Assessment of Gastric Residual Volume with Ultrasound in Children at Fasting and after Oral Intake of Carbohydrate-Rich Fluid in the Preoperative Period.

Purpose: Despite standard preoperative fasting guidelines, children are subjected to prolonged fasting due to various reasons. This does not reduce gastric residual volume (GRV) further, instead causes hypoglycemia, hypovolemia, and unnecessary discomfort. We calculated the cross-sectional area (CSA) of antrum and GRV in children in fasting state and 2 h after intake of oral carbohydrate-rich fluid, using gastric ultrasound. Methods: Anteroposterior and craniocaudal gastric antral diameters were measured by ultrasonography in the right lateral decubitus position, at fasting and at 2 h after 8 ml/kg of pulp-free fruit juice ingestion. CSA of antrum and GRV was calculated using validated mathematical models. Results: Data of 149 children of age >1-12 years were analyzed. Greater than ninety-nine percent of children emptied ≥95% of the ingested pulp-free fruit juice volume within 2 h. One hundred and seven (71.8%) children had reduced CSA and GRV at 2 h after fruit juice ingestion (2.01 ± 1.00 cm2 and 7.77 ± 6.81 ml) as compared to fasting state (3.18 ± 1.40 cm2 and 11.89 ± 7.80 ml). Fourty-nine (28.2%) children had slightly increased CSA and GRV at 2 h after fruit juice (2.46 ± 1.14 cm2 and 10.61 ± 7.26 ml) than at fasting (1.89 ± 0.92 cm2 and 8.61 ± 6.75 ml), but this increased GRV was grossly lower than limit of risk stomach (26.54 ± 8.95 ml). Conclusion: Carbohydrate-rich drink in the form of pulp-free fruit juice may be safely permitted up to 2 h before anesthetic induction, as it promoted gastric emptying in ≈ 72% of children and 28% of children, although GRV was slightly higher at 2 h after fruit juice ingestion than fasting but remained considerably lower than limit of risk stomach.

Study of Prevalence of Undiagnosed Diabetes Mellitus in Patients Presenting with Acute Coronary Syndrome.

Coronary Artery Disease (CAD) has become a prominent source of illness and mortality around the world, particularly in emerging nations such as India. Diabetes mellitus (DM) is one of the important and independent predictors of mortality in CAD. Diabetes affects outcomes after an ACS in addition to being a risk factor for development of coronary disease. MATERIAL: We included 200 patients of Acute Coronary Syndrome who were not previously diagnosed with Diabetes mellitus. Detailed history, clinical examination and relevant blood investigations were sent. OGTT was done once the patient was stabilised and free from clinical symptoms of CAD and started on full oral meals. OBSERVATION: We found that the prevalence of undiagnosed diabetes mellitus in ACS patients was 22%, prevalence of prediabetics was 14%, stress induced hyperglycemia was 12% of ACS patients and the remaining 52% had normal glycemic status. CONCLUSION: Diabetes was shown to be common among ACS patients in our area, according to our findings. These findings emphasise the necessity of early diabetes detection and control in ACS patients, as well as the use of certain medicines that had been shown to enhance outcomes.

Convolution neural network for effective burn region segmentation of color images.

BACKGROUND: Burn injuries are one of the most severe forms of wounds and trauma across the globe. Automated burn diagnosis methods are needed to provide timely treatment to the concerned patients. Artificial intelligence is playing a vital role in developing automated tools and techniques for medical problems. However, the use of advanced AI techniques for color images based burn region segmentation is not much explored. METHOD: In this work, we explore the use of deep learning for the challenging problem of burn region segmentation. We prepared a pixel-wise labelled new burn images dataset for segmentation and investigated the efficacy of existing state-of-the-art color images based semantic image segmentation techniques. Lately, we proposed a new convolution neural network (CNN) that uses atrous convolution for encoding rich contextual information and utilizes pre-trained model ResNet-101 for better extraction of low-level and middle-level layer features. RESULTS: The proposed approach achieves the state-of-the-art performance on the prepared burn image dataset with 77.6% of Mathews correlation coefficient (MCC) and 93.4% of accuracy. The improvement of 11.6/5.8/6.9/1.2% is observed in precision, Dice similarity coefficient, Jaccard index and specificity, in comparison to the second best performance. CONCLUSION: In this work, we propose a CNN based novel method for performing burn-region segmentation in color images and evaluate it using newly prepared Burn Images dataset. The experimental results illustrate its effectiveness in comparison to existing approaches. Further, the proposed pixel-level segmentation method could be useful in estimating the burn surface area and burn severity in an accurate and time efficient manner.

