Methemoglobinemia Secondary to a Traditional Healing Practice Using Mothballs: A Need of Pediatric Vigilance.

Acute-onset unexplained hypoxemia persisting despite 100% oxygen has a limited differential diagnosis but poses a challenging diagnostic dilemma. Methemoglobinemia, a hemolytic condition, may lead to significant complications if it goes undiagnosed during the critical golden hour of an emergency department (ED) presentation. This case report presents the clinical details of a 30-month-old child with acute intravascular hemolysis evident by severe pallor and hemoglobinuria and severe hypoxia documented on pulse oximetry. During the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) of the primary survey, "exposure" revealed the parent's deliberate fastening of a mothball around the waist of the baby on the advice of a traditional healer, which was identified as the source of naphthalene toxicity. The swift intervention was undertaken for hypoxic respiratory compromise with 100% oxygen just after triage, and the naphthalene ball with the tied cloth was removed. Arterial blood gas and co-oximetry analysis confirmed the diagnosis of methemoglobinemia, and other laboratory tests suggested severe hemolytic anaemia as well as hemoglobinuria favouring intravascular hemolysis. With the exclusion of other common differentials for hemolytic anaemia, including sickle cell crisis, autoimmune hemolytic anaemia, hemolytic uremic syndrome, and G6PD deficiency, naphthalene exposure was considered the culprit for both hemolysis and methemoglobinemia. After obtaining the history of another similar episode of anaemia six months ago requiring blood transfusion, we retrospected on similar mothball exposure, but parents denied that, saying they were using the mothball only for the last 10 days on the advice of a local healer with intent to get rid of some evil power and sickness in their child. After analyzing the old records of prior hospitalization and getting assured of a normal report of G6PD level, intravenous methylene blue was administered. But in view of an inadequate response, a single blood volume exchange transfusion was performed during the ED stay only, which resulted in a notable reduction in subsequent methemoglobin levels and an improvement of the child's clinical condition by the second day. The child was discharged by the third day with no distress and no further episodes of hemoglobinuria, with detailed parental counselling and follow-up advice. This case underscores the imperative need for timely recognition and effective management of methemoglobinemia in the paediatric population while emphasizing the potential hazards associated with naphthalene exposure. Further comprehensive investigations are warranted to elucidate optimal treatment strategies and explore long-term outcomes in similar clinical scenarios.

The Assessment of the Spectrum of Preventive Measures Taken by Healthcare Providers During the COVID-19 Pandemic in India: A Survey-Based Study.

INTRODUCTION: The first wave of the coronavirus disease 2019 (COVID-19) pandemic created havoc and confusion in choosing appropriate treatment, as well as prophylaxis, due to its rapid surge, disease novelty, and lack of evidence-based literature. It was even more concerning among the healthcare workers (HCWs), who had to take care of patients, themselves, and their own families. OBJECTIVE: This online survey-based study targeted finding the various options for COVID-19 precautionary or prophylactic measures opted for by HCWs. METHODOLOGY: This was an observational study based on a predesigned questionnaire, which was floated online for three months after institutional ethical approval, just after the first wave of COVID-19 in 2021, targeting HCWs of different cadres (doctors, nurses, paramedics/laboratory technicians, etc.), ages, and sexes and HCWs hailing from across the country. Questions were focused on HCW's adopted measures, the order of preference and its reasons, and concerns related to safety and efficacy. Data was collected through Google Forms (Google, Inc., Mountain View, CA) into an Excel spreadsheet (Microsoft® Corp., Redmond, WA) and analyzed by the latest Statistical Package for Social Sciences (SPSS) software (IBM SPSS Statistics, Armonk, NY) using appropriate statistics. RESULTS: The routine practice of standard precautionary measures (face mask, hand hygiene, and social distancing) and wearing a personal protective equipment (PPE) kit during the care of COVID-19-positive or COVID-19-suspected patients was adopted by the majority of HCWs, i.e., 306/312 (>98%) irrespective of cadre (p = 0.001). After the "routine measures," the most adopted measure by participant HCWs irrespective of profession, age, and gender was the consumption of allopathic drugs (n = 188; 60.26%). Anti-COVID-19 measures in the category of drugs used by healthcare providers (HCPs) were prophylactic allopathic drugs (60.26%), homeopathic drugs (11.86%), and other Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy (AYUSH)/traditional medical system drugs (11.86%). Vitamin C was the most consumed among all of the drugs for COVID-19 prophylaxis purposes. Non-drug measures espoused by the HCPs were physical exercises (46.47%), increased sleep duration (35.89%), change in dietary habits (42.62%), and spiritual measures (19.23%). CONCLUSION: The fear of COVID-19 imposed on the HCPs the obligation to use all the available preventive measures in spite of the lack of evidence on actual benefits. After the routine infection preventive measures, the most adopted measure by participant HCWs irrespective of profession, age, and gender was the consumption of prophylactic allopathic drugs (>60%), and the most non-drug preventive measures were the initiation of physical exercises and change in dietary habits. Adapting some form of physical exercise was more noted with males than females (p = 0.001), and it significantly increased with HCPs of higher age of >25 and >40 years than younger HCPs (58.6% versus 29.3%; p = 0.016). Females preferred more dietary and nutritional modifications.

