Fainting Attacks in Children

Fainting attack or syncope in children is a common occurrence, with vasovagal syncope being the commonest cause for majority of pediatric syncope. The aim of emergency room evaluation is not to miss the rare serious underlying disorder causing syncope. A complete detailed history of the event followed by physical examination helps in categorising syncope into the three major categories—neurally mediated, cardiovascular and non cardiovascular syncope. Investigations will remain normal in majority of the cases. A 12-lead ECG and standing test should be done in all the cases which helps in establishing the cause for syncope. Management varies depending upon the cause and majority of them do not require hospital admission.     

Congenital neuroblastoma: an autopsy report

Neuroblastoma (NB) is the foremost malignant neoplasm of the fetus and neonate. It has a distinct biologic behavior and varied clinical manifestations. The perinatal tumors are most frequently associated with a favorable outcome. We describe an autopsy case of a 2-day-old baby with congenital NB of the left adrenal with extensive metastatic deposits in the liver. Despite the tumor having a favorable histology, it proved to be fatal with death occurring on the second day of life.     

Peripartum cardiomyopathy: a short review

Peripartum cardiomyopathy is an unusual form of dilated cardiomyopathy, which manifests as acute heart failure in the last trimester of pregnancy or early postpartum period. Its aetiology is currently unknown. The presenting signs and symptoms are those of congestive heart failure and more specifically those of left ventricular failure. Its importance lies in the fact that it has a high mortality rate and strikes the patient in the prime of life. Peripartum cardiomyopathy has far reaching implications for the anaesthesiologist. The reason for this is that many of the signs and symptoms of normal pregnancy are indistinguishable from mild cardiac failure so that the condition may remain undiagnosed and can present suddenly at the time of induction of anaesthesia or in the peri-operative period. The goals of anaesthetic management include avoidance of drug induced myocardial depression and prevention of increases in ventricular preload and afterload. Vigilant monitoring is essential throughout the surgery and in the postoperative period and the need for invasive monitoring should be assessed according to the clinical condition of the patient. It is important to recognise the association of cardiac failure and pregnancy as a separate syndrome so that peripartum cardiomyopathy can also be kept as a differential diagnosis for cardiac failure occurring in the peripartum period and a high index of suspicion should be maintained for the timely detection and management of this condition.     

Mycotic aneurysm and subarachnoid hemorrhage following tubercular meningitis in an infant with congenital tuberculosis and cytomegalovirus disease

We describe autopsy findings in a 5-month-old infant with disseminated tuberculosis and congenital cytomegalovirus disease. The infant manifested with tubercular meningitis complicating as ruptured mycotic right middle cerebral artery aneurysm. Infiltrative, proliferative, and necrotizing vascular pathologies have been described; however, the occurrence of these is dependent on the duration of illness. The vessel pathology appears to be a payback of its immersion in the local inflammatory cell-rich exudates. Strokes early in the course of the disease are believed to be a consequence of vasospasm, and those occurring later during the disease course are due to proliferative intimal disease. Intracranial mycotic aneurysm following tubercular meningitis developing at such a young age has not been reported in the literature. The lung lesions in a congenitally transmitted tuberculosis and cytomegalovirus disease have also been elaborated.     

Hemoglobin test result variability and cost analysis of eight different analyzers during open heart surgery

The purpose of this study was to compare the variation in hemoglobin (Hgb) values among various point-of-care (POC) analyzers available on the market. Eight analyzers (Gem 3000, ABL 720, ABL 77, Rapidpoint 405, IL 682, GemOPL, Hb 201+, and manual/centrifugation) were compared with the Hgb values from the Beckman Coulter LH750. A total of 72 patient samples were analyzed on each test instrument. The samples were obtained after intubation, after heparinization, during cardiopulmonary bypass, and after protamine administration. Four of the samples were excluded from the study because of delayed sample analysis. The calculated mean differences of reference test method Hgb (mean +/- SD) for all samples (n = 68) were Gem 3000 = 1.431 +/- 0.396 g/dL; ABL 720 = -0.224 +/- 0.240 g/dL; ABL 77 = 0.341 +/- 0.578 g/dL; Rapidpoint 405 = 0.001 +/- 0.205 g/dL; IL 682 = -0.137 +/- 0.232 g/dL; GemOPL = 0.774 +/- 0.427 g/dL; Hb 201+ = 0.110 +/- 0.524 g/dL; and manual/ centrifugation = 0.547 +/- 0.499 g/dL. Cumulative results indicated that the bias in Hgb values from the Gem 3000, ABL720, ABL 77, IL 682, GemOPL, and the manual method were statistically significant (p < .05), compared with the Coulter LH750. Additionally, only the Rapidpoint 405 and Hb 201+ most closely matched the values from the Coulter LH750 (p > .05). Some of the methodologies have previously been shown to be affected during hemodilution, hypoproteinemia, and/or after blood transfusion. There is variability among methodologies, which can give rise to statistically different Hgb values, and one should consider the "ideal" instrument based on this and many other factors. Based on our results, the rank order of closest approximation to the Coulter LH750 measurement was Rapidpoint 405, Hb 201+, IL 682, ABL 720, ABL 77, manual/centrifugation, GemOPL, and Gem 3000.     

