Dyselectrolytemia in Children With Severe Pneumonia: A Prospective Study

Background Pneumonia is a condition characterized by inflammation of the lung parenchyma. It is one of the leading causes of mortality in children below five years of age. While predominantly prevalent in developing countries, it is also associated with significant healthcare-associated costs in developed countries. Among the many risk factors for childhood pneumonia, incomplete immunization, nonexclusive breastfeeding for less than six months, delayed weaning, poor household air quality, malnutrition, and low birth weight are the most commonly found. Electrolyte disturbances, also known as dyselectrolytemia, have been associated with a broad spectrum of acute infections, including pneumonia, particularly hyponatremia. It occurs in the majority of community-acquired pneumonia. Hyper- and hypokalemia are less frequently occurring electrolyte disturbances. Electrolyte disturbances are due to impairment of the intrarenal mechanism of urine dilution due to extracellular fluid volume depletion and inappropriate secretion of antidiuretic hormone. The central nervous system is imminently affected by acute hyponatremia. This condition frequently culminates in cerebral edema, a result of the rapid fluid shift, and causes sudden fatality. Aim of the study This study aims to study dyselectrolytemia in children with severe pneumonia. Objectives The study objectives are to assess dyselectrolytemia in children with severe pneumonia and to correlate dyselectrolytemia with morbidity and hospital stay. Methodology  This prospective study was conducted on 80 children in the age group of two months up to five years who visited our tertiary care center and had severe pneumonia. We evaluated the extent of dyselectrolytemia in our study population by analyzing the frequency correlation of different kinds of electrolyte imbalances. We also analyzed the correlation between morbidity and hospital stay. Results Out of 80 children in this study with severe pneumonia, 47 (59%) had electrolyte imbalance. Among the patients with electrolyte imbalance, 31 (39%) patients had hyponatremia followed by hypokalemia in 12 (15%) patients, hypernatremia in 3 (4%) patients, and hyperkalemia in 1 (1%) patient. Among the 17 (21%) children with pneumonia requiring ICU admission, 16 (94%) had dyselectrolytemia and 4 (24%) experienced fatal outcomes. Conclusions The majority of the children who were admitted to the ICU had severe pneumonia along with electrolyte imbalance. This necessitates the monitoring of the electrolyte and nutritional status of the patients with pneumonia. Providing proper nutrition advice for children with pneumonia may reduce morbidity and mortality. Early detection and treatment of electrolyte imbalances in pneumonia cases can decrease prolonged hospital stays, ICU admissions, and the need for mechanical ventilation, ultimately contributing to a reduction in morbidity and mortality.

Impact of oxygen therapy algorithm on oxygen usage in the emergency department

BACKGROUND

Although oxygen is one of the oldest drugs available, it is still one of the most inappropriately administered drugs leading to over utilization of this very expensive resource.

MATERIALS AND METHODS

This prospective observational study was done in a large emergency department (ED) in India. The pattern of oxygen usage was studied before and after the strict implementation of an oxygen treatment algorithm. The algorithm was taught to all doctors and nurses and its implementation was monitored regularly. The main outcome measures were proportion of patients receiving oxygen therapy, inappropriate usage, and avoidable direct medical cost to the patient.

RESULTS

The 3-week pre-protocol observation phase in April 2016 included 3769 patients and the 3-week post-protocol observation phase in April 2017 included 4608 patients. The baseline demographic pattern was similar in both the pre-protocol and post-protocol groups. After the strict implementation of the algorithm, the number of patients receiving oxygen therapy decreased from 9.63% to 4.82%, a relative decrease of 51.4%. The average amount of total oxygen used decreased from 55.4 liters per person in pre-protocol group to 42.1 liters per person in the post-protocol group with a mean difference of 13.28 (95% CI 5.30-21.26; P = 0.001). Inappropriate oxygen usage decreased from 37.2% to 8.6%. There was a significant decrease in inappropriate oxygen use for indications like low sensorium (60.8% vs 21.7%) and trauma (88.5% vs 15.8%). The mortality rate in the pre-protocol phase was 2.7% as compared with 3.2% in the post-protocol phase. The total duration of inappropriate oxygen usage significantly decreased from 987 h to 89 h over the 21-day study period.

CONCLUSION

The implementation of an oxygen therapy algorithm significantly reduces inappropriate oxygen use and decreases treatment cost to the patient with no additional mortality risk.

