High-Flow Nasal Cannula Versus Nasal Prong Bubble Continuous Positive Airway Pressure in Children With Moderate to Severe Acute Bronchiolitis: A Randomized Controlled Trial

OBJECTIVES

To compare high-flow nasal cannula (HFNC) versus nasal prong bubble continuous positive airway pressure (b-CPAP) in children with moderate to severe acute bronchiolitis.

DESIGN

A randomized controlled trial was carried out from August 2019 to February 2022. (Clinical Trials Registry of India number CTRI/2019/07/020402).

SETTING

Pediatric emergency ward and ICU within a tertiary care center in India.

PATIENTS

Children 1-23 months old with moderate to severe acute bronchiolitis.

INTERVENTION

Comparison of HFNC with b-CPAP, using a primary outcome of treatment failure within 24 hours of randomization, as defined by any of: 1) a 1-point increase in modified Wood's clinical asthma score (m-WCAS) above baseline, 2) a rise in respiratory rate (RR) greater than 10 per minute from baseline, and 3) escalation in respiratory support. The secondary outcomes were success rate after crossover, if any, need for mechanical ventilation (invasive/noninvasive), local skin lesions, length of hospital stay, and complications.

RESULTS

In 118 children analyzed by intention-to-treat, HFNC (n = 59) versus b-CPAP (n = 59) was associated with a lower failure rate (23.7% vs. 42.4%; relative risk [95% CI], RR 0.56 [95% CI, 0.32-0.97], p = 0.031). The Cox proportion model confirmed a lower hazard of treatment failure in the HFNC group (adjusted hazard ratio 0.48 [95% CI, 0.25-0.94], p = 0.032). No crossover was noted. A lower proportion escalated to noninvasive ventilation in the HFNC group (15.3%) versus the b-CPAP group (15.3% vs. 39% [RR 0.39 (95% CI, 0.20-0.77)], p = 0.004). The HFNC group had a longer median (interquartile range) duration of oxygen therapy (4 [3-6] vs. 3 [3-5] d; p = 0.012) and hospital stay (6 [5-8.5] vs. 5 [4-7] d, p = 0.021). No significant difference was noted in other secondary outcomes.

CONCLUSION

In children aged one to 23 months with moderate to severe acute bronchiolitis, the use of HFNC therapy as opposed to b-CPAP for early respiratory support is associated with a lower failure rate and, secondarily, a lower risk of escalation to mechanical ventilation.

Evaluation of a novel phantom for the quality assurance of a six-degree-of-freedom couch 3D-printed at multiple centres

This study aimed to validate a bespoke 3D-printed phantom for use in quality assurance (QA) of a 6 degrees-of-freedom (6DoF) treatment couch. A novel phantom design comprising a main body with internal cube structures, was fabricated at five centres using Polylactic Acid (PLA) material, with an additional phantom produced incorporating a PLA-stone hybrid material. Correctional setup shifts were determined using image registration by 3D-3D matching of high HU cube structures between obtained cone-beam computer tomography (CBCT) images to reference CTs, containing cubes with fabricated rotational offsets of 3.5°, 1.5° and -2.5° in rotation, pitch, and roll, respectively. Average rotational setup shifts were obtained for each phantom. The reproducibility of 3D-printing was probed by comparing the internal cube size as well as Hounsfield Units between each of the uniquely produced phantoms. For the five PLA phantoms, the average rot, pitch and roll correctional differences from the fabricated offsets were -0.3 ± 0.2°, -0.2 ± 0.5° and 0.2 ± 0.3° respectively, and for the PLA hybrid these differences were -0.09 ± 0.14°, 0.30 ± 0.00° and 0.03 ± 0.10°. There was found to be no statistically significant difference in average cube size between the five PLA printed phantoms, with the significant difference (P < 0.05) in HU of one phantom compared to the others attributed to setup choice and material density. This work demonstrated the capability producing a novel 3D-printed 6DoF couch QA phantom design, at multiple centres, with each unique model capable of sub-degree couch correction.

