Challenges in handling a civilian mass pediatric disaster during flood relief in a partially inundated armed forces medical facility

BACKGROUND

Armed forces hospitals are often called upon to provide medical aid to civilians during natural calamities. Though children are often the most vulnerable segment of population in these events, research that addresses their unique needs and the role of armed forces hospitals remains sparse.

OBJECTIVES

We examined pediatric morbidity and mortality at a flooded armed forces hospital. Factors that affected outcomes were identified.

METHODS

158 patients were evacuated en masse from a children's hospital in northern India that was submerged by flood to an adjacent partially inundated armed forces hospital specializing in military medicine and adult trauma. The children were provided case-based clinical care as per existing disaster management protocol. Geoclimatic vulnerability factors, morbidity/mortality, and medical and logistical challenges for future intervention were investigated.

RESULTS

One pediatrician who provided initial triage was joined by two others after 48 hours. A limited load of adult patients permitted more resources for the children, majority (49 percent) of whom were neonates. Intensive care was necessitated for 32 (20.2 percent) cases, with half managed in adult ICU. Overall in-hospital mortality was 5.7 percent. Experienced staff, cross-specialty multitasking, and innovative and noncensorious leadership were identified as assets amidst resources compromised by flooding. Clear delineation of primary caregiver role of pediatrician at outset, pediatric emergency care training, pediatric triage, resource allocation for thermoregulation, oxygen therapy and ventilation, earmarking centers for transfer of cases, and safe transportation to the centers were identified as areas meriting further attention.

CONCLUSION

Armed forces hospitals in vulnerable geoclimatic zones must address pediatric concerns in disaster management plans.

Hepatitis A-induced acute liver failure with glucose 6 phosphate dehydrogenase deficiency induced hemolysis and renal failure

Hepatitis A is the most prevalent viral hepatitis in India and rarely can lead to life-threatening complications such as acute liver failure (ALF). Glucose 6 phosphate dehydrogenase (G6PD) deficiency is the most common enzyme deficiency in the world, and in the setting of acute viral hepatitis, it can cause massive intravascular hemolysis, resulting in acute kidney injury. Here, we report a case of a 12-year-old male child who had hepatitis A-associated ALF, which was complicated by massive hemolysis due to underlying G6PD deficiency, manifesting as acute renal failure requiring renal replacement therapy with other supportive management. He had a prolonged, protracted stormy clinical course, which was further complicated by dialysis disequilibrium syndrome, posterior reversible encephalopathy syndrome, and nosocomial sepsis, which improved over 4 weeks. Our case highlights the importance of having high index of clinical suspicion for G6PD deficiency in a child with acute viral hepatitis with complications.

Clinical spectrum & changing presentation of celiac disease in Indian children

Background & objectives

Celiac disease (CD) is a genetic immune mediated disorder characterised by gluten intolerance. This single centre study, from north India was aimed to assess the clinical, serological and histological profile of CD in a large cohort of children and the changing trends in its presentation.

Methods

A review of clinical details of CD children diagnosed between 2000 and 2019 and currently on follow up was performed. Information on demography, symptoms, associated conditions, serology, biopsy findings and gluten-free diet were analyzed.

Results

The mean age (±standard deviation) of 891 children included in the study, at onset and at diagnosis was 4.0±2.7 and 6.2±3.1 yr, respectively. Growth faltering, abdominal pain, abdominal distension and diarrhoea were presenting symptoms in 70, 64.2, 61.2 and 58.2 per cent, respectively. A positive family history of CD was present in 14 per cent and autoimmune conditions in 12.3 per cent of children. Thyroid disorders were seen in 8.5 per cent of children and Type 1 diabetes mellitus (T1DM) in 5.7 per cent. The duration of breastfeeding had a weak positive correlation with age at onset and diagnosis of CD (P<0.001). Non-classical CD was significantly more common in children aged >10 yr and in those presenting after 2010 (P<0.01). T1DM and hypothyroidism occurred more frequently in non-compliant children.

Interpretation & conclusions

This was the largest single centre study, pertaining to the presentation and follow up of CD in children. Infants and young children were more likely to present with classical symptoms of diarrhoea, abdominal distension and growth failure while older children presented with non-classical CD. There was a trend towards non-classical forms of CD in recent years.

Challenges in handling a civilian mass pediatric disaster during flood relief in a partially inundated armed forces medical facility

BACKGROUND

Armed forces hospitals are often called upon to provide medical aid to civilians during natural calamities. Though children are often the most vulnerable segment of population in these events, research that addresses their unique needs and the role of armed forces hospitals remains sparse.