BPBSAM: Body part-specific burn severity assessment model.

BACKGROUND AND OBJECTIVE: Burns are a serious health problem leading to several thousand deaths annually, and despite the growth of science and technology, automated burns diagnosis still remains a major challenge. Researchers have been exploring visual images-based automated approaches for burn diagnosis. Noting that the impact of a burn on a particular body part can be related to the skin thickness factor, we propose a deep convolutional neural network based body part-specific burns severity assessment model (BPBSAM). METHOD: Considering skin anatomy, BPBSAM estimates burn severity using body part-specific support vector machines trained with CNN features extracted from burnt body part images. Thus BPBSAM first identifies the body part of the burn images using a convolutional neural network in training of which the challenge of limited availability of burnt body part images is successfully addressed by using available larger-size datasets of non-burn images of different body parts considered (face, hand, back, and inner forearm). We prepared a rich labelled burn images datasets: BI & UBI and trained several deep learning models with existing models as pipeline for body part classification and feature extraction for severity estimation. RESULTS: The proposed novel BPBSAM method classified the severity of burn from color images of burn injury with an overall average F1 score of 77.8% and accuracy of 84.85% for the test BI dataset and 87.2% and 91.53% for the UBI dataset, respectively. For burn images body part classification, the average accuracy of around 93% is achieved, and for burn severity assessment, the proposed BPBSAM outperformed the generic method in terms of overall average accuracy by 10.61%, 4.55%, and 3.03% with pipelines ResNet50, VGG16, and VGG19, respectively. CONCLUSIONS: The main contributions of this work along with burn images labelled datasets creation is that the proposed customized body part-specific burn severity assessment model can significantly improve the performance in spite of having small burn images dataset. This highly innovative customized body part-specific approach could also be used to deal with the burn region segmentation problem. Moreover, fine tuning on pre-trained non-burn body part images network has proven to be robust and reliable.

Diagnostic Performance of 6-Point Lung Ultrasound in ICU Patients: A Comparison with Chest X-Ray and CT Thorax.

OBJECTIVE: To evaluate the diagnostic performance of a rapid bedside 6-point lung ultrasonography (LUS) performed by an intensive care unit (ICU) physician for detection of four common pathological conditions of the lung, such as alveolar consolidation, pleural effusion, interstitial syndrome and pneumothorax, in critically ill patients and its comparison with bedside chest X-ray (CXR) and high-resolution computed tomography (CT) scan of the thorax. Volume of pleural effusion measured by LUS and CT thorax was also compared. METHODS: This was a cross-sectional, observational study of 90 adult patients with an acute lung injury score of ≥1 admitted to the medical-surgical ICU. They were examined by CXR and 6-point LUS as per BLUE protocol at bedside, followed by CT thorax in the radiology department. RESULTS: The sensitivity of 6-point LUS for detecting alveolar consolidation, pleural effusion, interstitial syndrome and pneumothorax was 76%, 88%, 83% and 89%, respectively, which was remarkably higher than that of CXR. The specificity of LUS was 100% for all pathologies, which was again notably higher than that of CXR except for interstitial syndrome for which it was 88.5%. Measurement of volume of pleural effusion by LUS was comparable and had a strong absolute agreement with CT thorax. CONCLUSION: 6-Point LUS can be a useful diagnostic tool and is better than CXR in diagnosing respiratory pathologies in critically ill patients. Owing to the comparable diagnostic performance of LUS and CT scan and with increasing evidence in favour of LUS, the requirement of CT thorax can be reduced. Radiation hazards associated with CXR and CT, as well as potentially risky transfer of patients to CT room, can also be minimised.

Identification of Various Perioperative Risk Factors Responsible for Development of Postoperative Hypoxaemia.

OBJECTIVE: Identification of risk factors that might be responsible for postoperative hypoxaemia, in view of changing profile of surgical patients and better but more complex perioperative care nowadays. METHODS: We conducted a prospective observational study that included patients aged 18-65 years, who underwent elective surgery and required general anaesthesia. Oxygen saturation was monitored before the induction in operating room and continued 72 hours post-surgery. Patients were maintained on room air if SpO2 remained >94%. If SpO2 was between 90% and 94%, then patients were provided oxygen therapy via face mask (flow rate at 5-6 litre min-1). If SpO2 was between 89%-85% despite oxygen therapy with face mask, the Bilevel Positive Airway Pressure (BiPAP) was applied. If SpO2 was <85% despite therapy with face mask, or if patient was unable to maintain SpO2>90% on BiPAP, then patient was intubated, and ventilatory support was provided. RESULTS: Out of 452 patients, 61 developed SpO2 ≤94% requiring oxygen therapy (13.5%). Oxygen therapy by face mask was required in 51 patients, BiPAP in 8 and ventilatory support with endotracheal intubation in 2. Age, body mass index (BMI), smoking status, presence of preoperative respiratory disease, SPO2 (on room air) at baseline and immediately after the transfer to the post-anaesthesia care unit (PACU) were independently associated with postoperative oxygen therapy. CONCLUSION: The risk of postoperative hypoxaemia was highest in patients aged 51-65 years, BMI higher than 30, current and former smokers, pre-existing respiratory disease, chronic obstructive pulmonary disease, patients with 96% oxygen saturation or less at baseline or after shifting to PACU. The type of surgical incision, duration of surgery and dose of opioids administered were not independent risk factors.

