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Objective To study the prevalence of different NPSLE manifestations in our cohort and to compare clinical and immunological features and outcomes including mortality of patients with NPSLE and SLE controls without NP involvement. Methods This was a retrospective study in a tertiary care referral centre. All patients of SLE seen in the last 10 years and fulfilling the SLICC criteria with neuropsychiatric manifestations as per the ACR definitions were included. Patients of SLE without NP involvement were sequentially assigned as controls in a ratio of 1:2. Results Of the 769 patients diagnosed with SLE from Jan 2011 to December 2020, 128 (16.6%) had NPSLE manifestations as per the ACR definitions. The commonest NPSLE manifestation was seizures (6.5%) followed by cerebrovascular accident (3.9%). NPSLE manifestation occurred at the first presentation of SLE in 99/128 (77.3%) patients and 58 (45.3%) patients had more than one NPSLE manifestation. Lupus anticoagulant and anticardiolipin antibody were tested in 120 patients and were positive in 16 (13.3%) and 12 (10%), respectively. No difference was found in anti-ribosomal p, lupus anticoagulant and anticardiolipin antibodies between the cases and controls. Twenty-one (16.4%) deaths occurred in patients with NPSLE (median follow-up of 40 months) as compared to 13 (5%) in controls (median follow-up of 32 months) ( p = Conclusions Seizures and cerebrovascular accidents are the commonest NPSLE syndromes in our patients. The presence of NPSLE was associated with high mortality in Indian patients with lupus.

Introduction: The incidence of Acute Coronary Syndrome (ACS) in the young has been increasing globally. Research in this population has been limited in developed countries or urban areas in developing countries. Identifying the various epidemiologic features in this age group is crucial to understand the disease. Aim: To describe the clinical characteristics of young adults presenting with ACS in a rural tertiary care hospital. Materials and Methods: This cross-sectional study included 50 patients diagnosed with ACS. Data were collected from consecutive patients between the ages of 18 to 45 years diagnosed with ACS between January 2014 to January 2015 in the Emergency Medicine Department of a tertiary care hospital in Davanagere, India. Data were collected on demographic characteristics, risk factors, laboratory tests, and angiographic findings. Range, mean and percentages were calculated for continuous and categorical variables, respectively. A 95% confidence intervals were calculated for all variables. Results: The mean age was 38.1±5.8 years with male preponderance 46 (92%). Risk factors were smoking 36 (72%), diabetes 17 (34%), hypertension 6 (12%) and Body Mass Index (BMI) >23 kg/m2, 36 (72%). Anterior Wall Myocardial Infarction (AWMI) was observed in 35 (70%) of subjects with angiography revealing Single Vessel Disease (SVD) 28 (56%), Double Vessel Disease (DVD) 5 (10%), Triple Vessel Disease (TVD) 3 (6%) and Myocardial Infarction with Non-Obstructive Coronary Artery Disease (MINOCA) 11 (22%). Three patients died during their course of treatment before initiating an interventional procedure. Conclusion: Smoking, diabetes mellitus and elevated BMI are associated with ACS among young patients. Interventions targeting these risk factors among younger individuals should be developed.

BACKGROUND Traditionally plasmodium vivax has been considered to be the cause for benign malaria and plasmodium falciparum to cause severe malaria. The incidence of P. vivax malaria in Rohtas district (Bihar) and neighbouring districts is quite high and P. vivax cases with severe complication are coming to NMCH, Rohtas for treatment. Thus, the present study was conducted to find out morbidity and mortality of P. vivax and P. falciparum malaria. MATERIALS AND METHODS The study period was from January 2015 to June 2018 and was conducted at NMCH (Narayan Medical College and Hospital), Jamuhar, Rohtas, Bihar. Patients of 16 years and above who were smear positive and/or malaria antigen positive were included in this study. RESULTS Total number of cases included for study were 306 out of which 192 (62.75%) were P. vivax, 102 (33.33%) cases of P. falciparum and 12 (3.92%) cases were mixed infection of P. vivax and P. falciparum. The commonest age group was 16-40 years and the commonest complication was thrombocytopenia followed by renal impairment, hepatic dysfunction, cerebral malaria and ARDS in that order. Statistically, there was no significant difference in clinical profile, morbidity and mortality in P. vivax and P. falciparum/mixed group. CONCLUSION Vivax malaria is no more a benign malaria and morbidity and mortality are comparable to P. falciparum/mixed infection