Cutaneous hyperpigmentation and familial gastrointestinal stromal tumour associated with KIT mutation

Gastrointestinal stromal tumours (GISTs) are mesenchymal tumours arising in the gastrointestinal tract. Early detection, before metastasis occurs, is important as complete surgical excision achieves cure. Approximately 85% of GISTs are associated with mutations in the KIT gene, and although the majority of GISTs are sporadic, familial GISTs have been identified. Several families with multiple GIST tumours have also been described with various cutaneous findings including hyperpigmentation, multiple lentigines, vitiligo and urticaria pigmentosa. We discuss a 6-year-old boy who presented with an unusual pattern of hyperpigmentation in association with a family history of GIST. A causative KIT mutation was identified in DNA from the pigmented skin and from the resected GIST, and the patient was referred to the Paediatric Gastroenterology department for GIST screening. The term 'GIST cutaneous hyperpigmentation disease' has been suggested previously for the association of familial GIST with cutaneous hyperpigmentation caused by a germline KIT mutation.

Jejunal perforation: an unusual presentation of metastatic cutaneous squamous cell carcinoma (SCC) in an immunosuppressed patient

We report the rare occurrence of a small bowel perforation secondary to a metastatic cutaneous squamous cell carcinoma (cSCC). A 70-year-old woman, who had previously undergone renal transplantation, presented with severe, sudden-onset abdominal pain. She was peritonitic on initial examination, with evidence of free intra-abdominal air on radiographic imaging. During an exploratory laparotomy, she was found to have a perforated jejunum secondary to disseminated metastases seen throughout her peritoneum. Following histopathological analysis, as well as further imaging studies, the primary malignancy was eventually identified as a cSCC on her upper back. Palliative care was started and the patient died 8 weeks following her initial presentation.

Stress, cognitive factors, and coping resources as predictors of relapse in alcoholics

One hundred alcohol-dependent individuals attending a detoxification unit were assessed on a variety of psychological, social and demographic variables. Sixty-one participants were contacted at follow-up over 1 year later. Alcohol consumption was assessed through self-report and corroborative information. Self-reported levels of stress and social support were also obtained. High self-efficacy predicted low levels of self reported drinking at follow-up. Negative coping predicted higher levels of drinking as reported by the corroborator. High levels of stress in the month prior to follow-up were related to self-reported poor drinking outcomes, while ongoing social support since treatment was associated with favorable drinking outcomes. Overall, higher levels of self-efficacy during detoxification and social support following treatment were the best predictors of a favourable drinking outcome.

Relationship between attributional style, individualized attributional style, and health

Attributional styles as measured by Peterson, et al.'s 1982 questionnaire and through an individualized questionnaire were not differentially related to measures of physical and psychological health for 27 nursing students.

Effectiveness of training in negative thought reduction and positive thought increment in reducing thought-produced distress

Subjects (N = 86) completed scales designed to measure distress caused by thoughts, distress caused by day-to-day experiences, positive affect caused by thoughts, positive affect caused by day-to-day experiences, anxiety, stress, depressive cognitions, well-being, and psychological health. Subjects who reported high distress as a result of one or more items on the Thought-Related Distress subscale were asked to nominate three specific thoughts related to one of the distress-producing thought categories. These subjects were randomly placed in one of the five training groups. One group was trained to reduce negative thoughts (NTR), the second group was trained to replace negative thoughts with positive thoughts (PTI), the third group was given training in both procedures, the fourth group was given a placebo treatment, and the fifth group was not given any treatment. NTR, PTI, and the combination of both were effective in reducing the distress caused by the specific thoughts. There was a significant reduction in the distress caused by specific thoughts in the NTR and combined-treatment groups. Training produced no significant changes in overall negative and positive affect caused by thoughts and day-to-day experiences or in anxiety, stress, depressive cognitions, well-being, and general health.

Effect of aerobic exercise on negative affect, positive affect, stress, and depression

Three groups of subjects, 15 Longer-term Exercisers, 14 Short-term Exercisers, and 18 Nonexercisers completed questionnaires designed to measure negative affect associated with thoughts, negative affect associated with day-to-day experiences, positive affect associated with thoughts, and positive affect associated with day-to-day experiences, depression, and stress. All the subjects also provided a rating of their over-all general stress. The Longer-term Exercisers reported more positive affect associated with their thoughts and day-to-day experiences than the Nonexercisers. There also was a trend for the Longer-term Exercisers to report less over-all stress than the Nonexercisers.