Author Reply - SOFA-based Prognostication in PICU: A Cardiovascular Critique!

How to cite this article: Lois A, Save S. Author Reply - SOFA-based Prognostication in PICU: A Cardiovascular Critique! Indian J Crit Care Med 2023;27(11):863.

Serial Evaluation of Sequential Organ Failure Assessment Score (SOFA) as a Predictor of Outcome in Children Admitted in Pediatric Intensive Care Unit (PICU) at Tertiary Care Hospital.

Background: Sequential organ failure assessment score (SOFA) is a score to quantify organ system dysfunction. This study was done to evaluate SOFA as a predictor of outcomes in children in pediatric intensive care unit (PICU). Objective: (A) To determine whether initial SOFA, Delta SOFA, and SOFA score at 72 hours are better predictors of outcome in terms of sensitivity and specificity. (B) To compare the initial SOFA, Delta SOFA, and SOFA score at 72 hours. Materials and methods: A prospective observational study was conducted on 160 patients aged from 29 days to 12 years admitted in PICU of a Tertiary Care Hospital in a metropolitan city in India for a period of 1 year. Then, the initial SOFA score, 72-hour SOFA, and Delta SOFA (T0 SOFA - T72 SOFA) were calculated and patients were followed up till discharge from PICU or deceased. Results: The best threshold to differentiate between discharged and deceased corresponds to as initial SOFA of 7.50 with a sensitivity of 64.71%, and specificity of 89.51%. The similar threshold for 72 hours SOFA is 10.50 which correspond to a sensitivity of 76.47% and specificity of 96.50%. The study showed strong evidence (p-value < 0.05) that, patients whose Delta SOFA values increased from the previous value (-1.5), had a greater chance to succumb to illness. Delta SOFA had the best sensitivity (82.35%) and 72-hour SOFA had the best specificity (96.50%) in predicting the outcome of PICU patients. Conclusion: This study emphasizes the use of SOFA score as a prognostic indicator in critically ill children, as variables measured are easily available. How to cite this article: Lois A, Save S. Serial Evaluation of Sequential Organ Failure Assessment Score (SOFA) as a Predictor of Outcome in Children Admitted in Pediatric Intensive Care Unit (PICU) at Tertiary Care Hospital. Indian J Crit Care Med 2023;27(8):590-595.

Clinical characteristics & severity profile of children with COVID-19 during the second wave pandemic: An experience from tertiary care hospital in Mumbai.

This retrospective observational study was aimed at defining the demographic and clinical characteristics as well as severity profile of COVID-19 disease in children admitted to dedicated COVID-19 tertiary care hospital in Mumbai, India, during the second wave. COVID-19 infection detected in children (1 month-12 years) by the rapid antigen test or reverse transcriptase polymerase chain reaction or TRUENAT from March 1 to July 31, 2021 on throat/nasopharyngeal samples were enrolled and their clinical features and outcomes were studied. During the study period, 77 children with COVID-19 infection were admitted, of whom two-third (59.7%) were <5 yr old. The common presenting symptom was fever (77%), followed by respiratory distress. Comorbidities were noted in 34 (44.2%) children. Most of the patients belonged to the mild severity category (41.55%). While 25.97 per cent of patients presented in severe category and 19.48 per cent were asymptomatic. Admission to intensive care was needed in 20 (25.9%) patients, with 13 patients needing invasive ventilation. Nine patients succumbed while 68 were discharged. The results might help understand the course, severity profile and outcomes of the second wave of the COVID-19 pandemic in the paediatric population.

Analysis of Fluid Balance as Predictor of Length of Assisted Mechanical Ventilation in Children Admitted to Pediatric Intensive Care Unit (PICU).

