Abstract Platypnea-Orthodeoxia syndrome (POS) is a rare clinical entity characterized by dyspnea and arterial desaturation while in the upright position. The various pathophysiologic mechanisms ...leading to POS has puzzled clinicians for years. The hypoxia in POS has been attributed to the mixing of the deoxygenated venous blood with the oxygenated arterial blood via a shunt. The primary mechanisms of POS in these patients can be broadly classified based on intracardiac abnormalities, extracardiac abnormalities and miscellaneous etiologies. A Patent Foramen Ovale (PFO) was the most common reported site of an intracardiac shunt. In addition to PFO, intracardiac shunt leading to POS has been reported from either an Atrial Septal Defect (ASD) or an Atrial Septal Aneurysm (ASA). Most patients with an intracardiac shunt also demonstrated a secondary anatomic or a functional defect. Extracardiac causes of POS included intra-pulmonary arteriovenous malformations and lung parenchymal diseases. A systematic evaluation is necessary to identify the underlying cause and institute an appropriate intervention. We conducted a review of literature and reviewed 239 cases of POS. In this article, we review the etiology and pathophysiology of POS and also summarize the diagnostic algorithms and treatment modalities available for early diagnosis and prompt treatment of patients presenting with symptoms of platypnea and/or orthodeoxia.
Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes. It is characterised by the triad of hyperglycemia (blood sugar >250 mg/dl), metabolic acidosis (arterial pH <7.3 and ...serum bicarbonate <18 mEq/L) and ketosis. Rarely these patients can present with blood glucose (BG) levels of less than 200 mg/dl, which is defined as euglycemic DKA. The possible etiology of euglycemic DKA includes the recent use of insulin, decreased caloric intake, heavy alcohol consumption, chronic liver disease and glycogen storage disorders. DKA in pregnancy has also been reported to present with euglycemia. The recent use of sodium glucose cotransporter 2 (SGLT2) inhibitors has shed light on another possible mechanism of euglycemic DKA. Clinicians may also be misled by the presence of pseudonormoglycemia.
Euglycemic DKA thus poses a challenge to physicians, as patients presenting with normal BG levels in ketoacidosis may be overlooked, leading to a delay in appropriate management strategies. In this article, we review all the possible etiologies and the associated pathophysiology of patients presenting with euglycemic DKA. We also discuss the approach to diagnosis and management of such patients. Despite euglycemia, ketoacidosis in diabetic patients remains a medical emergency and must be treated in a quick and appropriate manner.
Background Anastomotic leak, a potentially deadly postoperative occurrence, particularly interests surgeons performing gastrointestinal procedures. We investigated incidence, cost, and impact on ...survival of anastomotic leak in gastrointestinal surgical procedures at an academic center. Study Design We conducted a chart review of American College of Surgeons NSQIP operative procedures with gastrointestinal anastomosis from January 1, 2003 through April 30, 2006. Each case with an American College of Surgeons NSQIP 30-day postoperative complication was systematically reviewed for evidence of anastomotic leak for 12 months after the operative date. We tracked patients for up to 10 years to determine survival. Morbidity, mortality, and cost for patients with gastrointestinal anastomotic leaks were compared with patients with anastomoses that remained intact. Results Unadjusted analyses revealed significant differences between patients who had anastomotic leaks develop and those who did not: morbidity (98.0% vs 28.4%; p < 0.0001), length of stay (13 vs 5 days; p ≤ 0.0001), 30-day mortality (8.4% vs 2.5%; p < 0.0001), long-term mortality (36.4% vs 20.0%; p ≤ 0.0001), and hospital costs (chi-square 2 = 359.8; p < 0.0001). Multivariable regression demonstrated that anastomotic leak was associated with congestive heart failure (odds ratio OR = 31.5; 95% CI, 2.6–381.4; p = 0.007), peripheral vascular disease (OR = 4.6; 95% CI, 1.0–20.5; p = 0.048), alcohol abuse (OR = 3.7; 95% CI, 1.6–8.3; p = 0.002), steroid use (OR = 2.3; 95% CI: 1.1–5.0; p = 0.027), abnormal sodium (OR = 0.4; 95% CI, 0.2–0.7; p = 0.002), weight loss (OR = 0.2; 95% CI, 0.06–0.7; p = 0.011), and location of anastomosis: rectum (OR = 14.0; 95% CI, 2.6–75.5; p = 0.002), esophagus (OR = 13.0; 95% CI, 3.6–46.2; p < 0.0001), pancreas (OR = 12.4; 95% CI, 3.3–46.2; p < 0.0001), small intestine (OR = 6.9; 95% CI, 1.8–26.4; p = 0.005), and colon (OR = 5.2; 95% CI, 1.5–17.7; p = 0.009). Conclusions Significant morbidity, mortality, and cost accompany gastrointestinal anastomotic leaks. Patients who experience an anastomotic leak have lower rates of survival at 30 days and long term.