An uncommon cause of spontaneous pneumothorax in a febrile infant: Atypical Kawasaki disease

Kawasaki disease after respiratory viral infections is often observed but following Human Metapneumovirus infection (HMPV) is uncommon. Pulmonary presentation of Kawasaki disease without its classical features, though uncommon, can present as bronchopneumonia refractory to routine supportive care and antibiotics treatment. Lung collapse and pneumothorax as a pulmonary presentation of atypical Kawasaki disease are described very infrequently. We report an infant with atypical Kawasaki disease secondary to Human Metapneumovirus infection where the above pulmonary complications were observed.

Threshold of Inotropic Score and Vasoactive-Inotropic Score for Predicting Mortality in Pediatric Septic Shock

OBJECTIVE

To determine the threshold of the inotropic score (IS) and vasoactive-inotropic score (VIS) for predicting mortality in pediatric septic shock.

METHOD

This retrospective cohort study included children aged 1 mo to 13 y with septic shock, requiring vasoactive medication. The area under curve receiver operating characteristic (AUROC) was calculated using mean IS and mean VIS to predict PICU mortality, and Youden index cut points were generated. Sensitivity, specificity, and binary regression analysis were performed.

RESULTS

A total of 176 patients were enrolled (survivor, n = 72, 41% and nonsurvivor, n = 104, 59%). For predicting the PICU mortality, AUROC (95% CI) of IS was 0.80 (0.74-0.86) [sensitivity of 88.5 (80.7-94) and specificity of 58.3 (46.1-69.8)] and AUROC of VIS was 0.88 (0.82-0.92) [sensitivity of 83.7 (75.1-90.2) and specificity of 80.6 (69.5-89)]. The respective cutoff scores of IS and VIS were 28 and 42.5. On regression analysis (adjusted odds ratio, 95% CI), illness severity (PRISM-III) (1.12, 1.05-1.12), worst lactate value (1.31, 1.08-1.58), IS (> 28) (3.98, 1.24-12.80), and VIS (> 42.5) (4.66, 1.57-13.87) independently predicted the PICU mortality (r² = 0.625).

CONCLUSION

Threshold of inotropic score (> 28) and vasoactive-inotropic score (> 42.5) were independently associated with PICU mortality. In addition to IS and VIS, severity and worst lactate value independently predicted septic shock mortality in PICU.

Paradoxical upgrading reaction following treatment of disseminated tuberculosis-associated haemophagocytic lymphohistiocytosis in an infant without HIV: a case report and review of the literature

Tuberculosis-associated haemophagocytic lymphohistiocytosis (HLH) is rare in paediatrics and can be fatal if not recognised and treated on time. A 3-month-old infant with tuberculosis and HLH is described. He was successfully treated with anti-tuberculous therapy (ATT) which comprised isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin and dexamethasone (10 mg/m²/day). On Day 28 of therapy, he developed a paradoxical upgrading reaction to ATT for which he was again treated with (oral) corticosteroids for 4 weeks. He recovered successfully and is now completely well and asymptomatic. To the best of our knowledge, this is the first case of a child having a paradoxical upgrading reaction following treatment for TB-HLH.Abbreviations ATT: anti-tuberculous therapy; CB-NAAT: cartridge-based nucleic acid amplification test; CECT: contrast-enhanced computed tomography; HLH: haemophagocytic lymphohistiocytosis; NK: natural killer, PUR: paradoxical upgrading reaction; sHLH: secondary HLH.

Prospective Cohort Study on Cumulative Fluid Balance and Outcome in Critically Ill Children Using a Restrictive Fluid Protocol

OBJECTIVE

To study the association of cumulative fluid balance and clinical outcomes in a pediatric intensive care unit (PICU) practicing restrictive fluid protocol.

METHODS

In this prospective cohort study, children aged less than 13 y admitted for more than 48 h were screened. Children with unstable hemodynamics throughout the stay were excluded. Fluid balance was calculated by percentage fluid overload (%FO) for the first 7 d. Patients were divided into positive fluid and negative fluid balance groups. The primary outcome was all-cause 28-d mortality.

