Search

To study the antiseizure drug levels and associated factors in children with breakthrough seizures. This cross-sectional study conducted at a public hospital from November, 2017 to April, 2019, included 145 children with epilepsy aged 2 to 12 years presenting with breakthrough seizure. Antiseizure drug levels were measured, and the levels were categorized as within, below, and above the reference range. Children with epilepsy receiving sodium valproate, phenytoin and carbamazepine were 111 (73%), 31 (20.4%) and 10 (6.6%), respectively, of which 7 were receiving multiple antiseizure drugs. Drug levels below the reference range were found in 64 (44.1%), within the reference range in 70 (48.3%), and the above reference range in 11 (7.6%) children. Nearly half the children with breakthrough seizures had sub-therapeutic levels, especially those on phenytoin therapy. Drug levels in below therapeutic range were not associated with occurrence of breakthrough seizures.

Metallic frame of elevators attenuate the radio signals severely causing Radio Link Failure (RLF) at Mobile Device (MD). RLF results in connection interruption causing degradation in user experience. To overcome this problem, we propose a reinforcement learning based technique called Intelligent Elevator Detection and Network Adaptation (IE-DNA) algorithm, that can be implemented on MD. The IE-DNA algorithm has the capability to handle frequent RLF, detection of elevator movement and intelligent handover among the Cellular (i.e., 3G/4G/5G) or Wi-Fi networks. Using IE-DNA algorithm, MD can upload and store radio link statistics, experienced by the user, to a cloud server. Further, uploaded data can be utilized by any mobile user to know the radio link condition a-priory for a specific elevator, when visiting later in time and handle it by selecting a network that wouldn't cause interruption during elevator movement. Based on real data-set for Cellular/Wi-Fi collected by Samsung Galaxy S8 device, we conduct extensive experiments using real elevator environment to compute performance of the schemes with respect to the state of art.

Introduction Pure laparoscopic left lateral sectionectomy (LLS) is fast becoming the standard technique for donor hepatectomy in pediatric liver transplantation. We present the first case of pure laparoscopic LLS performed in Western India. Methods An 11-month-old male child suffering from biliary atresia with history of failed Kasai operation at the age of 3 months presented to our center in Mumbai for a living donor liver transplantation. The donor was his father, 32-year-old with body mass index of 22, LAI +10 and MRE fat fraction of 1%-3%. Projected graft weight of LLS was 187 grams with GRWR of 2.4. He had favorable vascular and biliary anatomy with left hepatic artery (LHA) arising from hepatic artery proper and segment 4 artery from LHA, type A portal vein and A1B1 biliary anatomy. Patient underwent pure laparoscopic LLS. Results The technique of pure laparoscopic LLS is demonstrated in the attached video. The graft warm ischemic time was 7 minutes, blood loss 300 mL and operating time 7 hours. The donor was discharged on 5th post-operative day with a minor post-operative bile leak that resolved spontaneously and is well at 1 month follow-up. Conclusions Pure laparoscopic living donor LLS is safe and should be performed by a team experienced in open donor hepatectomy, advanced laparoscopic surgery after specific training in the procedure and negotiating the learning curve under supervision. The operative time was long, but consistent with worldwide data for early cases, which we anticipate will reduce with more experience.

Introduction Liver grafts are often reduced for pediatric liver transplant in infants to accommodate them in the child's abdomen and avoid portal hypoperfusion. However, the most common technique of non-anatomical reduction does not reduce graft thickness. We describe the technique of anatomical segment 2 graft for liver transplant in an infant with acute liver failure. Methods A six-month-old child with acute liver failure required an emergency liver transplant in our unit. The child's mother was found medically suitable on pre-operative evaluation. However, the donor left lateral segment (LLS) was "blowfish" type with estimated GRWR of 3.5. The donor graft and recipient abdominal cavity measurements revealed that the donor's liver was too large for the child's abdominal cavity (distance from anterior abdominal wall to IVC-MHV-LHV confluence in the donor was 75 mm compared to 50 mm in the child). Results The dissection for LLS donor hepatectomy was performed using the standard technique followed by reducing segment 3 to obtain segment 2 graft, in-situ. The segment 3 pedicle was identified in the umbilical fissure and clamped. The ischemic plane was oblique, as demonstrated in the video, substantially reducing the graft thickness. Parenchymal transection was done using CUSA and the segment 3 pedicle and hepatic vein tributary were secured. The GRWR was 1.5 allowing good fit and primary closure of the child's abdomen. Post-operatively, the child had high transaminases (peak 2,000 IU/L) and high drain output (2.5 mL/kg/day) that settled down in a week. Conclusions The technique of anatomical mono-segment liver grafts is valuable for pediatric liver transplantation in.

In this paper, we develop a new lightweight pseudorandom number generator (PRNG) scheme for low-cost Radio-frequency identification (RFID) tags named JSpongeGen. EPC Gen2 RFID tags are used worldwide and considered as international standards. However, these are the low resource devices and even unable to support symmetric key based cryptographic operation. Although various promising PRNG generation schemes for RFID tags have been proposed, developing a lightweight and secure scheme which also fulfills the randomness criteria is one of the open research problems. To this end, we propose JSpongeGen, a lightweight and secure mechanism that satisfies NIST randomness tests and also fulfills EPC Gen2 randomness criteria. Our proposed scheme is based on multiple polynomial dynamic feedback shift register in which we added a sponge function to update the contents of the shift register during the change of feedback polynomial. We show that our scheme outperforms one of the promising lightweight schemes in certain randomness metrics while remaining lightweight and secure solution.