Advances in deep learning have yielded simplified solutions in many challenging medical imaging problems. Despite their capability, these learning approaches often fail to produce accurate and reliable segmentation in echocardiography image sequences due to varying amounts of speckle noise accompanied with ill-defined and missing boundaries. For this, we propose a combination of deep learning and a shape-driven deformable model in the form of level set. The proposed method uses an end-to-end trained fully convolutional network that acts as a prior to drive the level set-based deformable model. Further, we define a new energy formulation within the level set framework that accounts for characteristics of the desired structure. By employing the proposed method, we achieve accurate and reliable segmentation of cardiac structures (left ventricles) both qualitatively and quantitatively.

It is estimated that approximately 75% of medical devices and diagnostics come to India from imports. A WHO report on medical devices highlighted that most devices present in developing countries have been designed for use in developed countries. Consequently, when these medical devices are implemented in India, they are either unaffordable or are maladapted to fit the complex healthcare ecosystem. A strong need exists to develop technologies that are intentionally designed to suit the Indian healthcare system. To address these issues, we have applied a modified version of the biodesign process, originally developed by Stanford University, to identify unmet clinical needs in the field of emergency medicine at a tertiary referral hospital in southern India. Since the biodesign process was originally created to identify unmet needs in a more mature Medtech ecosystem, we have altered its implementation to make it more suitable to the evolving Medtech ecosystem that prevails in India. At the completion of 2 months of clinical immersion by a multidisciplinary team, 100 unmet needs with significant negative outcomes were identified. The team then took all the need statements collected during the period of the clinical immersion and applied four rounds of precalibrated filters to arrive at the top 10 most compelling clinically validated needs that would be selected for the phase of invention. In this article, we present our reasons for making modifications to the biodesign process, our results and our experiences while implementing this process in an Indian healthcare system.

Detection ofHelicobacter pyloriafter triple therapy is usually carried out by either rapid urease test (RUT), urea breath test (UBT), histology, bacterial isolation, and single round PCR or serological tests. In this study, antral biopsy specimens from 25 patients were tested forH. pyloriby RUT, culture, histology, and nested PCR in their antral biopsy specimens before and after treatment. Three genes, namely, heat shock protein (hsp60), phosphoglucosamine mutase (ureC), and flagellar export ATP synthase (fliI) ofH. pyloriwere targeted. Of the 25 antral biopsy specimens, the RUT, culture, histology, and nested PCR positivity dropped from 81.8% to 12%, 31% to 0%, 100 to 84%, and 100% to 92%, respectively, before and after therapy. Further,hsp60specific amplicons from 23 out of 25 patients gave identical restriction pattern, while 6fliIand 1ureCspecific amplicon produced different restriction pattern. Furthermore, variations infliIgene sequences inH. pyloriafter treatment were also confirmed by sequencing and comparedin silico. Nested PCR based detection ofH. pyloriis more sensitive method to detectH. pyloriafter therapy than culture, RUT, and histology. Further, this study suggests thatH. pyloriis not eradicated completely after triple therapy.