OBJECTIVES

We examined pediatric morbidity and mortality at a flooded armed forces hospital. Factors that affected outcomes were identified.

METHODS

158 patients were evacuated en masse from a children's hospital in northern India that was submerged by flood to an adjacent partially inundated armed forces hospital specializing in military medicine and adult trauma. The children were provided case-based clinical care as per existing disaster management protocol. Geoclimatic vulnerability factors, morbidity/mortality, and medical and logistical challenges for future intervention were investigated.

RESULTS

One pediatrician who provided initial triage was joined by two others after 48 hours. A limited load of adult patients permitted more resources for the children, majority (49 percent) of whom were neonates. Intensive care was necessitated for 32 (20.2 percent) cases, with half managed in adult ICU. Overall in-hospital mortality was 5.7 percent. Experienced staff, cross-specialty multitasking, and innovative and noncensorious leadership were identified as assets amidst resources compromised by flooding. Clear delineation of primary caregiver role of pediatrician at outset, pediatric emergency care training, pediatric triage, resource allocation for thermoregulation, oxygen therapy and ventilation, earmarking centers for transfer of cases, and safe transportation to the centers were identified as areas meriting further attention.

CONCLUSION

Armed forces hospitals in vulnerable geoclimatic zones must address pediatric concerns in disaster management plans.

Advances in management of end stage liver disease in children

End stage liver disease (ESLD) is an irreversible condition that is a management challenge to the paediatrician. The aetiology and natural history of ESLD in children is not only distinct from adults but also variable depending upon the age of presentation. Children are especially vulnerable to developmental delay, frailty and malnutrition. Nutritional support is the cornerstone of management of these children as it has a significant impact on the clinical course and survival, both before and after transplantation. Further, the complications of ESLD in children including but not limited to, ascites, portal hypertension, spontaneous bacterial peritonitis and encephalopathy raise unique management challenges. In this review we provide a concise review of and highlight recent advances in the management of paediatric ESLD.

Bilateral renal cortical necrosis in a child with acute pancreatitis

Bilateral renal cortical necrosis (RCN) as a cause of acute kidney injury is very rare in the pediatric population. Progression to end-stage renal disease is seen virtually in every patient with RCN. There are many causes for the occurrence of cortical necrosis in children, with severe pancreatitis being a rarity. In this report, we describe a child with severe acute pancreatitis complicated by bilateral RCN.

Life-threatening Upper Gastrointestinal Bleeding Due to Ruptured Gastroduodenal Artery Aneurysm in a Child

Gastroduodenal artery (GDA) aneurysm is a rare cause of massive life-threatening upper gastrointestinal (UGI) bleeding in children. Prompt resuscitation with fluids, administration of large amount of blood products (massive transfusion), prompt diagnostic evaluation using computed tomography (CT) angiography or digital subtraction angiography (DSA), and therapeutic endovascular or catheter-based interventions are life-saving. In cases with failed endovascular interventions, open surgical approach to ligate aneurysm is required. We report a 10-year-male with life-threatening UGI bleed due to ruptured GDA aneurysm possibly secondary to sepsis requiring resuscitation, massive transfusion, CT angiography and DSA, endovascular intervention, and ultimately surgical management with good outcome.

Clinical Characteristics of Children With Celiac Disease Not Responding to Hepatitis B Vaccination in India

The immunological response to hepatitis B virus (HBV) vaccine may be suboptimal in children with celiac disease (CD), but the reasons for this are not well defined.

Objectives

This study was undertaken to assess the immune response to HBV vaccine in CD children and to explore the possible factors affecting the immune response.

Methods

The study population consisted of 3 groups-50 newly diagnosed CD children (group 1), 50 previously diagnosed CD children who were on gluten free diet (GFD) >3 months (group 2), and 100 age and gender matched healthy controls (group 3). The patient characteristics were recorded, and the blood samples were analyzed for HBsAg and anti-HBs titers. The nonresponders were given a booster dose of HBV vaccine and reevaluated after 6 weeks.

Results

Positive anti-HBs response was found in 46% in newly diagnosed CD children, 60% in CD children on GFD, and 83% in healthy controls (P < 0.001). The immune response to HBV vaccine in CD children was inferior to that in healthy children (53% vs 83%, P < 0.001). The immune response was found to be significantly affected by age at diagnosis, delay in diagnosis, type of presentation, and compliance to GFD. 44 out of 45 (97.77%) nonresponders from CD group seroconverted after a single booster dose.