An Unusual Cause of Electrocardiographic Artefact: A Patient's Warming Blanket.

In electrocardiography, an electrocardiographic (ECG) artefact is used to indicate a misleading or confusing alteration in data or observation not arising from the heart. Although technological advancements have produced monitors that may provide accurate data and reliable heart rate alarms, interferences of the displayed electrocardiogram such as (but not limited to) electrical interference by outside sources, electrical noise from elsewhere in the body, poor contact and machine malfunction continue to occur. Artefacts are extremely common, and knowledge regarding them is necessary to prevent misinterpretation of a heart's rhythm, which can often lead to unnecessary and unwarranted diagnostic and interventional procedures. Here we report a case of ECG artefacts that occur owing to a patient's warming blanket and its consequences.

Ultrasound guided internal jugular vein cannulation in infants: Comparative evaluation of novel modified short axis out of plane approach with conventional short axis out of plane approach.

BACKGROUND AND AIMS: Central venous cannulation (CVC) through right internal jugular vein (IJV) route is routinely performed in paediatric patients undergoing major surgery and in those admitted to intensive care units. A novel technique (modified short-axis out-of-plane [MSA-OOP]) to improve first pass success rate of ultrasound-guided IJV CVC in neonates and infants is being compared with conventional SA-OOP method. METHODS: A total of 120 patients were enroled in the study over a period of 6 months. All paediatric patients with age <1 year and weight <10 kg who underwent a major surgery requiring CVC were included. Patients were randomised to either of the two approaches of ultrasound-guided IJV cannulation; SA-OOP and modified SA-OOP (MSA-OOP). In modified approach, the midline of probe footprint was marked with a radio-opaque barium wire that casted a central acoustic shadow on ultrasound screen. RESULTS: In MSA-OOP group, 83.1% of patients were cannulated in the first attempt as compared to 49.2% patients in group SA-OOP. Patients in MSA-OOP group required significantly fewer attempts for successful CVC as compared to patients in the SA-OOP group ( MSA-OOP: median = 1, interquartile range [1-1]; SAOOP: median = 2, interquartile range [1-2], P < 0.001, Mann-Whitney U-test). CONCLUSION: The use of MSA-OOP ultrasound technique for IJV CVC cannulation results in a higher first-attempt success rate and reduces the number of cannulation attempts.

Anaesthetic Considerations for Balloon Mitral Valvuloplasty in Pregnant Patient with Severe Mitral Stenosis: A Case Report and Review of Literature.

Even though, the incidence of Mitral Stenosis (MS) has reduced grossly, it still remains a health problem in developing countries and is the most common rheumatic valvular lesion encountered in pregnant patients. The already compromised cardiac status of a pregnant female deteriorates further by the presence of MS. So, pregnancy is a common situation during which untreated and frequently poorly tolerated MS are first diagnosed. Percutaneous Balloon Mitral Valvuloplasty (BMV) may be life saving in such a setting and a multidisciplinary approach in the management reduces the mortality and morbidity during the procedure. Anaesthetic management of such a procedure has hardly ever been reported. We report a case of a 23-year-old woman presenting at 28 weeks gestation with severe MS and severe pulmonary hypertension (52 mmHg) who underwent successful percutaneous BMV under monitored anaesthesia Care. The anaesthetic considerations in such situations are being discussed.

Need for Changes in the Practical Physiology Curriculum of Medical Undergraduates.