Posterior reversible encephalopathy syndrome (PRES) is a rare complication of nephrotic syndrome and corticosteroid therapy. Here, we discuss an 18 year old man with type 1 membranoproliferative glomerulonephritis (MPGN) secondary to hepatitis B infection who developed posterior leukoencephalopathy while on therapy with lamivudine and prednisone. He developed seizures and vision loss. He also had hypertension, but no sudden elevation was recorded at any time. Magnetic resonance imaging revealed patchy areas of altered signal intensity involving cortical gray and subcortical white matter in the bilateral frontoparietal regions, occipital cortices, temporal cortices and cerebellar hemispheres, and hyperintensity on T2W and FLAIR sequences. Tapering of prednisone and controlling hypertension resulted in clinical improvement within a few days, and in a month MRI was normal. Diagnosing PRES requires a high index of suspicion when treating similarly susceptible patients. PRES as a complication during the treatment of MPGN secondary to hepatitis B has, to our knowledge, never been reported previously in the literature.

Introduction: This study examines the feasibility of atrial fibrillation (AF) ablation using registered three-dimensional computed tomography (CT) images of the left atrium with fluoroscopy. Methods and Results: A total of 50 consecutive patients with symptomatic AF refractory to medical therapy (32 paroxysmal, 18 persistent, age 55 ± 10 years) were randomized to undergo a catheter-based AF ablation procedure with or without the CT-fluoroscopy guidance system. All patients underwent preprocedural contrast-enhanced CT imaging and segmentation of the left atrium. For the CT-fluoroscopy group, circumferential lesions encompassing the pulmonary vein (PV) antrum and linear lesions along the roof of the left atrium between the superior PVs and the mitral isthmus were created on the CT image, which was registered with real-time fluoroscopy. The registered images were then used to navigate the ablation catheters to the sites of planned ablation. After the ablation sites were completed, any remaining PV potentials were isolated with electrophysiological guidance. In the control patients, the same technique was performed without using the CT-fluoro guidance system. CT scans were accurately registered to fluoroscopic images with minimal manual correction. Operators could navigate catheters on the registered images to preplanned, extraostial sites for ablation. CT-fluoroscopy guidance decreased procedure duration and fluoro times (P < 0.05). At a mean follow-up of 9 ± 2 months, 21 patients (84%) in the CT-fluoro guidance group and 16 patients (64%) in the control group have had no recurrence of AF. Conclusion: CT-fluoroscopic-guided left atrial ablation is feasible and allows appropriate catheter manipulation in the left atrium.

Despite the great promise catheter ablation offers in the treatment of complex arrhythmias such as atrial fibrillation (AF), long procedure times and somewhat suboptimal results hinder the widespread use of this technique. As fluoroscopy does not provide contrast differentiation between the area of interest and the surrounding structures, there is a lack of proper intra procedure image guidance. Segmentation of anatomical structures such as the left atrium (LA) can be performed using images obtained with modalities such as computed tomography (CT). However, unlike the cardiac mapping systems, these imaging systems do not track catheters in real time. This review addresses the evolving concept of image registration to deliver therapy in cardiac arrhythmias.

Atrial fibrillation (AF) affects 1% of the population and results in a cost of 2.8 billion dollars from hospitalizations alone. Treatments that electrically isolate portions of the atria are clinically effective in curing AF. However, such minimally invasive catheter treatments face difficulties in mechanically positioning the catheter tip and visualizing the anatomy of the region. We propose a noncontact, intracardiac transducer that can ablate tissue and provide rudimentary imaging to guide therapy. Our design consists of a high-power, 20 mm by 2 mm, 128-element, transducer array placed on the side of 7-French catheter. The transducer will be used in imaging mode to locate the atrial wall; then, by focusing at that location, a lesion can be formed. Imaging of previously formed lesions could potentially guide placement of subsequent lesions. Successive rotations of the catheter will potentially enable a contiguous circular lesion to be created around the pulmonary vein. The challenge of intracardiac-sized transducers is achieving high intensities (300-5000 W/cm2) needed to raise the temperature of the tissue above 43 degrees C. In this paper, we demonstrate the feasibility of an intracardiac-sized transducer for treatment of atrial fibrillation. In simulations and proof-of-concept experiments, we show a 37 degrees C temperature rise in the lesion location and demonstrate the possibility of lesion imaging.

