Role of Repetitive Transcranial Magnetic Stimulation in Treatment of Fibromyalgia: A Randomized Controlled Trial.

Background and Objective: Fibromyalgia syndrome (FMS) is a chronic disease characterized by widespread, persistent musculoskeletal pain in association with impaired health-related quality of life. Repetitive transcranial magnetic stimulation (rTMS) is an emerging tool for the management of fibromyalgia. There is no standardized protocol of rTMS for the treatment of FMS, and both low- and high-frequency stimulation of the dorsolateral prefrontal cortex (DLPFC) are described in the literature with variable efficacy. The objective of this study was to determine the effectiveness of rTMS in people with fibromyalgia and compare the response of low- and high-frequency stimulation with sham stimulation. Materials and Methods: This study was a single-blinded, randomized, placebo-controlled trial. Ninety patients with the diagnosis of FMS were randomly allocated into one of the following three groups: low-frequency (1 Hz) group, high-frequency (10 Hz) group, and sham group. Pain, depression, anxiety, and quality of life were measured using the Numerical Pain Rating Scale (NPRS), Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HDRS), and Revised Fibromyalgia Impact Questionnaire (FIQR) immediately following treatment as well as at 1 and 3 months after treatment. The data was statistically analyzed using Statistical Package for the Social Sciences version 23 software. P value < 0.05 was considered statistically significant. Results: Intergroup analysis revealed a significant improvement in NPRS, HAM-A, HDRS, and FIQR scores in both low- and high- frequency groups immediately following treatment and for 3 months after treatment. No significant difference in the efficacy of low- and high-frequency stimulation was noticed. Conclusions: rTMS is an effective mode of treatment in people with FMS. Both low and high frequencies of stimulation at DLPFC are equally effective in reducing pain and associated symptoms.

Comparison of outcomes of different modalities of renal replacement therapy in patients of acute kidney injury: a single centre prospective observational study.

BACKGROUND: Acute Kidney Injury (AKI) is one of the most important causes of in-hospital mortality. The global burden of AKI continues to rise without a marked reduction in mortality. As such, the use of renal replacement therapy (RRT) forms an integral part of AKI management, especially in critically ill patients. There has been much debate over the preferred modality of RRT between continuous, intermittent and intermediate modes. While there is abundant data from Europe and North America, data from tropical countries especially the Indian subcontinent is sparse. Our study aims to provide an Indian perspective on the dialytic management of tropical AKI in a tertiary care hospital setup. METHODS: 90 patients of AKI, 30 each undergoing Continuous Renal Replacement Therapy (CRRT), Intermittent Hemodialysis (IHD) and SLED (Sustained Low-Efficiency Dialysis) were included in this prospective cohort study. At the end of 28 days of hospital stay, discharge or death, outcome measures were ascertained which included mortality, duration of hospital stay, recovery of renal function and requirement of RRT after discharge. In addition median of the net change of renal parameters was also computed across the three groups. Lastly, Kaplan Meier analysis was performed to assess the probability of survival with the use of each modality of RRT. RESULTS: There was no significant difference in the primary outcome of mortality between the three cohorts (p=0.27). However, CRRT was associated with greater renal recovery (p= 0.015) than IHD or SLED. On the other hand, SLED and IHD were associated with a greater net reduction in blood urea (p=0.004) and serum creatinine (p=0.053). CONCLUSION: CRRT, IHD and SLED are all complementary to each other and are viable options in the treatment of AKI patients.

Spatial coding in the hippocampus and hyperpallium of flying owls.

