Knowledge, Attitude, and Practice regarding Anaphylaxis among Pediatric Health Care Providers in a Teaching Hospital

Anaphylaxis is a severe, life threatening generalized or systemic hypersensitivity reaction which requires prompt, accurate diagnosis, and appropriate management. The objective of the study is to assess the extent of knowledge, management skills, and attitude on anaphylaxis among pediatric health care providers of a tertiary care teaching hospital. This was a cross-sectional study done in the department of pediatrics, which included faculty, residents, interns, and nurses. The knowledge, attitude, and practice were assessed using a standardized questionnaire comprised of 35 questions. The questionnaire was distributed and collected in person to all the participants. Informed consent was obtained from all participants and confidentiality was ensured at all stages. Collected data were analyzed using SPSS version 20. The mean of total knowledge score (TKS) was 7.36 ± 1.42. TKS of faculty was 8.36 ± 1.15, in residents 7.81 ± 1.25, in interns 7.46 ± 1.15, and in nurses 6.69 ± 1.57. Knowledge scores of faculty, residents, and interns were significantly higher than that of nurses while there was no significant difference between faculty, residents, and interns. The majority of participants have positive attitude toward anaphylaxis. Incorrect practice is followed by most of the participants. The extent of knowledge about anaphylaxis among pediatric health care providers is moderate but management skills remains suboptimal. Thus, proper training, through continued medical educations and programs to improve abilities to recognize and manage anaphylaxis are very crucial. Differential approach may be followed to different groups; nurses need extra training for optimal management of anaphylaxis.

A Rare Case of Podophyllin Poisoning: Early Intervention is Lifesaving

Accidental poisoning in children is very common, making up 10.9% of all unintentional injuries worldwide. Africa has the highest incidence of fatal poisonings worldwide, at 4 per 100,000. Poisoning with podophyllin is rare, with most cases documented around the 1970s to 1980s. Podophyllin is a resin mixture obtained from the dried Rhizome and roots of Podophyllin peltatum (North America) and Podopyllin emodi (India). Podophyllotoxin is the most toxic chemical present in the podophyllin, which is lipid soluble; so crosses the cell membrane easily and inhibits mitotic spindle formation. Both topical application and oral consumption can cause podophyllin poisoning. Neurotoxicity is the most serious effect along with bone marrow depression, gastrointestinal irritation, and hepatic and renal dysfunction. Management of podophyllin toxicity is mainly symptomatic, and no specific antidote exists. We report a case of a 2-year-old-year girl with accidental podophyllin poisoning, who presented with neurotoxicity followed by multiorgan dysfunction and then succumbed. Education of parents and healthcare workers on home safety still remains the mainstay of prevention. How to cite this article: Jain MK, Patnaik S, Rup AR, Gaurav A. A Rare Case of Podophyllin Poisoning: Early Intervention is Lifesaving. Indian J Crit Care Med 2020;24(6):477-479.

Seizure as a Presentation of Permanent Neonatal Diabetes Mellitus due to Mutation in KCNJ11 Gene: A Case Report

Diabetes Mellitus in first six months of life is usually monogenic and is referred to as neonatal diabetes mellitus. The incidence of neonatal diabetes is extremely rare and varies from 1:89000 to 1:400000 live births. We report a two months old baby presenting with repeated seizures; on evaluation found to have diabetic ketoacidosis and initially managed with IV insulin infusion. Genetic study revealed heterozygous mutation, p. Valin 252 Leu in KCNJ 11 gene. This mutation suggests responsiveness to oral glibenclamide. The baby has responded to therapy. Seizure as a presenting feature for hyperglycemia is a rare entity