Pulmonary artery aneurysm is a rare but important entity in the spectrum of pulmonary vascular diseases. The etiologies can be varied and patients can present with non-specific symptoms with the ...diagnosis being incidental. There is limited consensus regarding the diagnostic criteria and follow-up imaging for patients diagnosed with this entity. Further the management strategies can be variable depending upon underlying disease, etiology, center dependent expertise, and resources available. We review the etiologies, epidemiology, classification, clinical manifestations, and imaging features of pulmonary artery aneurysm. We also review the current management strategies and suggest an algorithmic approach to these patients.
Tuberculous pleural effusion (TPE) is the second most common presentation of extrapulmonary tuberculosis. The paucibacillary nature of the effusion poses diagnostic challenges. Biomarkers like ...adenosine deaminase and interferon-γ have some utility for diagnosing TPEs, as do cartridge-based polymerase chain reaction (PCR) methods. When these fluid studies remain indeterminate, pleural biopsies must be performed to confirm the diagnosis. This review article elaborates on the scientific evidence available for various diagnostic tests and presents a practical approach to the diagnosis of TPEs.
•Less than 10% of tuberculous pleural effusions (TPE) are AFB positive.•Bedside inoculation and liquid media cultures of TPE have a yield of about 45%.•Typical sensitivity (SE) and specificity (SP) for ADA is 0.9 and 0.9, respectively.•Reported sensitivity for Xpert Ultra PCR on TPE is low (0.38–0.75).•If clinical suspicion is high, a pleuroscopy (∼100% SE/SP) has to be performed.
Facial expression recognition is a challenging problem in image classification. Recently, the use of deep learning is gaining importance in image classification. This has led to increased efforts in ...solving the problem of facial expression recognition using convolutional neural networks (CNNs). A significant challenge in deep learning is to design a network architecture that is simple and effective. A simple architecture is fast to train and easy to implement. An effective architecture achieves good accuracy on the test data. CNN architectures are black boxes to us. VGGNet, AlexNet and Inception are well-known CNN architectures. These architectures have strongly influenced CNN model designs for new datasets. Almost all CNN models known to achieve high accuracy on facial expression recognition problem are influenced by these architectures. This work tries to overcome this limitation by using FER-2013 dataset as starting point to design new CNN models. In this work, the effect of CNN parameters namely kernel size and number of filters on the classification accuracy is investigated using FER-2013 dataset. Our major contribution is a thorough evaluation of different kernel sizes and number of filters to propose two novel CNN architectures which achieve a human-like accuracy of 65% (Goodfellow et al. in: Neural information processing, Springer, Berlin, pp 117–124,
2013
) on FER-2013 dataset. These architectures can serve as a basis for standardization of the base model for the much inquired FER-2013 dataset.
Coronavirus Disease-2019 (COVID-19) pandemic has been especially hard for children and adolescent’s mental health due to their inherent vulnerabilities and added stress of lockdown, mobility ...restrictions, school closure, absence of peer interaction. This case report highlights the unmasking of obsessive compulsive symptoms due to the COVID-19 pandemic stress and the role of inherent vulnerabilities in a 11-year-old female. The management of the index case emphasised upon age appropriate strategies for intervention. Although, Obsessive Compulsive Disorders (OCD) is not a stress disorder per se but the index case highlights the role of stress in manifestation of mental illness in vulnerable individuals favouring the biopsychosocial model for mental illness.
Abstract Urothelial carcinoma (Transitional cell carcinoma) of the bladder is the pre-dominant histological type of bladder cancer in the United States and Europe. Patients with bladder cancer ...usually present with painless hematuria. The diagnosis is often delayed, as the symptoms are similar to various other benign conditions such as urinary tract infection, prostatitis or renal calculi. In some patients, the metastatic lesions will cause the initial presenting symptoms. We conducted a MedLine/PubMED search identifying all relevant articles with “pulmonary manifestations”, “urothelial bladder cancer”, “manifestations of bladder cancer” or a combination of these terms in the title. The pulmonary manifestations of urothelial carcinoma of the bladder include metastatic disease including cavitary lesions, endobronchial, pleural, or lymph node metastasis pleural effusion and chylothorax. Pulmonary embolism and tumor embolism is another manifestation of this cancer. Intravesical Bacillus Calmette-Gurin therapy for bladder cancer has been associated with a range of adverse effects including the systemic spread of Bacilli Calmette-Guérin immunotherapy affecting the lungs. Other drugs used to treat bladder cancer can be associated with drug-related pneumonitis. Other rare manifestations include a sarcoid like reaction and systemic granulomatous disease to Bacilli Calmette-Guérin therapy. In this review we discuss the various pulmonary manifestations of urothelial carcinoma of the bladder. A high index of suspicion with these presentations can lead to an early diagnosis and assist in instituting an appropriate intervention.
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