ADVANCING THE UNDERSTANDING OF CLINICAL SEPSIS USING GENE EXPRESSION-DRIVEN MACHINE LEARNING TO IMPROVE PATIENT OUTCOMES.

ABSTRACT: Sepsis remains a major challenge that necessitates improved approaches to enhance patient outcomes. This study explored the potential of machine learning (ML) techniques to bridge the gap between clinical data and gene expression information to better predict and understand sepsis. We discuss the application of ML algorithms, including neural networks, deep learning, and ensemble methods, to address key evidence gaps and overcome the challenges in sepsis research. The lack of a clear definition of sepsis is highlighted as a major hurdle, but ML models offer a workaround by focusing on endpoint prediction. We emphasize the significance of gene transcript information and its use in ML models to provide insights into sepsis pathophysiology and biomarker identification. Temporal analysis and integration of gene expression data further enhance the accuracy and predictive capabilities of ML models for sepsis. Although challenges such as interpretability and bias exist, ML research offers exciting prospects for addressing critical clinical problems, improving sepsis management, and advancing precision medicine approaches. Collaborative efforts between clinicians and data scientists are essential for the successful implementation and translation of ML models into clinical practice. Machine learning has the potential to revolutionize our understanding of sepsis and significantly improve patient outcomes. Further research and collaboration between clinicians and data scientists are needed to fully understand the potential of ML in sepsis management.

Primary neurological manifestations of HIV in children.

Human immunodeficiency virus type 1 (HIV-1) causes various diseases in different age groups. Neurological manifestations of HIV are common and add to morbidity and mortality. It was previously thought that the central nervous system (CNS) was involved only in the advanced stages of the disease. However, recent evidence supports pathological involvement of the CNS from initial viral entry. Some of the CNS manifestations in children share similarities to neurologic disorders of HIV-infected adult patients, while others are unique to the pediatric population. Many HIV-related neurologic complications seen in adults are rarely encountered in children with AIDS and vice versa. However, with recent advances in the treatment, more HIV-infected children are surviving into adulthood. A systematic review of the available literature was performed to study the manifestations, causes, outcomes, and treatment of primary neurologic disorders in children with HIV. Online databases (Ovid Medline, Embase and PubMed), websites from the World Health Organization, commercial search engines, including Google, and chapters on HIV in standard textbooks of pediatrics and medicine were reviewed. HIV-associated neurological syndromes can be classified into four types: primary HIV neurological diseases, treatment-related neurological diseases, adverse neurological effects of antiretroviral therapy and secondary/opportunistic neurological illness. These conditions are not mutually exclusive and may co-exist in a given patient. This narrative review will focus mainly on the primary neurological manifestations of HIV in children.

Giant Coronary Aneurysm in an Infant with Multisystem Inflammatory Syndrome.

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV2), also known as COVID-19, has rapidly spread resulting in a worldwide pandemic. Although COVID-19 infections in children are generally mild and nonfatal, there is increasing recognition of its association with the multisystem inflammatory syndrome in children (MIS-C), leading to serious illness and possible long-term complications. This report describes a 6-month-old Indian infant who presented with a 4-day history of fever with nonspecific signs of viral illness and erythematous rash. Although the initial echocardiogram was normal, subsequent scans showed progressive dilatation of bilateral coronary arteries. Despite the timely intervention, he developed left coronary artery thrombosis, leading to myocardial infarction. His SARS-CoV-2 antibody titers were strongly positive. Through this case, we discuss the management of MIS-C with coronary artery involvement. The long-term outcome of coronary artery aneurysm due to MIS-C remains unknown and close follow-up is important. Further research is pivotal for a better understanding of MIS-C.

Postoperative Adhesive Small Bowel Obstruction Presenting as Acute Urinary Retention.

Postoperative adhesions are commonly seen after most abdominal surgeries. The majority of patients with intra-abdominal adhesions remain asymptomatic; however, some patients may develop symptoms ranging from mild abdominal pain to sometimes life-threatening complications. The most severe complication seen in association with postoperative adhesions is small bowel obstruction (SBO). This complication is rarely seen in the pediatric age-group. Adhesions have the potential to cause bowel obstruction. In addition, they can also affect the normal intestinal motility and transit leading to constipation. Several studies reported in literature show a strong association between constipation and the urinary disorders, such as incontinence and urinary urgency. We herein report a case of a boy who developed adhesive SBO with segmental ileal dilatation leading to constipation, urinary symptoms, and finally presenting to our hospital as acute urinary retention. How to cite this article: Zaki SA, Banur D, Chaudhary N, Gebran S. Postoperative Adhesive Small Bowel Obstruction Presenting as Acute Urinary Retention. Indian J Crit Care Med 2022;26(6):739-741.

