyceridemia, hepatomegaly and acromegaloid features. On the basis of mutational and haplotype analysis, BSCL families have been classified into three types BSCL 1, BSCL2 and BSCLX. We report Berardinelli-Seip congenital lipodystrophy (BSCL2 type) in three subjects from two unrelated Indian families (family1 and family2). The mutation (c.IVS2 11 A GT G ) found in affected members of family1 is a newly identified mutation. We also report the association of renal anomaly with this new mutation.

Iodine nutrition status of exclusively breast-fed infants and their mothers in New Delhi, India.

OBJECTIVE: To assess the iodine nutrition status of exclusively breast-fed infants and their mothers. HYPOTHESIS: In the presence of environmental and maternal iodine deficiency, an exclusively breast-fed baby is likely to receive a suboptimal iodine supply during the period of rapid brain growth. METHODS: Spot urinary iodine (UI) and serum TSH levels were measured in 175 healthy, exclusively breast-fed infants and their mothers. Iodine content of salt used by participants for domestic consumption was also analyzed. RESULTS: The median UI levels in mothers and infants was 124 microg/l and 162 microg/l, respectively. 34% of mothers and 21% of infants had UI levels <100 microg/l indicating iodine deficiency. Serum TSH was elevated in 29% of mothers and 2% of infants. No correlation was observed between individual mother-infant UI or serum TSH levels (r = -0.036, r = -0.1 for UI excretion and serum TSH, respectively). 96% of the salt samples tested had adequate iodine concentration, i.e. >15 ppm. CONCLUSION: The present study demonstrated significant iodine deficiency in both mothers and infants despite consumption of adequately iodized salt. The iodine nutrition status of the infants was better compared to the mothers, indicating a preferential iodine supply to the infants over the mothers.

Sleep and childhood epilepsy.

The inter-relationship between sleep and epilepsy is well recognized. Sleep is known to activate inter-ictal epileptiform discharges. A special timing of seizure in relation to sleep wake cycle is certainly a childhood epileptic syndrome. Children with epilepsy commonly have sleep problems which may be due to seizures or due to anxiety. Somnolence and diurnal sedation are frequent side effects of anti-epileptic drugs. Thus epilepsy and its treatment can affect sleep leading to adverse effect on behavior, cognition and seizure control. Lack of sleep is an important trigger for epileptic seizures, therefore regular sleep must be a part of management strategy in children with epilepsy.

Acute disseminated encephalomyelitis--a case series.

Acute disseminated encephalomyelitis(ADEM) is an uncommon inflammatory demyelinating disease involving central nervous system white matter. A series of seven cases seen over a period of one year have been described. The patients presented with acute onset of focal neurological deficit (3 patients), alteration of sensorium(3) and ataxia(1). CT scan showed non specific hypodensity in 4 cases and was normal in 3 patients . MRI showed characteristic radiological changes. Complete recovery was seen in 3 patients , one died and 3 were left with sequelae.

Spina bifida occulta in functional enuresis.

OBJECTIVE: To study incidence of spina bifida occulta in nocturnal enuresis cases and to compare outcome of enuresis with spina bifida occulta and enuresis without spina bifida occulta. METHODS: Patients with enuresis divided into two groups based on X-ray lumbosacral spine. Outcome of these patients were compared on behavioral therapy. RESULTS: Spina bifida occulta was detected in 18 out of total 48 patients. Levels of spina bifida were L5 vertebrae in 3,L5-S1 in 5,S1 in 8 and S1-S2 in 2 patients. Outcome was evaluated in 42 patients who were followed up for more than 6 months. There was no significant difference between both the groups. CONCLUSION: Spina bifida occulta is a common finding in enuresis. Outcome of patients with spina bifida occulta is not different than the patients without spina bifida occulta.