The elucidation of spatial coding in the hippocampus requires exploring diverse animal species. While robust place-cells are found in the mammalian hippocampus, much less is known about spatial coding in the hippocampus of birds. Here we used a wireless-electrophysiology system to record single neurons in the hippocampus and other two dorsal pallial structures from freely flying barn owls (Tyto alba), a central-place nocturnal predator species with excellent navigational abilities. The owl's 3D position was monitored while it flew between perches. We found place cells-neurons that fired when the owl flew through a spatially restricted region in at least one direction-as well as neurons that encoded the direction of flight, and neurons that represented the owl's perching position between flights. Many neurons encoded combinations of position, direction, and perching. Spatial coding was maintained stable and invariant to lighting conditions. Place cells were observed in owls performing two different types of flying tasks, highlighting the generality of the result. Place coding was found in the anterior hippocampus and in the posterior part of the hyperpallium apicale, and to a lesser extent in the visual Wulst. The finding of place-cells in flying owls suggests commonalities in spatial coding across mammals and birds.

Advances in the Diagnosis and Management of Congenital Heart Disease in Children.

The last five decades have witnessed an inordinate number of advances in the diagnosis and management of congenital heart defects (CHDs), as reviewed elsewhere [...].

Noninvasive Cardiac Output Monitoring Using Electrical Cardiometry and Outcomes in Critically Ill Children.

Cardiac output (CO) measurement is an important element of hemodynamic assessment in critically ill children and existing methods are difficult and/or inaccurate. There is insufficient literature regarding CO as measured by noninvasive electrical cardiometry (EC) as a predictor of outcomes in critically ill children. We conducted a retrospective chart review in children <21 years, admitted to our pediatric intensive care unit (PICU) between July 2018 and November 2018 with acute respiratory failure and/or shock and who were monitored with EC (ICON monitor). We collected demographic information, data on CO measurements with EC and with transthoracic echocardiography (TTE), and data on ventilator days, PICU and hospital days, inotrope score, and mortality. We analyzed the data using Chi-square and multiple linear regression analysis. Among 327 recordings of CO as measured by EC in 61 critically ill children, the initial, nadir, and median CO (L/min; median [interquartile range (IQR)]) were 3.4 (1.15, 5.6), 2.39 (0.63, 4.4), and 2.74 (1.03, 5.2), respectively. Low CO as measured with EC did not correlate well with TTE ( p = 0.9). Both nadir and mean CO predicted ventilator days ( p = 0.05 and 0.01, respectively), and nadir CO was correlated with peak inotrope score (correlation coefficient of -0.3). In our cohort of critically ill children with respiratory failure and/or shock, CO measured with EC did not correlate with TTE. Both nadir and median CO measured with EC predicted outcomes in critically ill children.

Advances in the Prenatal Management of Fetal Cardiac Disease.

Advances in the field have improved the prenatal management of cardiovascular diseases over the past few decades; however, there remains considerable challenges in the approach towards patient selection as well as the applicability of available therapies. This review aims to discuss the current knowledge, outcomes and challenges for prenatal intervention for congenital heart disease.

Utility of Three-Dimensional Printed Model in Biventricular Repair of Complex Congenital Cardiac Defects: Case Report and Review of Literature.

Heterotaxy is a rare syndrome associated with cardiac complexity, anatomic variability and high morbidity and mortality. It is often challenging to visualize and provide an accurate diagnosis of the cardiac anatomy prior to surgery with the use of conventional imaging techniques. We report a unique case demonstrating how the use of three-dimensional (3D) cardiac printed model allowed us to better understand the anatomical complexity and plan a tailored surgical approach for successful biventricular repair in a patient with heterotaxy syndrome.

Role of Three-Dimensional Visualization Modalities in Medical Education.

For the past two decades, slide-based presentation has been the method of content delivery in medical education. In recent years, other teaching modalities involving three-dimensional (3D) visualization such as 3D printed anatomical models, virtual reality (VR), and augmented reality (AR) have been explored to augment the education experience. This review article will analyze the use of slide-based presentation, 3D printed anatomical models, AR, and VR technologies in medical education, including their benefits and limitations.

Persistence of Late Gadolinium Enhancement on Follow-Up CMR Imaging in Children with Acute Myocarditis.