RESULTS

A total of 888 patients (positive fluid balance group = 531, negative fluid balance group = 357) were analyzed. Mean (SD) cumulative %FO was 1.52 (0.67) vs. -1.18 (0.71), p = < 0.001, and minimum and maximum cumulative %FO were -3.0% and 3.1%, respectively. There was no significant difference in all-cause 28-d mortality between the two groups (n = 104/531, 19.6% vs. n = 60/357, 16.8%, RR = 1.17, 95% CI 0.87 to 1.55; p = 0.29). There was no difference in organ dysfunction [mean (SD) sequential organ failure assessment (SOFA) score 3.3 (0.7) vs. 3.3 (0.6)], acute kidney injury (65% vs. 63.6%), need for renal replacement therapy (14% vs. 13%), and duration of ventilation (median, IQR 4, 2-6 vs. 4, 2-6 d). Longer stay in PICU (5, 3-9 vs. 4, 3-7 d; p = 0.014) and in hospital (8, 5-11 vs. 7, 4-10 d; p = 0.007) were noted in the positive fluid balance group.

CONCLUSION

Cumulative fluid balance within 3% using restrictive fluid protocol was not associated with a significant difference in PICU mortality and morbidity.

A Prospective Cohort Study on Serum Sodium and Clinical Outcome in Pediatric Nontraumatic Coma

OBJECTIVE

To study the serum sodium level and clinical outcome in pediatric nontraumatic coma.

METHODS

A prospective cohort study was conducted in a tertiary care pediatric intensive care unit (PICU) from September 2015 to June 2016. Children aged < 13 y with nontraumatic coma [modified-Glasgow Coma Scale (m-GCS) score ≤ 8 or fall of ≥ 3 from baseline within 24 h of admission] were included. Children who received intravenous fluids for > 24 h, those with developmental delay, or died within 24 h of admission were excluded. The serum sodium profile (mEq/L) in the first 72 h and clinical outcome [mortality, length of stay in mechanical ventilation, PICU, and hospital] were studied.

RESULTS

Eighty patients [Died n = 26 and Survived n = 54] were enrolled. Median [interquartile range (IQR)] age and m-GCS were 21 (4-78) mo and 9 (7-11), respectively. The mean [standard deviation (SD)] Pediatric Risk of Mortality-III (PRISM-III) was 17.7 (4). The most common etiology was acute central nervous system (CNS) infections (30%, n = 24) followed by an intracranial bleed (11.3%, n = 9). Mean (Standard error, SE) sodium levels and fluctuation of serum sodium from baseline up to 72 h were similar between nonsurvivors and survivors [140.8 (1.3) vs. 139.6 (0.8), p = 0.421] and [1.2 (0.3) vs. 0.8 (0.2), p = 0.307], respectively. On multivariate analysis, the need for vasoactive therapy was an independent predictor of mortality [adjusted odds ratio = 20.78, 95% CI 4.24-101.85, p = < 0.001, R² = 0.62].

CONCLUSION

Mean serum sodium within normal range and fluctuation of serum sodium of 0.8 to 1.2 mEq/L over 72 h was not associated with poor outcomes in pediatric nontraumatic coma. Vasoactive therapy was an independent predictor of mortality.

Prospective Inverse Probability of Treatment-Weighting Analysis of the Clinical Outcome of Red Blood Cell Transfusion Practice in Critically Ill Children

OBJECTIVE

To study the clinical outcomes of red blood cell (RBC) transfusion practices in critically ill children.

METHOD

This prospective cohort study was conducted in a tertiary care pediatric intensive care unit (PICU) from March-2015 to January-2018. Inverse probability of treatment weighting (IPTW) using propensity score analysis was used. Children aged 1 mo to 12 y admitted to the PICU were screened. Patients were classified into 'transfused' and 'nontransfused', based on whether they received a transfusion or not. Patients with hematological malignancies, or immunosuppressant drugs, or those who received repeated transfusions, or received transfusion before admission, or died within 24 h were excluded. The primary outcome was all-cause 28 d mortality. Secondary outcomes were new-onset organ dysfunction, mechanical ventilation duration, and length of PICU and hospital stay.