COVID-19 in Children: Present and Future Perspective, An Interim Review

Coronavirus disease 2019 (COVID-19) pandemic has affected millions of people worldwide. However, the mechanism by which the pathogen affects children is not understood completely. Children so far accounted for only1 to 6.4% of diagnosed cases and the mortality rate is also less. Though clinical findings are similar to adults, with fever and respiratory symptoms being prevalent, fewer numbers of children appear to develop severe pneumonia. Observed attenuated response to the virus may possibly be due to decrease in the expression of the angiotensin-converting enzyme 2 receptor in lungs, repeated viral exposure, and not having any underlying chronic diseases or immunosuppression. Suggested treatment included oxygen supplementation, mechanical ventilation in severe cases, nutritional support, and maintaining fluids and electrolyte balances. Although, no definitive pharmacological therapy is available, various combination of drugs like hydroxychloroquine, lopinavir/ritonavir, remdesivir, tocilizumab, and convalescent serum show promising result to an extent. As there is no specific therapeutic measure for this ailment, aggressive efforts are being made to develop a potential vaccine against the disease. Although few reports on epidemiology of COVID-19 in children have been published, comprehensive reports are lacking. The present article reviews on important issues such as epidemiological characteristics, postulations of milder disease, therapeutic aspect, and recent development of vaccination against COVID-19 in children.

Breakdown of Ohm's law and nontrivial Berry phase in magnetic Weyl semimetal Co3Sn2S2

The concept of realization of Weyl points close to the Fermi level in materials with broken time-reversal symmetry has significant theoretical and technological ramifications. Here, we review the investigation of magneto-transport measurements in single crystals of magnetic Weyl semimetal Co3Sn2S2. We see a turn-on like behaviour followed by saturation in resistivity under magnetic field in the low temperature region which is allocated to the topological surface states. A non-saturating magnetoresistance, linear at high fields, is observed at low temperatures where applied magnetic field is transverse to the current direction. The linear negative magnetoresistance at low magnetic fields (B< 0.1 T) provides evidence for time reversal symmetry breaking in Co3Sn2S2. Chiral anomaly in Weyl metallic state in Co3Sn2S2is confirmed from the breakdown of Ohm's law in the electronic transport. Shubnikov de Haas (SdH) oscillation measurement has unveiled the multiple sub-bands on the Fermi surface that corresponds to a non-trivial Berry phase. The non-linear behaviour in Hall resistivity validates the existence of two type of charge carriers with equal electron and hole densities. Strong temperature dependence of carrier mobilities reflects the systematic violation of Kohler's rule in Co3Sn2S2. Our findings open avenues to study kagome-lattice based magnetic Weyl semimetals that unfurl the basic topological aspects leading to significant ramification for spintronics.

Experimental system for studying temperature gradient-driven fracture of oxide nuclear fuel out of reactor

Temperature gradients in ceramic light water reactor (LWR) uranium dioxide (UO₂) nuclear fuel pellets generate thermal stresses that cause fractures in the fuel, which begins early in the life of fresh fuel. The combination of heating due to fission and forced convective cooling on the exterior of LWR fuel rods generates a temperature profile that is difficult to replicate outside the reactor environment. In this study, a state-of-the-art experimental setup using electrical heating to study certain aspects of temperature driven fracture was built, and surrogate fuel materials such as ceria (CeO₂) were used to validate the system. Cracking experiments were conducted on these surrogates by inducing reactivity-initiated-accident like temperature gradients in the pellets via induction and direct resistance heating. Induction heating was done using copper coils and molybdenum susceptors, which heated the surrogates to a threshold temperature that is sufficiently high for the fuel material to conduct current. Thereafter, direct resistance heating was achieved by passing current through the specimen using a DC power supply to introduce volumetric heating to replicate LWR operating conditions. The pellets were held against nickel electrodes and mounted on a boron nitride test-stand. All the tests were carried out in a stainless-steel vacuum chamber. Simultaneous real-time dual imaging of the surrogate pellet surface was implemented using an optical and infrared camera system that was mounted along axial and perpendicular directions to the pellet surface, respectively. A beam-splitter was used to split the incoming radiation from the sample into two halves. While one of the beams was transmitted from the splitter through a bandpass filter to obtain optical images, the other beam was reflected from the splitter to the thermal camera to capture full-field temperature gradients of the as-fabricated pellet surface during cracking. Some initial tests were conducted with a 2-color pyrometer that was later substituted with a forward-looking infrared thermal camera to capture the temperature profiles. A LabVIEW data acquisition system was set up for collecting useful data during experiments.