Cardiac magnetic resonance (CMR) imaging is the gold standard non-invasive test for the diagnosis of acute myocarditis. Late gadolinium enhancement (LGE) on CMR imaging signifies myocardial fibrosis or scar but information on long-term follow-up in pediatric patients is limited. The aim of this study is to evaluate the persistence of LGE in follow-up CMR imaging and highlight the need for serially following LGE after acute myocarditis in children. A retrospective review of the CMR images in pediatric patients less than 18 years of age at Children's Memorial Hermann Hospital was performed from October 31, 2010, to December 31, 2017. The ages of the patients included in the study ranged from 10 to 17 years. Out of 34 subjects, 12 subjects had a follow-up CMR imaging after the initial CMR imaging. Cardiac enzymes and inflammatory markers were elevated in all patients on initial presentation with normalization seen for all patients on follow-up testing. Baseline CMR imaging demonstrated depressed function in 50% of patients (6/12) with recovery of biventricular function seen in all except for one patient. LGE was detected in 10 out of 12 patients on baseline CMR and persisted in all on follow--up CMR imaging. Two patients did not have LGE at baseline CMR and had no evidence of LGE at follow-up CMR. Despite resolution of acute myocardial inflammation, LGE persisted in all of our study subjects. There is neither an agreement on time interval to perform follow-up CMR, nor on duration of follow-up. We recommend large-scale prospective CMR study for long-term follow-up evaluation of children after acute myocarditis.

Behavioral and neuronal study of inhibition of return in barn owls.

Inhibition of return (IOR) is the reduction of detection speed and/or detection accuracy of a target in a recently attended location. This phenomenon, which has been discovered and studied thoroughly in humans, is believed to reflect a brain mechanism for controlling the allocation of spatial attention in a manner that enhances efficient search. Findings showing that IOR is robust, apparent at a very early age and seemingly dependent on midbrain activity suggest that IOR is a universal attentional mechanism in vertebrates. However, studies in non-mammalian species are scarce. To explore this hypothesis comparatively, we tested for IOR in barn owls (Tyto alba) using the classical Posner cueing paradigm. Two barn owls were trained to initiate a trial by fixating on the center of a computer screen and then turning their gaze to the location of a target. A short, non-informative cue appeared before the target, either at a location predicting the target (valid) or a location not predicting the target (invalid). In one barn owl, the response times (RT) to the valid targets compared to the invalid targets shifted from facilitation (lower RTs) to inhibition (higher RTs) when increasing the time lag between the cue and the target. The second owl mostly failed to maintain fixation and responded to the cue before the target onset. However, when including in the analysis only the trials in which the owl maintained fixation, an inhibition in the valid trials could be detected. To search for the neural correlates of IOR, we recorded multiunit responses in the optic tectum (OT) of four head-fixed owls passively viewing a cueing paradigm as in the behavioral experiments. At short cue to target lags (<100 ms), neural responses to the target in the receptive field (RF) were usually enhanced if the cue appeared earlier inside the RF (valid) and were suppressed if the cue appeared earlier outside the RF (invalid). This was reversed at longer lags: neural responses were suppressed in the valid conditions and were unaffected in the invalid conditions. The findings support the notion that IOR is a basic mechanism in the evolution of vertebrate behavior and suggest that the effect appears as a result of the interaction between lateral and forward inhibition in the tectal circuitry.

Tetralogy of Fallot With Absent Pulmonary Valve and Nonconfluent Pulmonary Arteries: A Management Conundrum.

Tetralogy of Fallot with absent pulmonary valve syndrome is a rare form of congenital heart disease. Among the different variations with this rare anomaly is nonconfluent pulmonary artery branches with anomalous origin of the left pulmonary artery from the ductus arteriosus. The authors present one such case which was diagnosed prenatally to have tetralogy of Fallot with absent pulmonary valve and identified postnatally to have nonconfluent pulmonary artery branches in addition. We discuss the conundrum of respiratory management in this patient pre- and postoperatively due to a unique ventilation perfusion mismatch problem, which varies between the two lungs.

Association of left atrial pressure with left atrial volume and N-terminal prohormone brain natriuretic peptide in children with cardiomyopathy.