INTRODUCTION: Physiology is one of the foundation sciences for the medical curriculum. It forms the basis of all life sciences. Physiology practical classes in India are divided into three sections: exercises in haematology, exercises on humans and experiments on amphibians. Faculty and students of medical schools in India are of the opinion that animal experiments should be discontinued, that the curriculum in experimental physiology and pharmacology needs to be updated, that the same understanding of topics could be obtained by using alternative methods and that there is an urgent need to introduce alternatives of animal experiments. AIM: To assess the need for changes in the practical physiology curriculum of medical undergraduates. MATERIALS AND METHODS: The study was conducted among 300 MBBS, second and third professional students using a semi-structured questionnaire. The questionnaire consisted of two sections: the first section was based on the current experimental physiology curriculum regarding the relevance of topics taught in haematology, amphibian and human practical classes. In the second section, the opinion was also sought regarding introduction of new topics related to recent advances in clinical physiology and basic clinical skills. RESULTS: More than 60% of the students marked most of the haematology experiments useful. All the amphibian practicals were considered irrelevant/not useful by more than 75% of the students. Regarding the human experiments, more than 70% of the students marked useful. More than 65% students were of the opinion that basic clinical skills should be introduced at undergraduate level. More than 50% students favoured introduction of topics from recent advances in physiology. CONCLUSION: The present study concludes that there is an imperative need to implement radical changes in the experimental physiology curriculum which should be in consonance with patient care for the doctors of tomorrow to render better health service.

Anesthetic challenges of extrinsic trachea-bronchial compression due to posterior mediastinal mass: Our experience with a large esophageal mucocele.

Large posterior mediastinal masses may lead threatening complications such as critical tracheobronchial compression. Airway management in these individuals is a challenge and being a lower airway obstruction; rescue strategies are limited. We encountered one such case of a large esophageal mucocele causing extrinsic tracheobronchial compression. We have described the anesthetic management of this case using awake fiber-optic assessment followed by intubation. Close communication with the surgical team, meticulous planning of airway management, and early drainage of the mucocele are the cornerstones of management in such patients.

Unruptured sinus of Valsalva aneurysm mimicking as right atrial tumor.

Sinus of Valsalva aneurysm is a rare congenital cardiac abnormality and is usually diagnosed when it ruptures. An asymptomatic 55-year-old male of unruptured sinus of Valsalva aneurysm of noncoronary cusp was on medical follow-up. At 2-year follow-up, there was thrombus formation in the aneurysm, mimicking right atrium tumor on 2D transthoracic echocardiography. Cardiac computed tomography showed filling defect in the aneurysm suggestive of thrombus. Considering the high risk of systemic emboli surgery was performed, and aneurysm was repaired with Dacron patch.

Frequency of recovery and relapse in patients with nonischemic dilated cardiomyopathy on guideline-directed medical therapy.

Several key clinical questions, such as which patients with dilated cardiomyopathy (DC) will recover, how many will relapse, when will they relapse, and predictors of relapse, have sparse data. The present study examines the frequency and predictors of recovery and relapse in patients with DC. One hundred eighty-eight patients of a nonischemic DC cohort having baseline left ventricular ejection fraction (LVEF) ≤ 40% were divided into 3 groups: improved group with sustained recovery of LVEF to >40% with a net increase in LVEF of ≥ 10% from baseline, not-improved group without change or decrease in LVEF compared with that in baseline including patients with an increase in LVEF <10%, and relapsed group with decrease in LVEF ≥ 10% after initial improvement. Follow-up duration was 50 ± 31 months. One hundred ten patients (59%) did not improve. Of the 78 patients (41%) who improved, 50 (64%) had sustained improvement. Remaining 28 (36%) of the 78 improved patients relapsed on further follow-up of 36 ± 25 months. Baseline LVEF was similar in the 3 groups. Mean LVEF increased from 29 ± 8% to 50 ± 7% (p <0.001) in the improved group, changed from 27 ± 9% to 25 ± 9% (p = 0.95) in the not-improved group, and, after increasing from 30 ± 7% to 52 ± 6%, it decreased to 34 ± 9% (p <0.001) in the relapsed group. Multivariate analysis showed that the only variable associated with recovery of LVEF was shorter QRS duration (odds ratio 0.31, 95% confidence interval 0.15 to 0.67, p = 0.003). Recurrence of left ventricular systolic dysfunction was associated with long QRS duration (odds ratio 3.52, 95% confidence interval 1.27 to 9.76, p = 0.01). In conclusion, with currently recommended medical therapy, 1/4 of patients with nonischemic DC have sustained improvement, and >1/3 of those who improve relapse. QRS duration predicted both recovery and relapse. The survival rate of patients in the improved group was significantly better than that in the other 2 groups (p = 0.03, log-rank).

An idiosyncratic post-traumatic tetrad: compound odontome, dentigerous cyst, impaction, and double-dilaceration.