Validation of Modified Paediatric Triage Score in a Tertiary Care Hospital

Introduction: The global burden of paediatric mortality is high and majority of the deaths are preventable by providing timely access to specialised emergency care. An appropriate triage in a busy emergency department can identify the sickest patient for early intervention. Aim: To develop a simple score based on physical variables alone and assess its validation so as to predict Intensive Care Unit (ICU) admission. Materials and Methods: This prospective hospital based study included 936 children, aged 1 month to 18 years. Baseline demographic data along with clinical variables were noted in a pre-designed proforma at the time of admission. A scoring system was developed based on severity of various clinical variables i.e., heart rate, respiratory rate, respiratory effort, Oxygen Saturation (SpO2), Capillary Refill Time (CFT), temperature, level of consciousness and behaviour. The outcome i.e., admission to ward or Pediatric Intensive Care Unit (PICU) of the patient was correlated with the study variables and total score. An association of modified PETS with the PICU admission was done using Chi-square test. A p-value of <0.01 was considered as statistically significant. Results: The modified Paediatric Triage Score (PETS) which is developed based on eight physical variables, is reliable in discriminating the children with ward and ICU admission. A score of ≥6 leads to 14.8 times higher risk of getting admitted to ICU as compared to a child with score of <6. A cut-off of ≥6 for modified PETS score has a sensitivity of 79.6% and specificity of 79.2% in predicting ICU admission. Conclusion: This simple clinically developed scoring system based on physical variables alone with an optimal cut-off of ≥6 can predict severity of illness and need for PICU admission in Emergency Department with acceptable validity and can serve as a potentially excellent screening tool.

An intra-operative device for parallel drilling and femoral landmark estimation during medial patellofemoral ligament reconstructive surgery

ABSTRACT BACKGROUND: The aim of this study was to design and test a device to guide medial patellofemoral reconstruction surgeries. Materials and methods: A three-dimensional (3D) printed, modular and cost-effective medial patellofemoral ligament (MPFL) reconstruction guide, Pat-Rig, was designed with parallel holes running in the medio-lateral direction. This device was manufactured using a commercial additive manufacturing facility, and bench tested using a custom-built test rig. CT scans of patella bones were reconstructed, and the device was tested on four 3D-printed patellas of various sizes. RESULTS: The device was successful in guiding the surgical drill into the patella to drill parallel holes adhering to the current surgical requirements and specifications. The device was augmented with an innovative radiopaque scale which can allow the surgeon to accurately predict the landmarks to drill and measure the drill depth of the tunnels. CONCLUSION: There are no devices on the market that accurately predict the drill locations on the patella during MPFL reconstruction surgeries. The device, Pat-Rig, was found to overcome the current limitations of the MPFL surgeries and was able to provide satisfactory surgical guidance during the reconstruction. Level of evidence: Level 5 Keywords: knee surgery, patella, orthopaedic, MPFL reconstruction, 3D-printed, novel surgical device.

Demographic Profile and Outcome of Mechanically Ventilated Children in a Tertiary Care Hospital of a Developing Country