Cardiovascular Toxicity Due to Otilonium Bromide Overdose: A Case Report.

BACKGROUND: Otilonium bromide is a quaternary ammonium compound commonly used in the management of irritable bowel syndrome. There are no previously published cases of overdose of otilonium bromide in humans. Due to its poor systemic absorption, it acts locally and has an excellent safety profile. Data from safety and postmarketing observation showed that otilonium bromide is well tolerated and that side effects do not differ significantly from those seen with placebo. The drug has proven to be practically toxicity free in animals and hence, assumed not to cause any specific problems in humans in case of overdose. CASE REPORT: We report a rare case of a 16-year-old girl who developed systemic hypotension (76/40 mm Hg) after an overdose of otilonium bromide tablets. She ingested 25 tablets of otilonium bromide (40 mg) over a period of 4 h. Subsequently, she responded to a bolus of normal saline and calcium gluconate, leading to normalization of her hemodynamic parameters. Why Should an Emergency Physician Be Aware of This? Due to a lack of reported cases, it is generally assumed that otilonium bromide overdose does not cause any specific problems in humans. However, with the drug being widely used for irritable bowel syndrome and other conditions, the chance of encountering cases of otilonium bromide overdose will increase. Through this case we aim to increase awareness among emergency physicians regarding the potential toxic effects of otilonium bromide overdosage.

Severe hypertension in pediatric diabetic ketoacidosis a case report and review of literature.

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus in children. Despite the presence of dehydration, hypertension occurs in a significant proportion of children with DKA. There is a lack of clarity in the literature regarding the management of hypertension in patients with paediatric DKA. Herein, we report the case of an adolescent boy who presented with DKA and severe hypertension. His neurological status was closely monitored. There was a gradual decline in his blood pressure with an improvement in the pH over the next 72 hours. The combination of severe DKA and hypertension can be a challenging clinical dilemma, especially regarding fluid management. Studies on severe DKA in children are exacting, given the rarity of this condition. A multi-centre study is suggested to provide a meaningful analysis of this aspect of DKA.

Ortner's Syndrome as a Presenting Feature of Congenital Heart Disease in Infants.

Ortner's syndrome is a rare condition characterized by hoarseness of voice due to left recurrent laryngeal nerve (RLN) palsy in association with cardiovascular disease. We report two cases of congenital heart disease in infants presenting with Ortner's syndrome. We believe that the dilated pulmonary artery in the first case and the left atrial dilatation in the second case caused compression of the left RLN resulting in hoarseness of voice. After the corrective cardiac surgery, the voice of both the infants had normalized. Through this case report, we highlight that Ortner's syndrome is an important differential diagnosis of hoarseness of voice in infancy.

A review of artifacts in histopathology.

Histopathological examination is considered as gold standard procedure for arriving at a final diagnosis of various lesions of the human body. However, it is limited by a number of alterations of normal morphologic and cytological features that occur as a result of presence of artifacts. These artifacts may occur during surgical removal, fixation, tissue processing, embedding and microtomy and staining and mounting procedures. They can even lead to complete uselessness of the tissue. It is therefore essential to identify the commonly occurring artifacts during histopathological interpretations of tissue sections. This article reviews the common artifacts encountered during slide examination alongside the remedial measures which can be undertaken to differentiate between an artifact and tissue constituent.

Octreotide Use in Neonates: A Case Series.

BACKGROUND AND OBJECTIVE: Octreotide is a somatostatin analogue and has been used off-label for a variety of conditions. There are no specific guidelines for the use of octreotide in neonates and its safety and efficacy have not been systematically evaluated. The objective of this study is to present our experience of using octreotide therapy in neonates. METHODS: This is a retrospective study of neonates who received octreotide therapy during their hospital stay over a 15 years period (2003-2017) in a tertiary neonatal centre. The demographic details and indications of octreotide therapy including time of initiation, route, dose, duration and adverse effects of therapy were noted. The clinical course following octreotide administration was also analysed. RESULTS: Eleven neonates received octreotide therapy during the study period, of which nine had chylothorax and two had chylous ascites. Resolution of the chylous effusion with octreotide therapy was achieved in 4 out of 11 (36.3%) of the cases. The median duration of octreotide therapy in cases with successful resolution was 17.5 days. With the exception of minor side effects such as hyperglycaemia, none of the patients had any significant side effects that required discontinuation of therapy. CONCLUSION: Octreotide was used safely as an adjunctive therapy for the treatment of chylothorax and chylous ascites in neonates. However, larger prospective controlled trials are required to establish the optimal dose, time of initiation, duration and efficacy of octreotide therapy in neonates.

