Pediatric Risk of Mortality III Score - Predictor of Mortality and Hospital Stay in Pediatric Intensive Care Unit.

BACKGROUND: Pediatric Risk of Mortality (PRISM) III score is one of the widely used scoring systems to quantify critical illness in the pediatric age group. This study was carried out to find the association of PRISM III score with the outcome (discharge/mortality) and also hospital stay in survivors and nonsurvivors. SETTING: The study was conducted in a tertiary care hospital from January 2014 to June 2015. MATERIALS AND METHODS: A total of 524 patients were admitted, and after excluding the patients who met the exclusion criteria, 486 patients were analyzed. STATISTICAL ANALYSIS: Logistic regression was used to find the association of variables under the PRISM III score with mortality. Linear regression was used to find the association of PRISM III score with length of stay. RESULTS: Mortality was 31%; male: female ratio was 1.5:1. Maximum patients presented with respiratory system involvement (26.3%), and maximum mortality (20.3%) was observed in the patients with respiratory involvement. Discrimination by the model between mortality and survival was excellent (receiver operating characteristic curve [0.903]). Maximum risk of mortality was noticed in mechanically ventilated patients (odds ratio [OR]: 10.87) followed by lower systolic blood pressure (OR: 2.72), deranged prothrombin time, partial thromboplastin time (OR: 1.50), deranged mental status (OR: 1.41), and tachycardia (OR: 1.37). Length of stay (LOS) in patients increased till PRISM III score of 25. Average LOS in survivors was 4.327 days which was not accounted by difference in PRISM III score between different patients. With each unit increase in PRISM III score, LOS increased by 5 h. CONCLUSIONS: PRISM III score has excellent capacity to discriminate between survival and mortality. PRISM III score can be used to predict LOS among survivors.

Mitotic Recombination and Rapid Genome Evolution in the Invasive Forest Pathogen Phytophthora ramorum.

Invasive alien species often have reduced genetic diversity and must adapt to new environments. Given the success of many invasions, this is sometimes called the genetic paradox of invasion. Phytophthora ramorum is invasive, limited to asexual reproduction within four lineages, and presumed clonal. It is responsible for sudden oak death in the United States, sudden larch death in Europe, and ramorum blight in North America and Europe. We sequenced the genomes of 107 isolates to determine how this pathogen can overcome the invasion paradox. Mitotic recombination (MR) associated with transposons and low gene density has generated runs of homozygosity (ROH) affecting 2,698 genes, resulting in novel genotypic diversity within the lineages. One ROH enriched in effectors was fixed in the NA1 lineage. An independent ROH affected the same scaffold in the EU1 lineage, suggesting an MR hot spot and a selection target. Differences in host infection between EU1 isolates with and without the ROH suggest that they may differ in aggressiveness. Non-core regions (not shared by all lineages) had signatures of accelerated evolution and were enriched in putative pathogenicity genes and transposons. There was a striking pattern of gene loss, including all effectors, in the non-core EU2 genome. Positive selection was observed in 8.0% of RxLR and 18.8% of Crinkler effector genes compared with 0.9% of the core eukaryotic gene set. We conclude that the P. ramorum lineages are diverging via a rapidly evolving non-core genome and that the invasive asexual lineages are not clonal, but display genotypic diversity caused by MR.IMPORTANCE Alien species are often successful invaders in new environments, despite the introduction of a few isolates with a reduced genetic pool. This is called the genetic paradox of invasion. We found two mechanisms by which the invasive forest pathogen causing sudden oak and sudden larch death can evolve. Extensive mitotic recombination producing runs of homozygosity generates genotypic diversity even in the absence of sexual reproduction, and rapid turnover of genes in the non-core, or nonessential portion of genome not shared by all isolates, allows pathogenicity genes to evolve rapidly or be eliminated while retaining essential genes. Mitotic recombination events occur in genomic hot spots, resulting in similar ROH patterns in different isolates or groups; one ROH, independently generated in two different groups, was enriched in pathogenicity genes and may be a target for selection. This provides important insights into the evolution of invasive alien pathogens and their potential for adaptation and future persistence.

Emergent laparoscopic repair of a spigelian hernia: case report and review of the literature.

A spigelian hernia is a protrusion through an anterior abdominal wall defect along the linea semilunaris. The traditional method of repair consists of an open surgical technique requiring a lengthy abdominal incision to allow visualization of the defect. However, with the emergence and availability of laparoscopic techniques, a minimally invasive approach is feasible. Only eight prior case reports have documented emergent laparoscopic repair of a spigelian hernia. We describe the first successful laparoscopic repair of a spigelian hernia in an emergent setting at our institution.

NSAID-Associated Perforation of a Meckels Diverticulum: A Case Report.

UNLABELLED: Meckels diverticulum is the most frequent congenital malformation of the gastrointestinal tract. The most common ectopic tissue within a Meckels is heterotopic gastric mucosa, with bleeding being the most common presentation. However, perforation of a Meckels diverticulum is a rare presentation. NSAID-associated Meckels perforation has been suggested, however has not been documented in the literature. We present a case of a 17-year-old female with acute abdominal pain and tenderness following a 24-hour history of excessive ingestion of NSAIDS for pain related to tooth extraction. Chest radiograph demonstrated free intra-abdominal air and she was subsequently taken for exploratory laparotomy. A perforated Meckels diverticulum was isolated and resected. Though NSAID-associated bleeding of heterotopic gastric mucosa has been described, and perforation of the Meckels diverticulum has been suggested, no clear association between heterotopic gastric mucosa and perforation exists. On the other hand, the relationship between NSAIDS and gastric ulcer perforation is well documented. A similar mechanism may also play a role in NSAID-associated Meckels perforation. With how common NSAID use is, we believe it is important to document NSAID-associated perforation of a Meckels diverticulum. KEYWORDS: Meckels diverticulum; NSAIDS; Perforation; Heterotopic gastric mucosa.