Sternal tuberculosis

Extra-pulmonary tuberculosis constitutes 15-20% of total tuberculosis (TB) case load in immuno-competent patients. Affliction of the skeletal system is rare with still rarer presentation of sternal osteomyelitis even in endemic countries. A patient with primary sternal TB presenting with multiple cutaneous sinuses over the anterior chest wall is being reported. A high element of suspicion is needed more so in resource limited setting for early diagnosis and treatment.

Comparative Analysis of Birth Weight in a Hospital Over a Decade: Low Birth Weight Still a Major Problem

Introduction: The objective of this study was to compare the magnitude of birth weight and proportion of low birth weight in a hospital over a decade. Materials and Methods: A descriptive study was undertaken in a public funded hospital catering to rural and urban population of northern India. Pertinent information was collected for all intramural singleton births using structured proforma for a sample period in a calendar year. For comparison purpose birth data was extracted from log books for the corresponding period of previous decade also. Data management was done using MS excel sheet and analysis carried out by computing descriptive statistics using software statistical package. Results: The mean (2568 + 596.7 gm) & median (2600 gm) birthweight recorded for 2011 was low in-comparison to 2657 + 581.7gm (2750 gm) for 2001. The prevalence of low birth weight (LBW) was 36.1% (2011) in comparison to 30.5% (2001) and the state of deterioration was found to be statistically significant (p<0.001). Higher proportion of LBW birth was observed amongst un-booked ANC, pre-term, anemic mothers and whose residence was from outside the district of location of study institute (<0.001). Statistically significant (<0.001) and higher perinatal mortality was noticed in LBW neonates. Rising level of maternal education was protective against LBW. Mothers with their first pregnancy gave higher proportion of LBW births in comparison to mothers with higher gravida status (<0.001). DOI: http://dx.doi.org/10.3126/jnps.v33i1.6176 J Nepal Paediatr Soc. 2013;33(1):15-20.

Evolution of interventions for complex coronary lesions

The exponential growth of percutaneous coronary intervention (PCI) has in large part been due to expansion of the indications to include the procedure in patients with extensive coronary disease, multiple risk factors, older age and comorbidities. Improvement in PCI equipment, development of new interventional techniques, and availability of myocardial and systemic support techniques have all contributed to this growth. With these advances, patients once considered high risk for PCI are no longer considered high risk. This article reviews the complex coronary lesions challenges, various interventional and pharmacologic strategies for optimal results and novel technology.

Preliminary survey of leptospirosis amongst febrile patients from urban slums of East Delhi

AIM

To determine the possibility of leptospirosis among patients from urban slums presenting with febrile illness during monsoon and post-monsoon season.

METHODS

Evidence of leptospirosis in 180 patients with febrile illness was determined by looking for presence of immunoglobulin M (IgM) antibodies by leptospiral IgM enzyme linked immunosorbent assay (ELISA). The test was carried out on 160 Widal test negative and 20 Widal test positive sera received from febrile patients during June to September 2001.

RESULTS

Twenty-seven out of 180 (15%) sera were positive for leptospiral IgM antibodies.

CONCLUSIONS

This preliminary survey indicates that leptospirosis could be an important cause of febrile illness in patients from urban slums during monsoon and post-monsoon season.

Outcome in children receiving continuous venovenous hemofiltration

OBJECTIVE

Continuous venovenous hemofiltration (CVVH) alone or with dialysis (D) has become an important supportive therapy for critically ill children with acute renal failure. Previous reports of pediatric patient outcome either mix CVVH/D with other renal replacement modalities or do not examine severity of illness. The current study examines only outcomes of children receiving CVVH/D using Pediatric Risk of Mortality (PRISM) scores to control for severity of illness.

PATIENTS

Twenty-one patients (mean age: 8.8 +/- 6.3 years; mean weight: 28.3 +/- 20.8 kg) received 22 courses of CVVH/D.

OUTCOMES

Nine (42.8%) of 21 patients survived. Nine (75%) of 12 deaths occurred within 25 days of pediatric intensive care unit (PICU) admission. Mean PRISM score at PICU admission and CVVH initiation were 13.1 +/- 5.8 and 15.4 +/- 8.9, respectively. Mean patient weight, age, PRISM score at PICU admission and at CVVH/D initiation, maximum pressor number, estimated glomerular filtration rate at CVVH/D initiation and change in mean airway pressure did not differ between survivors and nonsurvivors. The degree of fluid overload at CVVH/D initiation was significantly lower in survivors (16.4% +/- 13.8%) compared with nonsurvivors (34.0% +/- 21.0%), even when controlled for severity of illness by PRISM score. Mean cost of providing CVVH/D accounted for only 1% of total PICU cost per patient.

