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.

Olfactory and taste dysfunction in coronavirus disease 2019 patients: its prevalence and outcomes

OBJECTIVES

To evaluate the occurrence, clinical course and outcomes of olfactory and gustatory dysfunction in patients with laboratory confirmed coronavirus disease 2019 infection.

METHODS

This is a prospective cross-sectional study of patients diagnosed with coronavirus disease 2019 infection by reverse transcription polymerase chain reaction over two months. The epidemiological and clinical outcomes studied were: age, sex, general symptoms, and olfactory and taste dysfunction.

RESULTS

A total of 410 coronavirus disease 2019 infected patients were included in the study, with 262 males (63.9 per cent) and 148 females (36.1 per cent). Ninety-nine patients (24.1 per cent) reported chemosensory dysfunction, of which 85 patients (20.7 per cent) reported both olfactory and taste dysfunction. Olfactory and taste dysfunction were proportionally more common in females. The mean duration of olfactory and taste dysfunction was 4.9 days, with a range of 2-15 days.

CONCLUSION

Olfactory and taste dysfunction are prevalent symptoms in coronavirus disease 2019 patients. In this study, they were more common in females than males. The occurrence of such dysfunctions is lower in the Indian population than in the European population.

Beta-blockers are associated with incident heart failure: a secondary analysis of the systolic blood pressure intervention (SPRINT) trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) evaluated whether a blood pressure (BP) goal of less than 120mmHg versus less than 140mmHg would reduce cardiovascular outcomes in subjects with at least one cardiovascular risk factor and without heart failure. Participating investigators were encouraged to use any antihypertensive medication class with a strong evidence base. The SPRINT trial was halted early due to a lower rate of the composite primary outcome in the 120mmHg group, which was mainly driven by a reduction in heart failure (HF).

Objective

As there is a concern that beta-blocker use may be associated with an excess risk for incident HF in subjects with a normal left ventricular systolic function, we evaluated the association between beta-blocker use and HF. Beta-blockers were compared with other major classes of antihypertensive medications. We also studied the association of antihypertensive class with loop-diuretic initiation.

Methods and results

In the 9,012 subjects, without HF at baseline, the association of beta-blocker exposure and incident HF was examined using time-variant competing risk analysis. Beta-blocker exposure was associated with an increased HF risk (HR 1.18; CI 1.07–1.30; p<0.001) and more frequent and earlier loop diuretic-use compared to other antihypertensive agents (both p<0.01). Sensitivity analyses of propensity-score matched cohorts confirmed a strong association of beta-blocker use and HF. Other major antihypertensive medication classes did not show this association.

Conclusions

Beta-blocker exposure was associated with a higher incidence of HF in hypertensive subjects without HF at baseline.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health

Brain Imaging of Patients with COVID-19: Findings at an Academic Institution during the Height of the Outbreak in New York City

BACKGROUND AND PURPOSE

A large spectrum of neurologic disease has been reported in patients with coronavirus disease 2019 (COVID-19) infection. Our aim was to investigate the yield of neuroimaging in patients with COVID-19 undergoing CT or MR imaging of the brain and to describe associated imaging findings.

MATERIALS AND METHODS

We performed a retrospective cohort study involving 2054 patients with laboratory-confirmed COVID-19 presenting to 2 hospitals in New York City between March 4 and May 9, 2020, of whom 278 (14%) underwent either CT or MR imaging of the brain. All images initially received a formal interpretation from a neuroradiologist within the institution and were subsequently reviewed by 2 neuroradiologists in consensus, with disputes resolved by a third neuroradiologist.

RESULTS

The median age of these patients was 64 years (interquartile range, 50-75 years), and 43% were women. Among imaged patients, 58 (21%) demonstrated acute or subacute neuroimaging findings, the most common including cerebral infarctions (11%), parenchymal hematomas (3.6%), and posterior reversible encephalopathy syndrome (1.1%). Among the 51 patients with MR imaging examinations, 26 (51%) demonstrated acute or subacute findings; notable findings included 6 cases of cranial nerve abnormalities (including 4 patients with olfactory bulb abnormalities) and 3 patients with a microhemorrhage pattern compatible with critical illness-associated microbleeds.