Background: Ventilator-associated lung injury (VALI) is a devastating complication of assisted mechanical ventilation (AMV) and is one of the root causes of prolonged AMV. Many strategies were made to decrease the effect of the same. This study is conducted to determine the association of prolonged AMV with fluid balance and pediatric index of mortality 2 (PIM2) score. Methods: This prospective observational study was carried out in a PICU of a tertiary care centre over a period of 12 months. Patient's fluid balance was calculated by tabulating fluid input-output over initial 48 hours of AMV. The PIM2 score on admission was documented. The association between qualitative variables was assessed by a chi-square test. Comparison of quantitative data measured between cases with duration of AMV ≥ 7 days and <7 days was done using the Mann-Whitney U test. Correlation between quantitative data was done by using the Pearson product moment correlation. Results: Out of 40 patients, 27 patients who had ≥15% positive fluid balance required prolonged mechanical ventilation. Similarly, 27 patients with PIM2 score ≥ 5 required prolonged AMV. On applying the Pearson chi-square test, we found a significant association between positive fluid balance and prolonged mechanical ventilation (P value = 2.25 × 10-7 (<0.05)). Likewise, a statistically significant association was found between PIM2 score and prolonged ventilation (P value = 1.19 × 10-5 (<0.05)). Conclusion: There is a significant association of prolonged AMV with positive fluid balance (>15%) and PIM2 score (>5). By strict maintenance of fluid balance with appropriate intervention, the length of AMV and PICU stay can be decreased.

DREEM Study: Students Perceptions of Learning Environment in a Medical College in Mumbai, India.

PURPOSE: This study was carried out to assess medical education environment (MEE) at our institution and to determine if there is an association between the assessment scores and factors such as gender, residence, family educational background and medium of instruction during school years. METHODS: Students appearing for the final qualifying examination were enrolled in the cross-sectional survey after obtaining written informed consent. Demographic data and personal information such as place of residence, parental education and medium of instruction was collected. The Dundee Ready Education Environment Measure (DREEM) Questionnaire was used for assessment of MEE. The numerical variables were described in terms of mean and standard deviation, median and inter-quartile range and percentages. Independent t-test, one-way Anova, Mann-Whitney test and Kruskall- Wallis test were the analytical tests used depending upon the number of groups and characteristics of the data. RESULTS: Fifty-five students were enrolled in the study. The overall DREEM score was 119+/-22 (Median 116), 46(83.64%) reported overall positive perception). Students' perception of atmosphere (SPA) scored highest as compared to other domains. Teacher-centered teaching with emphasis on factual learning, authoritarian teachers, boredom in the course and lacking support systems were some of the problem areas identified on the basis of students' perceptions. There was a significant difference in Students' academic self-perception (SASP) and students' social self-perception scores between students coming from urban and rural backgrounds. CONCLUSIONS: Students reported an overall positive perception of MEE. Problem areas and research priorities were identified leading to a preparation of an action plan.

Auto-immune Thyroiditis in an Infant Masquerading as Congenital Nephrotic Syndrome.

A seven-months-old girl under treatment for pneumonia presented with generalized edema, decreased urinary output and was found to have hypertension, muco-cutaneous fungal infection and pulmonary hypertension. Investigations revealed that she had heavy proteinuria, hypertriglyceridemia, hypoalbuminemia and elevated levels of free T3 and T4 with suppression of TSH levels in the serum. A diagnosis of autoimmune thyroiditis (AT) in thyrotoxic phase was made on the basis of clinical presentation and presence of anti-TPO antibodies and reduced uptake in thyroid (technetium) scintigraphy. The child responded to carbimazole therapy and propranolol. The case is presented to remind pediatricians about the rare occurrence of auto-immune thyroiditis in infancy with rare complications such as nephrotic syndrome and pulmonary hypertension.

Congenital Hypothyroidism: An Unusual Combination of Biochemical Abnormalities.