OBJECTIVE: This report describes the case of a 13-year-old patient who experienced traumatic intrusion of the primary maxillary right central incisor and subsequently suffered an atypical tetrad, comprising of an unerupted compound odontoma associated with a dentigerous cyst, and an impacted, doubly dilacerated permanent maxillary right central incisor; however, the high interconnectivity of the occurrence of four pathologies together is unusual has not previously been reported. SUMMARY: The pathologies were detected 7 years after trauma; surgical removal of odontome along with the dentigerous cyst was performed, followed by orthodontic extrusion of the impacted double-dilacerated permanent central incisor. The 18-month follow-up shows no pathology, no gingival recession, and normal probing depth.

Morbidity of chemotherapy administration and satisfaction in breast cancer patients: a comparative study of totally implantable venous access device (TIVAD) versus peripheral venous access usage.

BACKGROUND: This prospective, non-randomized, comparative study evaluated morbidity of chemotherapy administration via a totally implantable venous access device (TIVAD) versus peripheral intravenous access (PIVA), and satisfaction in breast cancer patients in a limited-resource setting. METHODS: Consecutive patients receiving chemotherapy via TIVAD (n = 114) or PIVA (n = 159) were studied. Venous access-related events were recorded. Morbidity and satisfaction with TIVAD or PIVA as perceived by the patients were assessed using a specifically designed questionnaire, which patients filled after 1st cycle of, and after completion of all chemotherapy. RESULTS: Patients in the two groups were of comparable age, body mass index, and disease stage. Acceptance of TIVAD was higher in literate patients. TIVAD did not interfere with sleep or activities in 90 % of patients. The majority (81.2 %) were satisfied with the cosmetic outcome, 91.5 % would have TIVAD re-inserted if the need arose, and 89.6 % would recommend it to others. Non-fatal complications occurred in 16 patients, and TIVAD had to be removed prematurely in five patients. In the PIVA group, 40 % needed multiple needle pricks and 55.8 % developed thrombophlebitis or staining of arms. Drug extravasation and ulceration were suffered by 8.3 and 4.2 %, respectively. However, 78.3 % of patients reported no interference with daily activities and only 26 % would prefer a TIVAD. Those receiving more than six chemotherapy cycles were dissatisfied to a greater extent with PIVA (p < 0.05). CONCLUSIONS: Breast cancer chemotherapy via TIVAD is safe and convenient and results in high satisfaction levels, although it involves additional expenditure. Chemotherapy via PIVA is acceptable, albeit with lower satisfaction, more so in those receiving more than six chemotherapy cycles.

DTI correlates of cognition in term children with spastic diplegic cerebral palsy.

BACKGROUND AND AIMS: Presently, there is no published study that shows association between cognition and white matter injury in spastic cerebral palsy. We aimed to correlate cognitive functions with diffusion tensor imaging derived metrics in spastic diplegic children. METHODS: Twenty-two term children with spastic diplegia and 22 healthy controls were recruited. All patients were graded on the basis of gross motor function. The Indian children intelligence Test was used to quantify cognition and diffusion tensor imaging was used to quantify microstructural changes in various white matter regions. Diffusion tensor imaging metrics were quantified by placing regions of interests in different white matter regions like corona radiata, anterior limb of internal capsule, posterior limb of internal capsule, mid brain, pons, medulla, genu, splenium, temporal white matter, parietal white matter, frontal white matter and occipital white matter. RESULTS: Spastic diplegic children showed significantly lower neuropsychological test scores as compared to controls. A significantly decreased fractional anisotropy values were observed in corona radiata, anterior limb of internal capsule, posterior limb of internal capsule, mid brain, pons, medulla, genu, splenium and occipital white matter; however significantly increased mean diffusivity values were observed in corona radiata, anterior limb of internal capsule, posterior limb of internal capsule, mid brain, pons and genu in spastic diplegic as compared to controls. A significant positive correlation in fractional anisotropy and negative correlation in mean diffusivity was observed with neuropsychological test scores. CONCLUSION: These results suggest that these imaging metrics may be used as a biomarker of cognitive functions in term children with spastic diplegia.

Clustered-dot halftoning with direct binary search.

In this paper, we present a new algorithm for aperiodic clustered-dot halftoning based on direct binary search (DBS). The DBS optimization framework has been modified for designing clustered-dot texture, by using filters with different sizes in the initialization and update steps of the algorithm. Following an intuitive explanation of how the clustered-dot texture results from this modified framework, we derive a closed-form cost metric which, when minimized, equivalently generates stochastic clustered-dot texture. An analysis of the cost metric and its influence on the texture quality is presented, which is followed by a modification to the cost metric to reduce computational cost and to make it more suitable for screen design.