CONCLUSIONS

Our experience confirms the wide range of neurologic imaging findings in patients with COVID-19 and suggests the need for further studies to optimize management for these patients.

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.

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.

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.

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.

Study of efficacy and safety of modified adjuvant intraperitoneal chemotherapy regimen in carcinoma ovary

OBJECTIVE

It has been demonstrated in few trials that intraperitoneal and intravenous (IP/IV) chemotherapy improves survival in advanced stage ovarian cancer (OC). However, in view of high treatment-related toxicities, various modifications in treatment schedules have been tried. In this study, response and tolerability of IP paclitaxel on day 8 with IV paclitaxel on day 1 and IV cisplatin day 2 in carcinoma ovary were evaluated.

PATIENTS AND METHODS

In this prospective observational study, from March 2013 to December 2015, the efficacy and tolerability of adjuvant IP/IV chemotherapy in optimally cytoreduced Stage III epithelial OC (EOC) patients were assessed.

RESULTS

Totally, sixty patients were enrolled. The median age of patients was 53 years (32-67 years). Out of a total of 360 IP cycles, 316 cycles (88%) were completed. Forty-five patients (76%) received all the 6 cycles by IP route. Eight out of those 45 patients had one or more adjustment including delay or dose reduction. After median follow-up of 22 months, eight patients (14%) had local or systemic recurrence. Median progression-free survival not reached yet. Catheter block was seen in five cases. Two cases had needle displacement and extravasations of drug around the port chamber. Six patients had Grade 3 abdominal pain and cramp. Grade 3/4 leukopenia was experienced by thirty patients (50%), but febrile neutropenia occurred in only 6 (10%) patients. Renal complication present in 4 (7%) patients.

CONCLUSIONS

In Indian patients, adjuvant chemotherapy with day 8 I/P paclitaxel in optimally cytoreduced EOC is associated with comparable survival outcomes, less side effects and high treatment completion rate relative to literature published from Western countries.

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.

Outcome of universal newborn eye screening with wide-field digital retinal image acquisition system: a pilot study

PurposeTo evaluate the outcome of universal newborn eye screening with wide-field digital retinal imaging (WFDRI) system.MethodsIn this pilot study, we examined 1152 apparently healthy newborn infants in the obstetrics and gynecology ward of a civil hospital in Eastern India over 1.5 years. The examination included external eye examination, red reflex test and fundus imaging by WFDRI (RetCam II, Clarity medical system, Pleasanton, CA, USA) by a trained optometrist. The pathologies detected, net monetary gain and skilled manpower saved were documented. The results were compared with three similar studies thus far published in the literature.ResultsOcular abnormality of any kind was seen in 172 (14.93%) babies. Retinal hemorrhage in 153 babies (88.9% of all abnormal findings) was the most common abnormality; it was bilateral in 118 (77.12%) babies and 4 babies had foveal hemorrhage. Other abnormalities included vitreous hemorrhage (n=1), congenital glaucoma (n=2), uveal coloboma (n=2), retinopathy mimicking retinopathy of prematurity (n=2), and cystic fovea (n=3). The retinal hemorrhages resolved spontaneously in all eyes. One baby with congenital glaucoma received surgery and the other was treated medically. The benefits included savings in skilled manpower, a net monetary gain of INR 4.195 million (US$ 62,612) and skilled manpower saving by 319.4 h.ConclusionsThe universal neonatal eye screening using WFDRI detected pathologies that needed immediate care or regular follow up; saved skilled manpower with a net monetary gain. But compared to a red reflex test the benefits were marginal in terms of detecting treatment warranting ocular pathologies.

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.

Epidemiology and resistance pattern of bacterial isolates among cancer patients in a Tertiary Care Oncology Centre in North India

OBJECTIVES

To examine the epidemiology of microbiologically documented bacterial infection and the resistance pattern, among cancer patients undergoing treatment at RGCIRC, Delhi.

DESIGN AND SETTING

Retrospective observational study in which culture reports obtained over 1 year in 2013, were analyzed.