Conclusion

Early diagnosis and good compliance to GFD may improve the immune response to HBV vaccine in CD children. Single additional booster dose is sufficient to attain optimal immune response.

Pulmonary thromboembolism: A rare complication of amoebic liver abscess in a child

Amoebic liver abscess is common in children in developing countries due to lack of hygiene and sanitary conditions. Inferior vena cava thrombosis is a rare complication of this disease, with only a few cases reported in the literature, where this thrombus led to pulmonary thromboembolism. We report the case of a 7‐year‐old child with amoebic liver abscess who developed pulmonary thromboembolism and was promptly diagnosed and managed.

Pancreatic ascites and Pleural Effusion in Children: Clinical Profile, Management and Outcomes

BACKGROUND

Pancreatic ascites (PA) and pleural effusion (PPE) are rarely encountered in children. They develop due to disruption of the pancreatic duct (PD) or leakage from an associated pancreatic fluid collection (PFC). The literature on childhood PA/PPE and its management is scarce.

METHODS

A retrospective review of children with PA/PPE diagnosed and managed at our center over the last 4 years was performed. The clinical, biochemical, radiological and management profiles were analyzed. Conservative management included nil per oral, octreotide and drainage using either percutaneous catheter or repeated paracentesis. Endotherapy included endoscopic retrograde cholangiopancreatography (ERCP) and transpapillary stenting.

RESULTS

Of the 214 children with pancreatitis, 15 (7%) had PA/PPE. Median age was 9 years with a third under 2 years. Median ascitic fluid amylase was 8840 U/L and all had elevated protein (>2.5 g/dl) and low serum ascites-albumin gradient ascites (<1.1). While PA/PPE was the first manifestation of underlying chronic pancreatitis (CP) in 10 children (67%), trauma was seen in 4 (26%) and hypertriglyceridemia in 1 (7%). On imaging, PD disruption could be identified in 10 (67%) children. ERCP and stenting was done in 10 children. Conservative management alone (n = 4) and endotherapy (n = 10) was successful in 93% with only one requiring surgery. The younger children (n = 4), were managed conservatively and only 1 of them required surgery. Resolution of PA/PPE was achieved in all with no recurrences.

CONCLUSIONS

Conservative management and ERCP plus transpapillary stenting results in resolution of majority of pediatric PA/PPE. Children presenting with PA/PPE needs to be evaluated for CP.

Leveraging Existing Institutional Resources to Maintain Quality Assurance Practices in Anatomic Pathology in the Era of Social Distancing

Introduction/Objective

Due to the COVID-19 pandemic, hospitals had to adapt practices to incorporate social distancing while maintaining quality assurance (QA) in anatomic pathology (AP). Prior to this, our general surgical pathology (SP) and cytopathology (CP) services held daily consensus conferences (CC) at a multi-headed microscope. Implementing social distancing meant only a few faculty were present onsite and avoidance of interactions at the multi-headed scope. In an effort to preserve QA through CC, faculty exploited the use of web conferencing through our HIPAA-compliant Zoom. We describe the utility of this new practice.

Methods

From 3/25-4/30/20, all SP and CP cases selected for CC were presented by respective pathologists (n=8) in their own offices by using individual microscopes with cameras, image acquisition software, and screen-sharing through Zoom. One pathologist was responsible for sending out a new CC Zoom link daily and recording the consensus diagnosis. All onsite pathologists and those at home participated.

Results

We presented 95 SP and 31 CP cases through Zoom compared to 300 SP and 60 CP cases presented at a similar timeframe prior to social distancing. This 68% and 48% decline could be attributed to elective procedure cancellation. We assigned a consensus diagnosis to all cases, with 77% overall being malignant diagnoses, and breast being the most common SP specimen type (22%). Additionally, all participating pathologists felt comfortable with the new format irrespective of being onsite or at home. Apart from minor audio issues, we did not notice significant lag time or visual disturbances that interfered with diagnostic abilities. Importantly, the transition did not involve investing in new technology.

Conclusion

The new virtual CC allowed our department to maintain QA practices in AP without sacrificing quality and serves as a starting point to investigating the use of this technology to other applications in AP, such as overnight frozen sections.