BACKGROUND: Enlargement of the left atrium is a non-invasive marker of diastolic dysfunction of the left ventricle, a determinant of prognosis in children with cardiomyopathy. Similarly, N-terminal prohormone brain natriuretic peptide is a useful marker in the management of children with cardiomyopathy and heart failure. The aim of this study is to evaluate the association of left atrial pressures with left atrial volume and N-terminal prohormone brain natriuretic peptide in children with cardiomyopathy. METHODS: This was a retrospective study reviewing the medical records of patients <18 years of age, who were diagnosed with cardiomyopathy or acute myocarditis with eventual development of cardiomyopathy. Left atrial volume by transthoracic echocardiogram and pulmonary capillary wedge pressure, a surrogate of left atrial pressure, obtained by means of cardiac catheterisation were analysed. In addition, N-terminal prohormone brain natriuretic peptide levels obtained at the time of the cardiac catheterisation were also reviewed. Statistical analysis was performed to evaluate the association of left atrial pressures with left atrial volume and N-terminal prohormone brain natriuretic peptide levels. RESULTS: There was a linear correlation of left atrial pressure estimated in the cardiac catheterisation with indexed left atrial volume (r=0.63; p<0.001) and left atrial volume z-scores (r=0.59; p<0.001). We found no statistically significant association between the left atrial pressure and N-terminal prohormone brain natriuretic peptide levels. CONCLUSIONS: Left atrial volume measured non-invasively by echocardiography can be used as a surrogate for left atrial pressure in assessing diastolic dysfunction of the left ventricle in children with cardiomyopathy. The larger the size of the left atrium, worse is the diastolic function of the left ventricle.

Evaluation of Neonates With Suspected Congenital Heart Disease: A New Cost-Effective Algorithm.

We assessed the value of existing guidelines for the evaluation of suspected congenital heart disease (CHD) in term neonates and propose a revised algorithm. Retrospective chart review of newborns referred for cardiac evaluation at a tertiary care center was performed. A total of 777 newborns qualified for the study. Among these, 3 critical and 8 major CHD were identified. The sensitivity of the combination of abnormal physical examination and pulse oximetry screening for major and critical CHD was 100%. The cost to detect a case of critical CHD, based on echocardiograms done for all abnormal electrocardiograms, was 3.4 times more than that incurred for performing this test on the basis of abnormal pulse oximetry and physical examination. Adding electrocardiogram to CHD screening increases cost without adding diagnostic yield. Based on our findings, we propose a revised algorithm for a systematic cost-effective approach to cardiac evaluation of term newborns with suspected CHD.

EXIT procedure for fetal mediastinal teratoma with large pericardial effusion: a case report with review of literature.

BACKGROUND: Large mediastinal teratomas in the fetus are rare and can present with direct compression of intrathoracic structures as well as pericardial and pleural effusions. Mediastinal fetal teratoma may be detected as a mass in the chest during a routine prenatal ultrasound. Because of the pressure on mediastinal structures it may result in non-immune fetal hydrops (NIFH) and polyhydramnios. The development of hydrops may lead to fetal demise. Timely obstetric and/or surgical intervention is important to improve survival in this patient population. Case review: We report a case of a large mediastinal teratoma in a fetus who presented with a large pericardial effusion at 28 weeks gestation. The fetus developed NIFH at 31 weeks gestation. The fetus was successfully managed with an ex utero intrapartum therapy (EXIT) procedure which involved pericardiocentesis and surgical resection of the large teratoma. Histological examination revealed an encapsulated immature teratoma. DISCUSSION: Mediastinal teratomas are usually detected by routine second- and third-trimester ultrasound. Large teratomas have been described to present with airway compromise and NIFH. Some cases have been managed by postnatal surgery and rare cases by EXIT procedure. CONCLUSIONS: This is the first reported case of a fetal mediastinal teratoma and severe pericardial effusion who developed NIFH, in whom EXIT procedure was successfully employed to simultaneously drain the effusion and resect the tumor.