RESULTS

13329 cultures were obtained over 1 year in 2013 and were analyzed. 23.6 % samples showed positive culture with majority being gram negative isolates (67.9 %). E. coli was the commonest gram negative isolate (49.4%) followed by klebsella (29.7%) and Staph. aureus was the commonest gram positive isolate. There was high incidence of ESBL in blood and urine (87.2% & 88.5%) and BLBLI were also high (78% & 83.9%). Carbapenem resistance was comparatively low (10%) and colistin sensitivity was quiet high (> 95%).

CONCLUSIONS

Prevalence of MRSA and VRE in our institute is very less, whereas prevalence of ESBLs and BLBLI isolates amongst gram negative infections is around 80%. Gram negative isolates had poor sensitivity to cephalosporins and fluoroquinolones.

Cytological Diagnosis of Primary Thyroid Tuberculosis

Primary thyroid tuberculosis is an extremely rare disease, even in countries where other forms of tuberculosis are abundant. TT has no age bar but usually affects women in fourth and fifth decade. Hereby, we report a case of 16-years-old girl presented with complaint of progressively increasing, painful thyroid swelling. Diagnosis of TT was made on cytology and there was no evidence of involvement of any other organ by tuberculosis. Despite of its rarity, TT is usually misdiagnosed. So, a clinician should always consider this entity in the differential diagnosis of thyroid swelling. Fine needle aspiration cytology is the best diagnostic method and can result in the avoidance of unnecessary thyroid surgeries.

Flow accelerated corrosion study in feeder pipes

The Indian Pressurized Heavy Water Reactor (PHWR) core consists of a number of horizontal channels containing nuclear fuel bundles. Parallel coolant channels are connected to Inlet and Outlet header through feeder pipes. Coolant from Reactor Inlet Header is distributed to the coolant channels and after removing heat combines at Reactor Outlet Header. Due to space constraints the feeder pipes are joined to the channel with one or two elbows close to the end fittings of the coolant channels. The carbon steel feeder pipes carry high temperature fluid at higher velocity and are liable to undergo Flow Accelerated Corrosion (FAC). In the recent inspection it has been found that feeders having double elbow are more susceptible to FAC on the intrados of second elbow. But it was found that in some of the elbows maximum thinning due to FAC was observed on the intrados of the first elbow. Hence to resolve this, effect of first bend orientation with respect of upstream direction has been studied. Two different approaches are used for predicting the FAC rate from calculated value of wall shear stress by CFD. One method is based on evaluating of wear rate using Colburn analogy and the other using an empirical equation between wear rate and shear stress. In Colburn analogy, mass transfer coefficient is evaluated by knowing shear stress and equilibrium concentration. For a case study, wall shear stress obtained from k-∊ turbulence model was compared with k-ω SST turbulence model and no appreciable change in the wall shear stress has been found. Hence for subsequent analysis k-∊ turbulence model was chosen because large mesh size near to the surface (first layer thickness) is permitted due to higher y+ value.

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).

Polymorphism of the IL-8 gene and the risk of ovarian cancer

Ovarian cancer still represents a challenge in gynecological oncology. Most patients are diagnosed in an advanced tumor stage. No specific screening or prevention strategies for ovarian cancer exist as of yet. Interleukin 8 (IL-8) is a pro-inflammatory chemokine known for its angiogenetic activity, and is supposedly responsible for tumor-associated angiogenesis in several malignant tumors. The aim of the study was to investigate the susceptibility of patients with an IL-8 gene polymorphism to developing ovarian cancer. Four single nucleotide polymorphisms (SNPs) (IL-8 -251, IL-8 +781, IL-8 +1633 and IL-8 +2767) of the IL-8 gene were screened, using the PCR method in 268 patients with ovarian cancer and 426 healthy women as a control group. Significant associations were noted in patients with the IL-8 +781 (T/T) genotype (p=0.0048) with increased frequencies of ovarian cancer, while women with the IL-8 +781 (C/C) allele suffer from ovarian cancer significantly less frequently (p=0.0003). Furthermore, the IL-8 +2767 (T/T) genotype is also associated with a higher risk of ovarian cancer (p=0.0177). Our results indicate, for the first time, that IL-8 polymorphism is associated with ovarian cancer.

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.