CONCLUSIONS

The pattern of early multiorgan system failure and death, minimal relative cost of CVVH/D provision, and potential for improved outcome with initiation of CVVH/D at lesser degrees of fluid overload are factors that may support early initiation of CVVH/D in critically ill children with acute renal failure.

Multiple aortic thrombi associated with protein C and S deficiency

We describe a woman with an unusual case of thromboembolism of the mesenteric artery in whom multiple thrombi were subsequently found in the aorta and right heart chambers on transesophageal echocardiography. Further evaluation revealed a deficiency of protein C and S plasma proteins, inhibitors of the clotting system. The patient was treated successfully with systemic anticoagulation. Aortic thrombus is common in the setting of underlying atherosclerosis. However, the association of aortic thrombus with a deficiency of protein C and S is rare. To our knowledge, this is the first reported case of mural thrombus of the thoracic aorta associated with combined protein C and S deficiency. Our report underscores the important role of transesophageal echocardiography in the evaluation of patients with arterial thromboembolism.

Factors affecting longevity of homograft valves used in right ventricular outflow tract reconstruction for congenital heart disease

BACKGROUND

Few studies have explored the long-term function of cryopreserved homograft valves used for reconstruction of the right ventricular tract (RVOT) in patients with congenital heart disease.

METHODS AND RESULTS

Among 205 patients receiving cryopreserved homografts for reconstruction of the RVOT between November 1985 and April 1999, the outcome of 220 homografts in 183 operative survivors was analyzed. There were 150 pulmonary and 70 aortic homografts used. Median age at implantation was 4.4 years (mean 6.9+/-7.6 years, range 3 days to 48 years). End points included (1) patient survival, (2) homograft failure (valve explant or late death), and (3) homograft dysfunction (homograft insufficiency or homograft stenosis). Survival was 88% at 10 years. Freedom from homograft failure was 74+/-4% at 5 years and 54+/-7% at 10 years. Univariable analysis identified younger age, longer donor warm ischemic time, valve Z: value <2, and previous procedure as risk factors for homograft failure and dysfunction. Aortic homograft type and extracardiac operative technique predicted homograft failure but not dysfunction. For patients </=1 year of age, valve type did not predict failure or dysfunction. Multivariable analysis identified younger age and longer donor warm ischemic time as risk factors for homograft failure and dysfunction, whereas, Z: value <2 and aortic valve type predicted homograft valve failure.

CONCLUSIONS

Homograft valves used for RVOT reconstruction provide effective intermediate palliation with excellent late survival. Factors that adversely affect graft longevity include younger age, longer donor warm ischemic time, smaller homograft size, use of aortic homograft in the older patient, and extracardiac operative technique.

Relationship between Af temperature and load changes in Ni-Ti orthodontic wire under different thermomechanical conditions

Simple three point bending tests were performed on Ni-Ti wires with three different Af points (1 degree C, 13 degrees C and 34 degrees C) to clarify the relationship between Af temperature and load changes under constant deformation. Each wire was deformed at 37 degrees C and then thermal changes were imposed by temperatures of 2 degrees C or 60 degrees C. The load changes with thermal changes from 37 degrees C to 2 degrees C or 60 degrees C showed the same tendency on the wires with different Af points: In the loading stage, the load became lower than the initial level at 37 degrees C and in the unloading stage, the load became higher than the initial load. The largest load change in the unloading stage was measured with the 13 degrees C Af point wire. Care must be taken when handling Ni-Ti wire with an Af point of less than 1 degree C in order to prevent it from reaching the limit of critical stress of slip deformation when the temperature in the mouth rises to above 40 degrees C.