Contrast Enema and Risk of Sepsis in Premature Babies: A 12-Year Retrospective Study.

Objective The objective of this study was to investigate the association between contrast enema (CE) and clinical sepsis (CS) in premature babies (PB) and the role of antibiotics (ABs) in its prevention. Study Design A retrospective electronic chart review of preterm babies, who underwent CE during their stay in the neonatal intensive care unit. Group I includes CEs of babies exposed to AB during or within 48 hours of the procedure. Group II represents CEs of babies, not exposed to AB. Variables for both groups were collected and analyzed. Results There were 161 CEs performed in 133 babies. The overall incidence of CS after CE in preterm babies was 21/160 cases (13%). The incidence was significantly lower in Group I (1/79, 1.2%), compared with Group II (20/81, 24.7%) (p < 0.001). Six (30%) of the 20 babies from Group II had positive blood culture and all 20 required AB after the CE. There were no statistical differences in the variables between the two groups. Conclusion There is a possible association between CE and CS in preterm babies. ABs given during or before the procedure prevent this complication.

Association of A Dilated Coronary Sinus in the Fetus with Actual and Apparent Coarctation of the Aorta and Diminutive Left Heart Structures.

Evidence suggests an association between left heart obstructive lesions and dilated coronary sinus (DCS), but this has not been studied in fetuses. A retrospective review of fetal echocardiograms (FE) over an 8-year period was conducted, and patients with DCS were identified and confirmed postnatally. There were 5840 FE performed on 4920 women during this period. Of 49 patients with DCS, 22 had normal intracardiac anatomy and 27 patients had congenital heart disease (CHD) yielding an incidence of 4.6 % in the presence of CHD (27/584). Of 27 patients with DCS and CHD, approximately a third had either hypoplastic left ventricles and/or coarctations (10/27, 37 %). The incidence of left heart obstructive lesions was much higher in the presence of a DCS (37 % vs 45/557, 8 %, p < 0.0001). The odds ratio of left heart hypoplasia in fetuses with CHD and a DCS was 6.6 (95 % CI 2.8-15.3). Comparison of patients with postnatally confirmed coarctation with those with normal intracardiac anatomy with DCS, revealed that in the former, the right ventricle (p = 0.005), pulmonic valve annulus (p = 0.0001) and the tricuspid inflow were larger (p = 0.001) compared to corresponding left-sided structures. The size of the DCS was not significantly different between the two groups, but in the former, the DCS was more closely related to the posterior leaflet of the mitral valve and caused a significant diminution of the mitral inflow. Our study suggests a strong association, possibly causal, between left heart obstructive lesions and DCS in utero.

Injection practices of healthcare professionals in a Tertiary Care Hospital.

BACKGROUND: Unsafe injection practices are prevalent worldwide and may result in spread of infection. Thus the present study was planned to observe the injection practices of healthcare professionals (HCP), including aseptic precautions and disposal of used syringes/needle. MATERIALS AND METHODS: Injection practices were observed in the outpatients and inpatients departments. Questionnaire was designed, tested and administered for this purpose. RESULTS: 130 patients receiving injections were observed. Overall injection practices of the HCP were satisfactory. However, unsafe practices with respect to not washing hands (95.4%), not wearing/changing gloves (61.6%), recapping of needles (12.2%), wiping of needle with swab (15.4%) and breaking of ampoule with solid object (44.4%) were observed. CONCLUSION: The problem of unsafe injections can be successfully addressed by organizing continuing medical education/symposium/workshops for improving the knowledge, attitude and practices of the HCP. Periodic monitoring and such interventions may also further improve safe injection practices.

Trauma care - a participant observer study of trauma centers at Delhi, Lucknow and Mumbai.