Cardiac status in children with acute poststreptococcal glomerulonephritis.

Acute poststreptococcal glomerulonephritis (PSGN) is the most common type of glomerulonephritis seen in children. It can affect multiple organs with heart being frequently involved. Yet, there are very few studies on cardiac status in children with PSGN and hence this study was conducted. All consecutive children from 1 month to 12 years of age, admitted over a two-year period with a diagnosis of PSGN, were included in the study. An electrocardiogram (ECG) and two-dimensional echocardiogram were performed in all patients on admission and repeated at six and 12 weeks, if abnormal. A total of thirty patients (18 males and 12 females) were enrolled in the study. The median age was six years. Prolonged QTc interval was found in 11 patients (37 %), of whom nine had hypertension. Seven of the 30 patients had a left ventricular ejection fraction (LVEF) <60%. The same patients also had left atrium/aorta ratio >2 and E/A ratio >2. LVEF returned to normal by six weeks in all except one patient, in whom it was normal by 12 weeks. Two of seven patients with low LVEF had normal blood pressure. All the seven patients recovered completely on follow-up. ECG and echocardiographic abnormalities may be seen in the acute phase of PSGN but are usually transient, returning to normal in most patients by three months. Although hypertension is the most common cause of cardiac failure, the role of primary myocardial dysfunction should also be considered.

Panayiotopoulos syndrome in a child masquerading as septic shock.

Panayiotopoulos syndrome (PS) is a benign childhood epilepsy with predominant autonomic symptoms. The syndrome can have varied presentations resulting in diagnostic dilemma. We herein describe a 3-year-old boy with PS, who had manifestations similar to septic shock. His investigations were normal and had a complete recovery. Through this case, we wish to highlight the unusual presentation of PS as septic shock. Physicians should be aware of the different ways in which this syndrome can present to ensure its early diagnosis and treatment.

Community-acquired pseudomonas aeruginosa liver abscess with portal vein thrombosis in a child.

Pseudomonas aeruginosa is usually considered a relatively rare pathogen of pyogenic liver abscess in healthy children. A 3-year-old girl presented with fever, abdominal pain, and vomiting. Ultrasonography of the abdomen showed multiple liver abscesses. During her stay in hospital, she developed portal vein thrombosis, hepatic encephalopathy, and multiorgan dysfunction. Her blood culture and pus culture grew pseudomonas aeruginosa. She was started on intravenous antibiotics and supportive treatment. Ultrasound guided aspiration was done and a pigtail catheter was inserted. However, she did not respond to the treatment and died on the 14(th) day of admission. The immune work up of the patient was normal. Through this case, we wish to highlight this unusual case of community-acquired pseudomonas aeruginosa liver abscess in a previously healthy child. Clinicians should be aware of this association for early diagnosis and timely management.

Levetiracetam-induced acute psychosis in a child.

Levetiracetam is well-tolerated and commonly used as a broad spectrum antiepileptic in both partial and generalized seizures. Few cases of levetiracetam-induced psychosis in children are reported in the literature. The present case of levetiracetam-induced acute psychosis highlights the adverse effect of this drug and also emphasizes the need for close monitoring of children on levetiracetam.

Unusual presentation of poststreptococcal glomerulonephritis as posterior reversible encephalopathy syndrome.

Posterior reversible encephalopathy syndrome (PRES) is a rare clinicoradiologic condition manifesting with headache, seizures, altered sensorium, visual disturbances, and characteristic lesions on neuroimaging predominantly affecting the posterior regions of the brain. We report a case of an 8-year-old boy with poststreptococcal glomerulonephritis, presenting as PRES. A magnetic resonance imaging showed hyperintense lesions in bilateral frontal and parietooccipital parenchyma on fluid-attenuated inversion recovery and T2-weighted images, suggestive of "PRES." Patient made a complete neurological recovery without any deficit.

Caroli's syndrome with autosomal recessive polycystic kidney disease.

Caroli's syndrome (CS) is a rare congenital disorder characterized by multiple segmental cystic or saccular dilatations of the intrahepatic bile ducts and congenital hepatic fibrosis. We report a 9-year-old boy who was diagnosed with CS and autosomal recessive poly-cystic kidney disease. On screening, his 5-month-old asymptomatic sister had multiple dilated biliary radicals with multiple bilateral renal cystic lesions. Both the patient and the affected sibling have been advised regular follow-up for monitoring the progression of the disease. In conclusion, patients with CS should be screened for renal cystic lesions and vice versa even if they are asymptomatic. Also, as the disease is inherited in an autosomal recessive manner, it is important to screen family members for early diagnosis and management.