Pulmonary Granuloma Associated with Pneumocystis Jirovecii in a Patient with Peripheral T-Cell Lymphoma: Presentation of a Rare Case with Review of the Literature

Casestudy: Although Pneumocystis jirovecii (PJ) is a known opportunistic pulmonary infection among immunocompromised patients, it is a rare (&lt;5%) cause of pneumonia in this cohort. Majority of cases are observed in patients with HIV or solid organ transplant recipients. Granuloma formation in patients infected with PJ is even rarer. We present a case of multiple pulmonary granulomas associated with PJ in a non-HIV patient. A 49-year-old female with a history of asthma presented with worsening dyspnea. Initial imaging revealed multifocal bilateral areas of consolidation and a diagnostic bronchoalveolar lavage (BAL) demonstrated PJ organisms. Additional investigation was pursued to determine the etiology of this infection in a seemingly immunocompetent patient. New findings noted during hospitalization included a new maculopapular skin rash, significant weight loss, and lymphopenia. A bone marrow biopsy revealed a clonal proliferation of plasma cells. Subsequent imaging revealed mediastinal adenopathy. There was no improvement in symptoms despite treatment for pneumonia and a month later, a lung wedge biopsy revealed organizing acute lung injury and multiple non-caseating granulomas without lymphoid rimming, asteroid, or Schaumann bodies. Silver stain highlighted numerous PJ organisms within and outside of the granulomas. An inguinal lymph node and skin biopsies eventually revealed involvement by peripheral T-cell lymphoma (PTCL). Repeat BAL revealed clearance of organisms after additional therapy; however, the PTCL was refractory to chemotherapy and palliative care was pursued. To date, we could only find &lt;30 cases of pulmonary PJ granulomas in patients with hematologic malignancies. Most are in patients with B cell lymphomas and just 1 report in a patient with adult T-cell leukemia/lymphoma. In summary, this case highlights that PJ associated pulmonary granulomas are uncommon, can be a harbinger of an underlying immunocompromised state, such as a lymphoma, and are even rarer to be associated with PTCL.

Coinfection with Hymenolepis nana and Hymenolepis diminuta infection in a child from North India: A rare case report

Hymenolepiasis is considered the most common tapeworm infection throughout the world infecting 50-75 million people. Hymenolepis diminuta infection is not commonly reported in human beings as compared to Hymenolepis nana because it is primarily a parasite of rats and mice. There are few case reports of H. diminuta in the Indian population. To the best of our knowledge, not a single case of coinfection with H. nana and H. diminuta has been reported from India. We present here a rare case report of coinfection of H. nana and H. diminuta in a 4-year-old male child from a semirural area of India who presented with acute and severe colitis.

Assessment of quality of life before and after successful percutaneous transvenous mitral commissurotomy in patients with severe mitral stenosis

BACKGROUND

Rheumatic mitral stenosis (MS) is a significant cause of morbidity and mortality in India. Percutaneous transvenous mitral commissurotomy (PTMC) has become the procedure of choice for severe MS with pliable leaflets. Despite a wealth of literature on the technical aspects of PTMC, there is a dearth of literature addressing the impact of PTMC on the quality of life (QOL).

AIM

The aim of the study is to assess the impact of PTMC on clinical status and QOL of patients with severe MS.

MATERIALS AND METHODS

Twenty-five consecutive patients with severe MS undergoing PTMC were included in the study with their informed consent. All patients were subjected to routine blood tests, electrocardiogram, chest X-ray, two-dimensional and color echocardiography, treadmill test (TMT), and World Health Organization (WHO) QOL scale. The echocardiography, TMT, and WHOQOL scale were repeated after the procedure.

RESULTS

The procedural success was 98%. The mean (range) mitral valve area preprocedure was 0.82 (0.59-0.92) cm² and postprocedure was 1.61 (1.51-1.76) cm². The difference was statistically significant (t = 5.02; P < 0.01). The mean (range) of TMT preprocedure was 4.05 (3.0-7.0) METS and postprocedure was 8.52 (6-12) METS. The difference was statistically significant (T = 3.08; P < 0.01). The mean (range) of QOL assessment pre- and post-procedure on physical domain was 8.83 (8.3-10.1) which increased to 11.11 (10-12.7); on social relationship domain from 9.17 (7.5-12.4) to 11.37 (9.4-12.0); on personal relationship from 11.6 (11-13) to 12.52 (12-13); on environment domain from 10.78 (10.2-11.7) to 11.56 (10.8-12); and on level of independence from 9.02 (8-10) to 12.29 (11.0-13.6). All the differences were statistically significant (Wilcoxon signed-rank test z = -4.376; -4.379; -4.234; -4.200; -4.375; respectively, all P < 0.001 highly significant).