Changes in thrombospondin-1 levels in the endothelial cells of the anterior pituitary during estrogen-induced prolactin-secreting pituitary tumors

Thrombospondin-1 (TSP-1), a multifunctional matrix glyco-protein, has been shown to control tumor growth by inhibiting angiogenesis in various tissues. However, the role of this glycoprotein in pituitary angiogenesis is not well studied. In this report, we determined the changes in the production and action of TSP-1 on endothelial cells in anterior pituitary following estradiol treatment, which is known to increase prolactin-secreting tumor growth and vascularization in this tissue. We showed that TSP-1 immunoreactive protein is distributed in the anterior pituitary, particularly in the endothelial cells. Estradiol treatment for 2 and 4 weeks decreased the total tissue immunoreactive level of TSP-1 as well as the endothelial cell-specific immunoreactive level of this protein in the anterior pituitary. The steroid treatment also decreased the protein levels of TSP-1 in anterior pituitary tissues and in purified pituitary endothelial cells in primary cultures. Determination of the effects of TSP-1 on proliferation and migration of pituitary-derived endothelial cells in primary cultures elucidated an inhibitory action of TSP-1 on these vascular cell functions. These results suggest that locally produced TSP-1 may regulate estrogen angiogenic action on the pituitary.     

A Conference-Friendly,Hands-on Introduction to Deep Learning for Radiology Trainees

Artificial or augmented intelligence, machine learning, and deep learning will be an increasingly important part of clinical practice for the next generation of radiologists. It is therefore critical that radiology residents develop a practical understanding of deep learning in medical imaging. Certain aspects of deep learning are not intuitive and may be better understood through hands-on experience; however, the technical requirements for setting up a programming and computing environment for deep learning can pose a high barrier to entry for individuals with limited experience in computer programming and limited access to GPU-accelerated computing. To address these concerns, we implemented an introductory module for deep learning in medical imaging within a self-contained, web-hosted development environment. Our initial experience established the feasibility of guiding radiology trainees through the module within a 45-min period typical of educational conferences.

     

Emergency obstetric care and referral: experience of two midwife-led health centres in rural Rajasthan,India

This paper documents the experience of two health centres in a primary health service located in interior rural areas of southern Rajasthan, northern India, where trained nurse-midwives are providing skilled maternal and newborn care round the clock daily. The nurse-midwives independently detect and manage complications and decide when to refer women to the nearest hospital for emergency care, in telephonic consultation with a doctor if required. From 2000-2008, 2,771 women in labour and 202 women with maternal emergencies who were not in labour were attended by nurse-midwives. Of women in labour, 21% had a life-threatening complication or its antecedent condition and 16% were advised referral, of which two-thirds complied. Compliance with referral was higher for maternal conditions than fetal conditions. Among the 202 women who came with complications antenatally, post-abortion or post-partum, referral was advised for 70%, of whom 72% complied. The referral system included counselling, arranging transport, accompanying women, facilitating admission and supporting inpatient care, and led to higher referral compliance rates. There was only one maternal death in nine years. We conclude that trained nurse-midwives can significantly improve access to skilled maternal and neonatal care in rural areas, and manage maternal complications with and without the need for referral. Protocols must acknowledge that some families might not comply with referral advice, and also that initial care by nurse-midwives can reverse progression of certain complications and thereby avert the need for referral.