BACKGROUND: Trained doctors and para-medical personnel in accident and emergency services are scant in India. Teaching and training in trauma and emergency medical system (EMS) as a specialty accredited by the Medical Council of India is yet to be started as a postgraduate medical education program. The MI and CMO (casualty medical officer) rooms at military and civilian hospitals in India that practice triage, first-aid, medico-legal formalities, reference and organize transport to respective departments leads to undue delays and lack multidisciplinary approach. Comprehensive trauma and emergency infrastructure were created only at a few cities and none in the rural areas of India in last few years. AIM: To study the infrastructure, human resource allocation, working, future plans and vision of the established trauma centers at the 3 capital cities of India - Delhi (2 centres), Lucknow and Mumbai. SETTING AND DESIGN: Participant observer structured open ended qualitative research by 7 days direct observation of the facilities and working of above trauma centers. MATERIAL AND METHODS: Information on, 1. Infrastructure; space and building, operating, ventilator, and diagnostic and blood bank facilities, finance and costs and pre-hospital care infrastructure, 2. Human resource; consultant and resident doctors, para-medical staff and specialists and 3. Work style; first responder, type of patients undertaken, burn management, surgical management and referral system, follow up patient management, social support, bereavement and postmortem services were recorded on a pre-structured open ended instrument interviewing the officials, staff and by direct observation. Data were compressed, peer-analyzed as for qualitative research and presented in explicit tables. RESULTS: Union and state governments of Delhi, Maharashtra and Uttar Pradesh have spent heavily to create trauma and emergency infrastructure in their capital cities. Mostly general and orthopedics surgeons with their resident staff were managing the facilities. Comprehensively trained accident and emergency (AandE) personnel were not available at any of the centers. Expert management of cardiac peri-arrest arrhythmias, peripheral and microvascular repair were occasionally available. Maxillo-facial, dental and prosthodontic facilities, evenomation grading and treatment of poisoning - anti venom were not integrated. Ventilators, anesthetist, neuro and plastic surgeons were available on call for emergency care at all the 4 centers. Emergency diagnostic radiology (X-ray, CT scan, and ultrasound) and pathology were available at all the 4 centers. On the spot blood bank and component blood therapy was available only at the Delhi centers. Pre-hospital care, though envisioned by the officials, was lacking. Comprehensively trained senior A and E personnel as first responders were unavailable. Double barrier nursing for burn victims was not witnessed. Laparoscopic and fibreoptic endoscopic emergency procedures were also available only at Delhi. Delay in treatment on account of incomplete medico-legal formalities was not seen. Social and legal assistance, bereavement service and cold room for dead body were universally absent. Free treatment at Delhi and partial financial support at Lucknow were available for poor and destitute. CONCLUSION: Though a late start, evolution of trauma services was observed and huge infrastructure for trauma have come up at Delhi and Lucknow. Postgraduate accreditation in Trauma and EMS and creation of National Injury Control Program must be mandated to improve trauma care in India. Integration of medical, non traumatic surgical and pediatric emergency along with pre-hospital care is recommended.

A study of knowledge, attitude and practice of hospital consultants, resident doctors and private practitioners with regard to pre-hospital and emergency care in Lucknow.

BACKGROUND: Burden of death and disability resulting from lack of emergency medical system (EMS) and emergency care is very high in low and middle income countries (LMIC). AIM: To study the knowledge, attitudes and practices of pre-hospital care and emergency services among health care providers of Lucknow SETTING AND DESIGN: Cross-sectional survey, 200 residents, 104 hospital consultants and 108 private practitioners MATERIAL AND METHODS: A close ended, self administered questionnaire based on 5-point Likert scale with 30 items of knowledge, attitude and practice of pre-hospital and emergency care RESULTS: Median scores of knowledge (26/50), attitude (41/50) and practices (27/50) showed less than adequate knowledge and practices. However, a positive attitude was seen in all the 3 group of respondents i.e. resident doctors, hospital consultants and private practitioners. CONCLUSION: Lucknow is the capital city of Indian largest state - Uttar Pradesh with over 100 years of established medical education. The results of the study in this town are applicable to most developed cities in India. Lack of adequate knowledge and practices in emergency medical system (EMS) at Lucknow represent a dismal situation and require continuing medical education in this area.