Health status of children with special health care needs: measurement issues and instruments

The methods for measuring health care outcomes and monitoring the health status of the child with a chronic health condition must be available, accessible, and meaningful. This review was evoked by this need to identify reliable and valid instruments for measuring the health status of children with special health care needs. The objectives are as follows: (1) to review the methodologic and substantive issues related to the selection of instruments and (2) to identify those instruments available currently for collecting data regarding health status of children with special health care needs. A Medline search of the literature published since 1966 through 1998 and restricted to human subjects and the English language was conducted. Indexing terms included health status, quality of life, outcome assessment, functional status, and patient satisfaction. Multiple reviewers selected instruments based on their usefulness in clinical settings as generic, disease nonspecific, child health status instruments. Few instruments were identified that can be used by pediatricians for tracking and monitoring the health status of children with special health care needs. In conclusion, to progress in the field of outcomes measurement of children with special health care needs, it will be necessary to develop new measurement tools. These instruments must (1) provide valid and reliable information on health status; (2) be useful in guiding the management of patients; and (3) not be a burden for physicians, patients, or patient's families.

Evaluation of a real-time blood glucose monitor in children with diabetic ketoacidosis

Use of a real-time bedside glucose monitor was analyzed during the course of management of diabetic ketoacidosis (DKA) in children. Simultaneous determinations of blood glucose were obtained, using three methods: bedside glucose meter (One Touch II), laboratory glucose analyzer (YSI 2300 STAT), and a real-time bedside glucose monitor (VIA 1-01G Blood Chemistry monitor). Study patients included seventeen patients < 18 years of age admitted to a Pediatric Intensive Care Unit, with blood samples obtained during treatment of DKA by continuous insulin infusion. Four patients did not complete the study. Three experienced temporary technical problems with the monitor, and four required repeat IV placement. Duration of monitor use ranged between 6 and 47 h (mean 24 +/- 4 h). Blood glucose values ranged between 2.6 and 22.5 mmol/l. Overall correlation of blood glucose values were as follows: 0.965, 0.965, 0.973, VIA 1-01G vs. One Touch II, VIA 1-01G vs. YSI 2300 STAT, and One Touch II vs. YSI 2300 STAT, respectively (all P-values < 0.0001). This real-time bedside glucose monitor is accurate at glucose values < 13.8 mmol/l, and reliable for rapid, repetitive analyses. Results indicate that blood glucose values obtained using this real-time monitor are comparable to those using standard methods of measurement, and that this device is clinically applicable for use in management of children with DKA.

Long-term ingrowth and apposition of porous hydroxylapatite implants

Bone implant materials are often used to fill in bone gaps that frequently result from orthognathic and craniofacial reconstruction. The substrate hydroxylapatite (HA) is commonly implanted into the bone voids, resulting from these conditions due to its established biocompatibility and osteoconductive properties. The porous structure of HA provides a three-dimensional guideline for fibrovascular ingrowth, facilitating the process that ultimately results in the deposition of new bone. Porous HA (Interpore, 200) implants were implanted in the mandible or maxilla of nine humans and removed after 14-30 months (19.1-month mean). There was no evidence of an inflammatory response. The sample composition and apposition against the implant were determined using point counting and a digitizing tablet and software. Percent ingrowth in available space (%IAS) was defined as %Bone/(%Bone + %Void). A new measure of implant saturation (%IAS-%Apposition of bone) was established to help determine the fundamental manner in which long-term HA implants incorporate bone. In the mean, the samples were composed of 27% bone, 21% void, and 53% implant. The apposition percentages averaged 60% bone, 16% void, and 24% soft tissue. The %IAS averaged 58%, and implant saturation averaged -3%, indicating that a near-balance between the implant and surrounding bone has been established.

Condylar change after upward and forward rotation of the maxillomandibular complex

Tomographic radiographs of 44 healthy temporomandibular joints in 22 patients undergoing large upward and forward rotations of the maxillomandibular complex were evaluated. Immediate postsurgery results showed decreases in all areas of the joint space. Long-term results showed a decrease in the superior and posterior regions, 14.8% and 19.7%, with no significant change anteriorly. Simple and multiple regression analysis did not show any relationship with age, gender, or degree of change in the decrease of the occlusal plane angle, to the temporomandibular joint changes described. Some condylar remodeling was noted.

Nutritional status of school age children of salt-workers in Rajasthan

Nutritional status of 1044 school age children (6-18 yr) of salt workers in various salt manufacturing sites of Rajasthan, was assessed using anthropometry. Heights and weights of girls were observed to be better than in boys in the menarcheal age groups. Children of the present study showed reduced growth in comparison to National Centre for Health Statistics (NCHS), World Health Organisation (WHO), well-to-do Indian children and Rajasthan reference values of the same age groups. The prevalence of stunted with severe wasting was 4.5 per cent in the children of salt workers. Higher prevalence of severe wasting was observed in girls than the boys (P < 0.01).