CONCLUSIONS

PTMC resulted in a significant improvement in the QOL of patients with severe MS. The significant improvement in QOL post-PTMC may be an indication for offering PTMC at an earlier stage to those patients whose QOL is severely compromised.

Utility of portable monitoring in the diagnosis of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common but underdiagnosed sleep disorder, which is associated with systemic consequences such as hypertension, stroke, metabolic syndrome, and ischemic heart disease. Nocturnal laboratory-based polysomnography (PSG) is the gold standard test for diagnosis of OSA. PSG consists of a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness including electroencephalography (EEG), electrooculography (EOG), surface electromyography (EMG), airflow measurement using thermistor and nasal pressure transducer, pulse oximetry and respiratory effort (thoracic and abdominal). Multiple alternative and simpler methods that record respiratory parameters alone for diagnosing OSA have been developed in the past two decades. These devices are called portable monitors (PMs) and enable performing sleep studies at a lower cost with shorter waiting times. It has been observed and reported that comprehensive sleep evaluation coupled with the use of PMs can fulfill the unmet need for diagnostic testing in various out-of-hospital settings in patients with suspected OSA. This article reviews the available medical literature on PMs in order to justify the utility of PMs in the diagnosis of OSA, especially in resource-poor, high-disease burden settings. The published practice parameters for the use of these devices have also been reviewed with respect to their relevance in the Indian setting.

Life-stage Analysis of Solvent Induced Fissures under Static Stress in PET Fibers

The paper discusses the impact of drawing poly(ethylene terephthalate) (PET) fibers in the presence of solvents, which consist of the first five homologues of aliphatic primary alcohols, namely methanol to amyl alcohol. The solvent induced deformation under tensile load leads to surface fissures characterized by four stages: fissure formation (birth), incipient draw (neck formation), partial draw, and full draw. This process results in internal void formation in the presence of a propagating neck. A design of experiment (DOE) was performed to screen out the process parameters critical for understanding surface fissure formation. Four process parameters were investigated: initial material properties (orientation); environment of draw (i.e. type of alcohols used as solvent); rate of extension; and amount of extension. The response of solvent induced deformation were characterized by the natural draw force reduction; number of fissures formed at time of birth, fissure width at time of formation, and neck angle. Of all the four process parameters involved, the analysis indicates that the material properties and amount of extension were the best predictors of solvent induced fissure formation. Organic solvents reduce the tension required for draw and create internal voids, a porous network, with possibly the penetrant being “sucked” into the interior of PET fibers drawn in the presence of alcohols.

R542X mutation in SMPD1 gene: genetically novel mutation with phenotypic features intermediate between type A and type B Niemann-Pick disease

Niemann-Pick disease (NPD) is a heterogenous group of progressive neurovisceral disorder characterised by lysosomal accumulation of sphingomyelin. NPD types A and B are caused by mutations involving sphingomyelin-phosphodiesterase-1 (SMPD1) gene and are characterised by deficiency of acid sphingomyelinase activity. We present a case of a 9-month infant with clinical manifestations intermediate between types A and B NPD and genetically illustrating a novel R542X mutation in the exon 6 of SMPD1.

Distal and proximal resource influences on economic dependency among the oldest old

BACKGROUND

As exceptional survivors, centenarians may have characteristics that reduce their dependency on family and community support systems despite the expectation that their extreme age creates a burden on those systems. The Georgia Centenarian Study obtained information about assistance for income, medical care, and caregiving of all types for a sample of centenarians and octogenarians. Previous studies have not established which characteristics may contribute to economic dependency among the oldest old.

OBJECTIVE

To identify distal and proximal resource influences on economic dependency, considering past lifestyle, proximal health, economic resources, personality, and coping behavior.

METHODS

Analysis sample sizes ranged from 109 to 138 octogenarians and centenarians. Blockwise multiple regressions predicted whether they received income assistance, number of medical care events, number of caregiving types, and total caregiving hours.

RESULTS

Past life style, gender, ethnicity, socioeconomic status, functional health, and coping were not related to economic dependency. With the exception of the number of types of care, centenarians were not more dependent than octogenarians. Cognitive ability had the strongest effects for medical care and caregiving services. 'Extraversion', 'ideas', 'neuroticism', and 'competence' personality factors had significant effects for caregiving types and total hours of care received.

CONCLUSION

Monitoring and intervention to maintain cognitive ability are critical practices for autonomy and reduced economic dependency among the oldest old. Psychological resources are more important influences on social support than functional health and other proximal economic resources.