A forty-five-day-old female infant presented with prolonged jaundice with clinical features suggestive of congenital hypothyroidism (CHT). On investigations, the infant was noted to have indirect hyperbilirubinemia (13.8 mg/dl) with increased levels of AST (298 IU/dl) and ALT (174 IU/dl) in the serum. The child had low levels of free T3 (<1 pg/ml) and free T4 (0.4 ng/dl) secondary to thyroid agenesis detected on radionuclide scan and ultrasonography of the neck and raised levels of TSH (>500 microIU/ml) in the serum. The combination of indirect hyperbilirubinemia and raised levels of hepatic transaminases has not been reported in babies with CHT. Following institution of oral thyroxin therapy, the serum bilirubin levels ameliorated (2.9 mg/dl) considerably by 15 days of therapy and the serum levels of AST (40 IU/dl) and ALT (20 IU/dl) got normalized. The case demonstrates that raised levels of hepatic transaminases can occur in infants with CHT and these can resolve just with thyroxin therapy, obviating the need for extensive investigative laboratory work-up.

A Swelling over Sternum in a Child: Reminder of an Uncommon Diagnosis.

Lack of awareness about isolated tubercular osteomyelitis of the sternum resulted in a delay in diagnosing the condition in an eleven-year-old girl who presented with a gradually increasing swelling over the sternum. Radiological, histological, and microbiological investigations helped diagnose the condition and the child responded well to antitubercular therapy (ATT) and surgical debridement. The report provides a brief description about the various management options available.

Choosing the Right Journal for a Scientific Paper.

Authors need to take the crucial decision of choosing the journal for their prospective manuscript before even starting to write it. Although, this choice is influenced by many factors, matching the intended recipients of the main message of the manuscript with a journal's readership should override all other consideration in journal selection. That done, availability of time-bound review process,journal's visibility, indexation in databases, regularity of publication, acceptance rate and expenses involved are some other factors that will help decide the choice.

Writing Case Reports: Contributing to Practice and Research.

Case reports describe a patient with unusual or unexpected features. They represent the oldest type of medical publication. They are about generating a new hypothesis and not about proving a hypothesis. Hence, despite being considered as the lowest level of evidence; they continue to be relevant for clinical practice, research and medical education. This article intends to provide guidance regarding writing a case report to those wishing to make a foray in scientific writing through reporting an interesting case.

Off-label and unlicensed drug use in children admitted to Pediatric Intensive Care Units (PICU).

BACKGROUND: There is paucity of data regarding the use of off-label (OL) and unlicensed drug (UL) use in children admitted to the Pediatric Intensive Care Units (PICUs). OBJECTIVE: To determine prevalence of OL- and UL-drug use in children admitted to PICU. DESIGN: Prospective observational study. SETTING: PICU in Mumbai (formerly Bombay), India. PARTICIPANTS: Consecutive patients aged 28 d-12 yr admitted over 12-mo period. METHODS: Prescriptions issued to PICU patients were surveyed and demographic data, diagnosis and details of drugs used (dose, frequency, route of administration, indication, and UL use) were noted. Descriptive statistics was used for providing prevalence of OL drug (including category) and UL use. Fisher-Pearson test was used to determine the significance of age, mechanical ventilation and number of systems involved with reference to OL- and UL-drug use. RESULTS: 482 participants received 1789 [OL: 738(41.25%) and UL: 376(21.01%)] drug prescriptions; OL-drug use was highest in infants (56.52%) with indication outside the license (32.37%) being the commonest category of OL-drug use across all age-groups. Unlicensed drug use was entirely due to extemporaneously-prepared drug (EPD) use. The OL drug- and EPD-use were significantly associated with infancy and ventilation therapy. CONCLUSIONS: The high prevalence of OL- and UL-drug use in children admitted in the PICU significantly compromises their right to safe drugs. As most of the OL drug use is related to drugs used in children for several years; legislative and regulatory initiatives are required to ensure that accumulated evidence and experience gets incorporated in the license.

A rare nonfatal presentation of disseminated Chromobacterium violaceum sepsis.

We present a case of disseminated Chromobacterium violaceum sepsis with multiple liver and splenic abscesses presenting with skin lesions and cardiogenic shock, and later diagnosed to have chronic granulomatous disease. The patient was treated with prolonged antimicrobial therapy, after which she recovered and remained asymptomatic on follow-up.