Background: We assessed whether cardiovascular magnetic resonance imaging (CMR) of peri-infarct ischemia provides prognostic information in severe ischemic cardiomyopathy (ICM) patients referred for revascularization. Methods: Twenty-one patients with severe ICM were recruited prospectively for combined stress adenosine perfusion, late gadolinium enhancement, and rest perfusion studies. The patients were followed for in-hospital and post-discharge cardiovascular events. Results: During 12± 9.8 months follow-up, 67% of the patients with peri-infarct ischemia and 13% of the patients without peri-infarct ischemia had cardiovascular events (p = 0.03). Conclusion. In severe ICM patients, the presence of peri-infarct ischemia was associated with a higher incidence of cardiovascular events.

Despite advances in non-pharmacologic therapy for atrial fibrillation (AF), some patients remain highly refractory. We report our experience with the unique combined use of 1C and III agents in patients with highly refractory paroxysmal atrial fibrillation. Six patients with symptomatic AF (three persistent) were selected after failing multiple antiarrhythmic medications and radiofrequency ablation. They were started on flecainide or propafenone and sotalol or dofetilide during three days of inpatient monitoring. No patient had coronary artery disease. All patients had loop recorder follow-up and ECG recordings during clinic visits for a mean follow-up of 9 ± 11 months. After therapy, all patients had complete, sustained control of their symptoms with no evidence of AF or proarrhythmia on monitoring. One patient had recurrence of AF after stopping sotalol and was started back on the drug with complete control. Combined therapy with a 1C and III agent may be an effective alternative for the treatment of selective, highly refractory AF. Careful patient selection and hospitalization for initiation is necessary to minimize potential proarrhythmic effects. As this is a short-term therapy, further study is needed to assess the extent of efficacy in a larger number of patients.

Purpose: To validate a novel, real-time, steady-state free precession (SSFP), single-breathhold technique for the assessment of left ventricular (LV) and right ventricular (RV) function in heart failure patients. Materials and Methods: A total of 20 heart failure patients (mean age 59 17 years) underwent scanning with our new, real-time, spiral SSFP sequence in which each cardiac phase was acquired in 118 msec at a resolution of 1.8 1.8 mm. Each cardiac slice (1-cm thick) was automatically advanced based on a cardiac trigger, allowing complete coverage of the heart in a single breathhold. The patients also underwent LV and RV assessment with the gold standard: multiple breathhold, cardiac-gated, segmented k-space strategy. LV and RV end-systolic volume (ESV) and enddiastolic volume (EDV) and LV mass were compared between the two imaging techniques. Results: The new real-time strategy was highly concordant with the gold standard technique in the assessment of LVEDV (r 0.98), LVESV (r 0.98), RVESV (r 0.86), RVEDV (r 0.91), LVMASS (r 0.95), RVEF (r 0.70), and LVEF (r 0.94). The mean bias (95% confidence interval [CI]) for each parameter is LVEDV: 10.6 cc (cm 3 ) (3.8 –17.4 cc), LVESV: – 0.8 cc (–5.3 to 3.7 cc), RVEDV: 3.7 cc (–5.6 to 13.2 cc), RVESV: –3.1 cc (–11.1 to 4.9 cc), LVMASS: 26 g (12.4 –39.8 g), RVEF: –2.9% (1.3 to –7.2 %), LVEF: 1.9% (5 to –1.1%). In addition, data acquisition was only nine two seconds with the real-time strategy vs. 312 41 seconds for the standard technique. Conclusion: In patients with heart failure, real-time, spiral SSFP allows rapid and accurate assessment of RV and LV function in a single-breath hold. Using the same strategy, increased temporal resolution will allow real-time assessment of cardiac wall motion during stress studies.