A 32-year-old man presented with a 10-day history of fever, chills, nausea, vomiting, myalgia, nonproductive cough, and worsening dyspnea after freshwater swimming in the Caribbean 1 week prior to presentation. Shortly after arrival at the hospital, the patient developed severe respiratory distress with massive hemoptysis. Based on serologic workup, he was diagnosed with leptospirosis pulmonary hemorrhage syndrome leading to diffuse alveolar hemorrhage, severe hypoxemic respiratory failure, and multiorgan failure. He received appropriate antibiotic coverage along with hemodynamic support with norepinephrine and vasopressin, mechanical ventilation, and renal replacement therapy in an intensive care unit. Introduction of extracorporeal membrane oxygenation was initiated to provide lung-protective ventilation supporting the recovery of his pulmonary function. Aminocaproic acid was used to stop and prevent further alveolar hemorrhage. He fully recovered thereafter; however, it is uncertain whether it was the use of aminocaproic acid that led to the resolution of his disease.

A two months old female child presented to us with an antenatal diagnosis of left suprarenal mass. Laparotomy revealed a large cystic mass in the left suprarenal location which was completely excised. The histological diagnosis was a mature, cystic teratoma. Although, the diagnosis of adrenal teratoma is rare, it should be considered in the differential diagnosis of antenatally diagnosed suprarenal lesions. How to cite this article Garg R, Mandelia A, Agarwala S, Bhatnagar V, Singh MK, Jana M. Antenatally Diagnosed Suprarenal Cystic Teratoma. World J Endoc Surg 2015;7(2):44-46.

Background Neurological involvement due to intraspinal extension in sacrococcygeal malignant germ cell tumors (SC-MGCTs) has rarely been reported. Aim To evaluate the incidence, presentation, management and the outcome of patients of SC-MGCT with intraspinal extension. Materials and Methods Case records of all cases of SC-MGCT from 2001 to 2008, were reviewed to identify cases with vertebral involvement and intraspinal extension. They were evaluated in terms of their presentation, response to therapy, extent of surgical resection, recovery of neurological symptoms and outcome. Results Of the 31 cases of SC-MGCT, 5 (16%) had intraspinal extension. Age ranged from 12 to 84months (median 24months). Four patients had Altman type 4 disease (stage 4) and 1 had Altman type 3 (stage 3) disease. The intraspinal extension in all patients was detected on contrast CT scan. Patients presented with neurological symptoms in the form of lower limb paresis (80%), bowel and bladder (20%) incontinence. All the tumors responded to pre-operative chemotherapy. Gross complete local resection could be achieved in 4(80%). Neurological recovery was complete in all except for persisting neurogenic bladder in one. During follow up of 3–32months, all were alive with no recurrence. Conclusions SC-MGCT presenting with neurological deficits due to intraspinal extension is usually advanced disease. These patients respond to chemotherapy and surgical resection and most have complete neurological improvement.

Title: Cerebrovascular Events in Patients with Chronic Kidney Disease on Erythropoiesis Stimulating Authors: Ali M Rad, MD, MPH; Shubham Misra,MD;Rajan Garg, MD;Karine Karapetyan, MD;Sheila Roxana Safar, MD; Daniel Goldsmith, MD Background: Anemia is associated with an increased risk of cardiovascular events among patients with Chronic Kidney Disease (CKD). Guidelines have been developed for hemoglobin (Hgb) targets. Erythropoietin Stimulating Agents (ESA) are commonly used to increase hemoglobin level in CKD patients. The recent TREAT study found an increased incidence of stroke and cancer when maintaining the Hgb level at 12.5 g/dl. In the opposite, Watanabe et al showed no significant increase in risk of developing stroke in a Japanese population. Methods: All patients with chronic kidney disease who admitted between Jan 2009 till June 2011 were selected. Patients are categorized to 2 groups, CKD patients with cerebravascular events and CKD with no cerebrovascular events. Binary logistic regression was used for analysis. All results were adjusted for age and gender. Results: A total of 4926 patients were recognized. 348 out of 4926 had cerebrovascular events in their admissions between Jan 2009 till June 2011. 241/341 had ischemic cerebrovascular events, and the remainder had hemorrhagic events. Using binary logistic regression, our study shows a significant association between ESA injections and cerebrovascular events after adjusting for age, sex and Hgb level (p < 0.001). Conclusions: We showed there is significant association between ESA use and cerebrovascular events adjusting for hemoglobin level, age and sex. Even though there was association between Hgb level and cerebrovascular events in our preliminary data, after adjusting for ESA injections, there was no association between Hgb level and cerebrovascular events. This suggests less of an association between Hgb level and stroke than use of an ESA and stroke. Based on these results, we recommend considering iron replacement and blood transfusion in the treatment of anemia and CKD. More studies should be done to establish possible causation and pathophysiology between ESA injections and cerebrovascular agents which may include evaluating for any dose related association.