Introduction: The need for mechanical ventilation (MV) is an absolute indication for admission to Paediatric intensive care unit (PICU). Management of children requiring invasive ventilation in resource limited developing countries is challenging. Scare data is available from Asian countries regarding use of MV in PICUs. The objectives of this study were to determine the clinical profile, characteristics, common causes for ventilation, ventilation related complications and final outcome of these patients.Material and Methods: A retrospective study of children requiring ventilator support in PICU of Kalinga Institute of Medical Sciences from January 2014 to December 2016 was done. Data collected included epidemiological trends, indications for ventilation, complications, length of stay on ventilator and outcome.Results: A total of 1172 patients were admitted to PICU, 101 (8.6%) patients required MV. 42% of the mechanically ventilated patients were infants and 75% were males. Impending respiratory failure (34.6%) and low Glasgow coma scale (17.8%) were the commonest indication for ventilation in this study. The median length of MV was 2.1 days. The mortality rate of these children was 38.6%. We report the epidemiological trends, frequency, indications and outcomes of children requiring ventilator support in PICU. Analysis of this data can be helpful in improving outcome in future by planning better treatment strategies.Conclusion: The frequency of MV in our PICU is low. Respiratory failure was the most common reason for mechanical ventilation.  

Dilemmas and Challenges in Treating Seronegative Autoimmune Encephalitis in Indian Children

Objective:

The main objective is to assess the challenges in diagnosis and treatment while managing seronegative cases of autoimmune encephalitis (AIE) in Indian children.

Methods:

A cohort study of patients with AIE was done where clinical presentations, investigations, management were analyzed and these patients were followed up to assess the evolution of the disease.

Results:

Nine patients were included in the study. Four patients presented with super-refractory status epilepticus (SRSE). Other presentations were behavioral change, hemiplegia, and autonomic dysfunction. Initial magnetic resonance imaging brain was suggestive of AIE in two patients. Only two were seropositive for cerebrospinal fluid (CSF) autoimmune panel. Five patients responded to the first-line immunotherapy and four required the second-line immunotherapy.

Conclusion:

The possibility of autoimmune encephalitis should be considered in patients with super-refractory status epilepticus. A large proportion of children with suspected AE may be “seronegative.” A trial of immunotherapy should be given to these children when there is a strong clinical suspicion of autoimmune encephalitis even in the absence of cerebrospinal fluid autoantibodies.

Curcumin loading potentiates the chemotherapeutic efficacy of selenium nanoparticles in HCT116 cells and Ehrlich's ascites carcinoma bearing mice

The anticancer properties of selenium (Se) and curcumin nanoparticles in solo formulations as well as in combination with other therapeutic agents have been proved time and again. Exploiting this facet of the two, we clubbed their tumoricidal characteristics and designed curcumin loaded Se nanoparticles (Se-CurNPs) to achieve an enhanced therapeutic effect. We evaluated their therapeutic effects on different cancer cell lines and Ehrlich's ascites carcinoma mouse model. In vitro results showed that Se-CurNPs were most effective on colorectal carcinoma cells (HCT116) compared to the other cancer cell lines used and possessed pleiotropic anticancer effects. The therapeutic effect on HCT116 was primarily attributed to an elevated level of autophagy and apoptosis as evident from significant up-regulation of autophagy associated (LC3B-II) and pro-apoptotic (Bax) proteins, down-regulation of anti-apoptotic (Bcl-2) protein and Cytochrome c (cyt c) release from mitochondria along with reduced NFκB signaling and EMT based machineries marked by downregulation of inflammation (NFκB, phospho-NFκB) and epithelial-mesenchymal transition (CD44, N-cadherin) associated proteins. In vivo studies on Ehrlich's ascites carcinoma (EAC) mice model indicated that Se-CurNPs significantly reduced the tumor load and enhanced the mean survival time (days) of tumor-bearing EAC mice.

Antimicrobial assay and genetic screening of selected freshwater Cyanobacteria and identification of a biomolecule dihydro-2H-pyran-2-one derivative

AIMS

Explorations of freshwater Cyanobacteria as antimicrobial (bacteria, fungi and methicillin-resistant Staphylococcus aureus (MRSA) strains) drug resource using bioassay, NRPS (non-ribosomal polypeptide synthetase) and PKS (polyketide synthase) genes, as well as in silico approach.