Background: Burnout is a syndrome explained as serious emotional depletion with poor adaptation at work due to prolonged occupational stress. It has three principal components namely emotional exhaustion(EE), depersonalization(DP) and diminished feelings of personal accomplishment(PA). Thus, we aimed at measuring the degree of burnout in doctors and nurses working in emergency medicine department (EMD) of 4 select tertiary care teaching hospitals in South India. Methods: A cross sectional survey was conducted among EMD professionals using a 30-item standardized pilot tested questionnaire as well as the Maslach burnout inventory. Univariate and Multivariate analyses were conducted using binary logistic regression models to identify predictors of burnout. Results: Total number of professionals interviewed were 105 of which 71.5% were women and 51.4% were doctors. Majority (78.1%) belonged to the age group 20-30 years. Prevalence of moderate to severe burnout in the 3 principal components EE, DP and PA were 64.8%, 71.4% and 73.3% respectively. After multivariate analysis, the risk factors [adjusted odds ratio (95% confidence intervals) for DP included facing more criticism [3.57(1.25,10.19)], disturbed sleep [6.44(1.45,28.49)] and being short tempered [3.14(1.09,9.09)]. While there were no statistically significant risk factors for EE, being affected by mortality [2.35(1.12,3.94)] and fear of medication errors [3.61(1.26, 10.37)] appeared to be significant predictors of PA. Conclusion: Degree of burn out among doctors and nurses is moderately high in all of the three principal components and some of the predictors identified were criticism, disturbed sleep, short tempered nature, fear of committing errors and witnessing death in EMD.

Unilateral renal agenesis (URA) is a developmental defect associated with ano-malies of the genitourinary system. The associations vary from absence of testis alone to high anorectal anomalies in other patients. We present two interesting patients with URA, encountered recently. Our first case was diagnosed with URA at the age of 11 years, which was detected on sonography, when he presented with pain abdomen. The presence of an epididymal cyst masked the absence of ipsilateral testes leading to delay in the diagnosis. Our second case was diagnosed with URA during the neonatal period when he presented with anorectal agenesis. He underwent abdomino-anal pull-through operation and later clinical course was complicated by recurrent cystitis, secondary vesicoureteral reflux and hydroureteronephrosis of solitary kidney, progressing to chronic kidney disease.

Atrial fibrillation (AF) affects 1% of the population and is responsible for 15-20% of all strokes (1); this results in more than 460,000 hospitalizations and a cost of more than $2.8 billion per year. Clinical studies show that circumferential pulmonary vein ablation, a surgical procedure that creates contiguous patterns of lesions that electrically isolate regions of the atria, have been effective in curing AF (2). However, current minimally invasive catheter procedures that use radiofrequency (RF) electrodes under fluoroscopic guidance are often unable to create these contiguous patterns. Difficulties arise in visualizing the anatomy and location of previous lesions and moving the catheter tip to those locations, particularly in the dynamic environment of the heart. Not only can intravascular ultrasound arrays deliver dy- namically, steerable therapy, they can also image the region of interest with good tissue contrast to correctly position the lesion. We propose the use of an intracardiac linear ultrasound array placed at the end of a 7 French catheter. Previously, we showed an intracardiac-sized transducer (20 mm by 2 mm) can create temperature rises of 45 degrees necessary for ablation. In this work, we illustrate the possibility of visualizing such a high intensity focused ultrasound (HIFU) lesion with conventional ultrasound imaging. I. INTRODUCTION An intracardiac ultrasound transducer addresses the issues of precisely positioning lesions and visualizing these lesions and anatomy during the AF procedure. Ultrasound therapy can be dynamically and electronically steered to precise locations as the transducer is roughly anchored in particular position; this dynamic steering can compensate for cardiac motion and variable anatomy. Unlike fluoroscopy, ultrasound imaging also provides real-time images of tissue and lesions with good tissue contrast. This can offer significant improvement in the ability to treat arrhythmias (4), (5), (6). Separate ultrasound imaging probes have been used to guide high intensity focused ultrasound (HIFU) transducers by displaying the anatomy and also detecting past lesions as bright echogenic regions (7), (8), (9). Though these echogenic regions fade 1-2 min after HIFU application, they persist for long enough periods to guide the placement of adjacent lesions for formation of contiguous patterns.