RESULTS

A total of 1014 patients [transfused = 277; nontransfused = 737) were included. In IPTW analysis, the risk of all-cause 28 d mortality was 53% higher in transfused than nontransfused patients [hazard ratio = 1.53, 95% CI: 1.18-1.98, p = 0.001 by Log-rank test]. Organ dysfunction was higher in transfused than nontransfused patients [3.8% vs. 1.3%, hazard ratio = 3.0, 95% CI: 1.40-6.48, p = 0.005]. The risk of staying in the mechanical ventilation was similar in both groups [hazard ratio = 1.03, 95% CI: 0.86-1.23, p = 0.756]. The risk of extended stay in the PICU and hospital was 16% and 21% higher in transfused than nontransfused patients [hazard ratio = 1.16, 95% CI: 1.03-1.30; p = 0.005; and 1.21, 95% CI: 1.08-1.36; p = 0.001], respectively.

CONCLUSION

Red blood cell transfusion was independently associated with higher all-cause 28 d mortality and morbidities in critically ill children.

Pyridoxine Therapy: Not Just the Dose, the Duration Matters Too

Pyridoxine-dependent epilepsy (PDE) (OMIM 266100) is an autosomal recessive disorder of lysine metabolism secondary to antiquitin deficiency. The prototypical presentation is intractable neonatal seizures that do not respond to conventional antiseizure medication but are well controlled by pyridoxine supplementation. Atypical forms account for one-third of the PDE spectrum and may escape early diagnosis. The common atypical presentations include the prenatal onset of seizures, seizures onset as delayed as 3 years of age, autism, arrested hydrocephalus, and fetal ventriculomegaly. Herein, we describe a 9-month-old child with neonatal-onset refractory seizures who failed two short trials of pyridoxine therapy and was later diagnosed with PDE by molecular studies. Regardless of the therapeutic response, a prolonged course of pyridoxine therapy is justified to identify delayed responders in infants with drug-refractory epilepsy of no apparent etiology.

Knowledge and Awareness of Diabetes and Diabetic Ketoacidosis (DKA) Among Medical Students in a Tertiary Teaching Hospital: An Observational Study

BACKGROUND

The management of Diabetes Mellitus and its important complication Diabetic Ketoacidosis is very crucial in today's world where the prevalence of Diabetes is very high. Medical students are the pillars of our future healthcare system and it is important to evaluate and update their knowledge and awareness regarding these both conditions.

MATERIALS AND METHODS

This study was a cross-sectional; Questionnaire based observational study conducted in a tertiary care hospital. The respondents were final year MBBS students of that college. Study instrument was a self developed, pre-validated, semi-structured questionnaire.

RESULTS

A total of 73 questionnaires were considered for analysis, giving a response rate of 90.12% with 43.83% and 56.16% were male and female respondents respectively. About 81.25% and 90.24% of male and female respondents gave correct answer to question related to the best indicator of glycemic control. Lack of knowledge was seen regarding the world Diabetes day. Approximately 37% of the respondent's parents were diabetic. Only 12 out of 73 respondents were aware about the factors leading to DKA.8 out of 73 were aware about investigations to be done in DKA. Around 43.84% of responders knew regarding the proper screening duration in person with risk of diabetes.

CONCLUSION

From the study it was concluded that most of the students have basic knowledge regarding diabetes mellitus, its clinical features and management etc but only 50 % of the respondent were aware about DKA and further teaching and post teaching evaluation are needed in future direction.

A clinical study on glucosamine sulfate versus combination of glucosamine sulfate and NSAIDs in mild to moderate knee osteoarthritis

Background. Glucosamine may be effective in treating and possibly slowing the progression of Osteoarthritis (OA). It is believed Glucosamine supplements may help to stop cartilage breakdown, build cartilage and decrease swelling. Objective. The objective of this study was glucosamine sulfate versus combination of glucosamine sulfate and Non-Steroidal anti-inflammatory drugs (NSAID) in mild to moderate knee osteoarthritis. Methods. Subjects were randomly recruited from Rheumatology outpatient department after a diagnosis of mild or moderate Osteoarthritis. Study tools like patient data collection form, Western Ontario McMaster Universities Arthritis index (WOMAC) of Osteoarthritis questionnaires and Visual Analog Scale (VAS) were used. Results. After 12 weeks, WOMAC total score the result showed that the significant mean difference between the group A and Group B treatment (P < 0.01), with a combination of GS and NSAIDs reducing VAS pain scores. Thus, it is found that Group B treatments over 4 and 12 weeks produced improved WOMAC and VAS grades. Conclusions. Study results may suggest that the Glucosamine Sulfate has a carryover effect like Disease modifying agents. Long-term treatment of Glucosamine Sulfate may reduce the dependence of NSAIDs usage and delay the disease progression. Thereby we can reduce the NSAIDs side effects and improve the patient's quality of life.