METHODS AND RESULTS

We have bioassayed the extracts of Phormidium CCC727, Geitlerinema CCC728, Arthrospira CCC729, Leptolyngbya CCC732, Phormidium CCC730, Phormidium CCC731 against six pathogenic bacteria comprising Gram (+ve): S. aureus including seven clinical MRSA and Enterococcus faecalis, Gram (-ve): Escherichia coli, Salmonella Typhimurium, Klebsiella pneumoniae and Shigella boydii along with non-pathogenic Enterobacter aerogenes as well as fungal strains (Cryptococcus neoformans and Candida albicans, C. krusei, C. tropicalis and Aspergillus niger) exhibiting antimicrobial potential. The NRPS and PKS genes of the target strains were also amplified and sequenced. The putative protein structures were predicted using bioinformatics approach.

CONCLUSION

PKS gene expression indicated β keto-acyl synthase as one of the important active domains in the biomolecules related to antitumour and antifungal group. The simultaneous identification of the biomolecule (dihydro-2H-pyran-2-one derivative) was also inferred spectroscopically.

SIGNIFICANCE AND IMPACT OF THE STUDY

Freshwater Cyanobacteria are prolific producers of secondary metabolite(s) that may act as the antimicrobial drug resource in addition to their much explored marine counterpart.

Ask-Upmark kidney: Renovascular hypertension in a child; A case report

Ask-Upmark Kidney is a rare disease complex which is characterised by segmental renal hypoplasia and is usually associated with hypertension. We report the clinical, laboratory and radiological features of a case, which was managed effectively with antihypertensive drugs. Pathological examination of kidney revealed features consistent with AskUpmark Kidney.

Effect of pressure on superconductivity in the indium-doped topological crystalline insulator SnTe

We report on the impact of hydrostatic pressure on the superconductivity of optimally (indium)-doped SnTe which is established to be derived from a topological crystalline insulating phase. Single crystals of Sn(1-x)In(x)Te were synthesized by a modified Bridgman method that exhibited maximum superconducting Tc of 4.4 K for x = 0.5. Hydrostatic pressure up to 2.5 GPa was applied on the crystals of Sn0.5In0.5Te, and electrical resistivity as a function of temperature and pressure was measured. We observed a decrease in the onset superconducting transition temperature from 4.4 K to 2.8 K on increasing pressure from ambient to 2.5 GPa. The normal state resistivity also decreased abruptly by an order of magnitude at 0.5 GPa but for higher pressures, it decreased marginally. From onset, offset and zero resistivity values, dTc/dP of ∼ -0.6 K GPa(-1) was confirmed. The low temperature normal state resistivity followed T(2) dependence suggesting Fermi liquid behaviour both for ambient and high pressure data. This increase in metallic characteristics accompanied by normal state Fermi liquid behaviour is in accordance with a 'dome structure' for Tc variation with varying carrier concentration.

Methylene blue unresponsive methemoglobinemia

Acquired methemoglobinemia is an uncommon blood disorder induced by exposure to certain oxidizing agents and drugs. Although parents may not give any history of toxin ingestion; with the aid of pulse-oximetry and blood gas analysis, we can diagnose methemoglobinemia. Prompt recognition of this condition is required in emergency situations to institute early methylene blue therapy. We report an unusual case of severe toxic methemoglobinemia, which did not respond to methylene blue, but was successfully managed with exchange transfusion.

Evidence for fully gapped strong coupling s-wave superconductivity in Bi4O4S3

We report on the superconducting gap and pairing symmetry in the layered superconductor Bi4O4S3. The measurement of temperature dependence of magnetic penetration depth was carried out using the tunnel diode oscillator technique. It is observed that Bi4O4S3 is a conventional s-wave type superconductor with a fully developed gap. The zero-temperature value of the superconducting energy gap Δ0 was found to be 1.54 meV, corresponding to the ratio 2Δ0/k(B)T(c) = 7.2 which is much higher than the BCS value of 3.53. In the superconducting range, superfluid density is very well described by the single gap s-wave model.