Myocardial performance index (Tei index)

Myocardial performance index (Tei index)

•        Estimates combined systolic and diastolic function of heart following myocardial infarction, congestive heart failure or cardiomyopathy.
•        Doppler derived time interval index used for both ventricles.
•        Myocardial performance index is calculated as:

    (Isoventricular contraction time + isoventricular relaxation time) / Ejection time

•        Mean normal values for left ventricle: 0.39+/- 0.05 and mean normal values for right ventricle: 0.28+/- 0.04 (Values of <0.40 for LV and <0.30 for RV are considered normal)
•       Higher values correspond to overall cardiac dysfunction.

ECG in infants

ECG in infants

  Prenatal right ventricular dominance causes

1             .     R in lead V1

2             .     Right axis deviation in limb leads

3             .     T wave inversion in V1

 Features of right ventricular dominance regress over time and are replaced by left ventricular    dominance which leads to appearance of small q waves in lateral leads (V5 and V6) in the adolescence.

Invasive fungal infections and treatment (Simplified for residents)

Invasive fungal infections and treatment (Simplified for residents)

Antifungals: AEFA; Azoles, Echinocandins (Capsofungin, Micafungin and Anidulafungin), Flucytocine, Amphotericin B (Including Liposomal preparations)

Fungal infections: CA-CHM; Candida, Aspergillus, Cryptococcus, Histoplasmosis, Mucormycosis

Table		Antifungal agents
Fungal infections		Azoles	Echinocandins	Flucytocine	Amphotericin B
	Candida	+	+	+	+
	Aspergillus	-	+	-	+
	Cryptococcus	Fluconazole	-	+	+
	Histoplasmosis	Itraconazole	-	-	+
	Mucormycosis	Posaconazole	-	-	+

Candida albicans is sensitive to Fluconazole as well newer azoles (Posaconazole, Itraconazole and Voriconazole).

Non albicans candida (Candida glabrata and krusei) is not sensitive to Fluconazole but is effectively controlled by newer azoles such as Posaconazole, Itraconazole and Voriconazole.

Similarly Aspergillus is not sensitive to Fluconazole but newer azoles are effective against it (Posaconazole, Itraconazole and Voriconazole).

Flucytosine is effective against all candida and Cryptococci but not against aspergillus.

Posaconazole and Amphotericin B are effective against all fungi.  

You can also download the pdf file (https://drive.google.com/open?id=0B7fMzOzGc51UYUpvOVJDQVhlSm8) or the text file (https://drive.google.com/file/d/0B7fMzOzGc51ULVZ3dllUS2h4dG8/view?usp=sharing) from these links.

Comments and suggestions are welcomed.

Felty's syndrome- Infections in rheumatoid arthritis

Felty's syndrome is characterised by triad of rheumatoid arthritis, splenomegaly and neutropenia. There is a risk of recurrent infections due to neutropenia. Patient may also have anemia and thrombocytopenia because of hypersplenism. Best treatment for Felty's syndrome is to control underlying rheumatoid disease.

Patient with deforming RA found to have splenomegaly

Moyamoya disease- An uncommon cause of stroke

Moyamoya disease is a progressive, occlusive disease of the cerebral vessels with particular involvement of the circle of Willis and the arteries that form it. Collateral vessels develops around the blocked artery to compensate for the blockage, but the collateral vessels are small, weak, and prone to hemorrhage, aneurysm and thrombosis. On conventional X-ray angiography, these collateral vessels have the appearance of a "puff of smoke" for which it is named as Moyamoya (Moyamoya is term for puff of smoke in japanese). It can present as migraine type headache, recurrent transient ischemic attacks (TIAs), stroke or hemorrhage in the brain. Therapy is primarily directed at the complications of the disease.

Rich collaterals around the blocked artery giving the appearance of puff of smoke.

Gianotti-crosti syndrome : An atypical presentation of Hepatitis B virus infection

In children, Hepatitis B may present rarely with anicteric hepatitis, a non-pruritic papular rash on the face, buttocks and limbs, and lymphadenopathy. This is known as papular acrodermatitis of childhood or Gianotti- Crosti syndrome.  Likely pathogenesis for this condition is local type IV hypersensitivity reaction to offending viral antigen within the dermis. It is more common among children with atopic dermatitis. With the advent of global HBV vaccination, EBV is now more common pathogen for this uncommon disorder. It is a benign self limited condition which requires no treatment.

Child with acute hepatitis B infection with non pruritic papular rash

Lump in epigastrium

57 years old male chronic alcoholic for last 30 years presented with c/o pain abdomen, vomiting for last 20 days. Pain abdomen was constant dull aching mainly in epigastric region. Vomiting used to occur just after intake of meal and it did not contain altered or fresh blood. He also had 1 episode of melena 15 days back. Similar type of abdominal pain was present 1 year back for which he required hospitalisation for 4 days. On examination there was pallor, palpable diffuse lump in the epigastrium. There was no lymphadenopathy, icterus, cyanosis, hepatosplenomegaly. On evaluation he was found to have anemia (Hb-7.2), large pseudocyst (22 cms by 10 cms) in pancreas compressing the stomach from posterior side as seen in UGI endoscopy. There was also a duodenal ulcer in D1. A diagnosis of acute on chronic pancreatitis complicated by pseudocyst formation, etiology being alcohol, was made. For duodenal ulcer he we started on proton pump inhibitors in double strength. He also received i/v fluids, analgesics and anti-emetics. Liver function and renal function tests were normal. CECT abdomen showed hyperdense content in the pancreatic pseudocyst causing cyst in cyst appearance so possibility of pseudoaneurysmal bleed was kept, but CT angiogram did not reveal any sign of pseudoaneurysm. He received 3 units of blood transfusion in the hospital following which his haemoglobin raised from 7.2 to 9.7. Then cystogastrostomy was done for the drainage of large cyst which was eminent to rupture. Patient recovered uneventfully thereafter.

TAKE HOME MESSAGE-

1.  Most common cause of acute pancreatitis is Gall stone and of chronic pancreatitis is alcohol.

2.  Incidence of pseudocyst in acute pancreatitis varies from 5% to 20%.

3.  Pseudoaneurysm formation and subsequent rupture is one of the fearsome complication.

4.  Endoscopic drainage is effective method of management of pancreatic pseudocyst. Most commonly used technique is gastrocystostomy which is performed endoscopically.