Surgical reconstruction for chronic painful acromioclavicular joint dislocations

INTRODUCTION

We reviewed the results of modified Weaver-Dunn procedure in patients with persistent painful shoulder following acromioclavicular joint dislocations.

MATERIALS AND METHODS

Modified Weaver-Dunn procedure using of mersilene tape was done. There were 15 patients with Rockwood type III injury. The mean age and time interval for surgery was 42 years and 21 months, respectively. The mean follow-up period was 27 months.

RESULTS

There were no complications in the peri-operative period. The average return to full activities was 5 months. The mean constant score was 91 with scores above 90 in 11 patients. Two patients had moderate levels of pain and stiffness, which was better than preoperative status. There were two patients with symptomless noticeable lateral end of clavicle. The overall percentage of unfavourable results was 26%. All patients were satisfied with the results of the surgery.

CONCLUSION

There was no correlation between delay in surgery and outcome. Modified Weaver-Dunn procedure with mersilene tape is a valuable method of treatment in patients with persistent painful acromioclavicular joint dislocations and have low incidence of postoperative complications. However, it should be undertaken after adequate clinical assessment and trial of conservative treatment of painful Type III injuries.

Comparison of serum fructosamine and blood glucose concentrations as indices of glycaemic control in non-insulin dependent diabetic out-patients

The usefulness and validity of blood glucose measurement as an index of diabetic control were assessed with reference to serum fructosamine. Two hundred and twenty-eight non-insulin dependent diabetic out-patients were studied in the usual clinical setting. Fasting blood glucose (FBG) concentration was positively correlated with serum fructosamine (r = 0.42, t = 6.78 p less than 0.01). On the basis of their serum fructosamine concentrations, patients were divided into 3 groups. They were good control (fructosamine less than or equal to 288 umol/l), acceptable control (fructosamine less than or equal to 320 umol/l) and poor control groups (fructosamine greater than 320 umol/l). The mean fasting blood glucose concentration was significantly higher in the latter than the former 2 groups. However, at each level of control, there was a wide range of FBG concentrations. Thus, the value of FBG in predicting glycaemic control is limited. Its positive predictive value was only 32%, and its overall accuracy as an index of diabetic control was only 58% though its negative predictive value was high (93%). In 162 patients with poor diabetic control as indicated by their serum fructosamine concentrations, 81 (50%) of them had FBG less than 10 mmol/l on their clinic visit day. Fasting blood glucose is therefore not a reliable measure of good diabetic control, though it is useful in predicting poor control. FBG is simple to measure, cheap and rapidly available on clinic day, thus ensuring its continuing use. Doctors should be aware of its limitations and should not rely solely on FBG to assess diabetic control.

Morbidity associated with asthma and audit of asthma treatment in out-patient clinics

A study was undertaken to determine the extent of morbidity associated with asthma and to audit the management of asthma in two out-patient clinics of two district hospitals. Patients were recruited for the study during a 3-month period from December 1990 to February 1991. Seventy asthmatic patients were studied. Eighty-six percent of the patients had their sleep disturbed by asthma, 77% took daily medication regularly, 63% felt that their activities were restricted by asthma, 60% had at least one acute exacerbation in the preceding six months. Of those who had their peak expiratory flow rate (PEFR) measured, 40% had a PEFR below 50% predicted, and only 11% had normal PEFR (greater than 80% predicted). The morbidity of asthma was thus considerable. On the other hand, the drug treatment of these asthmatics was grossly inadequate. They were prescribed on average 2.1 item of drugs, which for most patients comprised an oral beta agonist and a theophylline. Only 43% of the patients received inhaler therapy, but no patients were given steroids, inhaled or oral. The drug treatment was unrelated to the severity of patients' asthma. Further, objective measurement of severity was under-used in the assessment of asthma, only 8.5% of patients ever had their PEFR recorded. This study has found that asthma is poorly managed in out-patient clinics. We need to improve the training of doctors in the optimal management of asthma.