Trivial Blunt Chest Trauma Leading to Acute Respiratory Distress Syndrome in a Child.

Both blunt and penetrating chest trauma in children are less common than in adults but cause severe acute morbidity and mortality. As the literature suggests, pulmonary contusion is the most common chest injury in children, occurring in more than half of all blunt chest trauma cases. Even patients with blunt injuries are likely to have a longer hospital stay. The difference in physiological and anatomical variations in children compared to adults makes it more difficult from the diagnosis, management, and monitoring perspectives. A thorough physical examination is needed with close clinical monitoring, and additional vigilance is important during the management of a child. The physiologic consequences, such as the dreaded complication of alveolar hemorrhage and pulmonary parenchymal destruction, usually manifest within a few hours of the trauma and can take up to seven days to recover. Hence, timely diagnosis is crucial during the emergency evaluation. The clinical diagnosis can be supported by a special imaging modality in the form of chest computed tomography (CT), which confirms the radiological parenchymal destruction with high sensitivity. Management is mostly supportive to start with and includes high-flow oxygen, ventilatory pressure support as needed for the severity of acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), judicious fluid administration, control of the pain associated with bony and thoracic soft tissue injuries, and careful hemodynamic monitoring for other complications and sequelae likely to develop. Here, we report an interesting case of a 10-year-old male child presenting to the Pediatric Emergency Department with acute moderate-to-severe respiratory distress that developed after two days of a few vomiting episodes along with non-specific lower chest and substernal pain following blunt trauma to the chest. The injury was trivial in nature as described by the father caused by an accidental fall on a small pile of bricks while playing near his home. After triaging under the red category, the child was managed in line with acute respiratory distress. We ruled out pneumothorax, hemorrhagic pleural effusion or pericardial effusion, and other evidence of invasive chest as well as gross abdominal injuries by comprehensive but focused history and clinical examinations, including adjuncts such as point-of-care ultrasound) and chest X-ray (CXR). Although the initial arterial blood gas analyses were suggestive of a mild form of ARDS or ALI by the criteria based on the P:F ratio (PaO2 to FiO2 ratio, which was between 200 and 300 for the case), the CXR and the chest CT revealed that the child had significant lung parenchymal injury in the form of bilateral fluffy pulmonary infiltrates. This case indicates that even a trivial blunt trauma can induce certain mechanisms of lung injury, leading to severe manifestations and sometimes fatal complications such as pulmonary contusion, hemorrhage, and ARDS.

Accidental Phosgene Poisoning: A Case Report and Short Review of Management.

BACKGROUND: Phosgene is a chemical used in the manufacture of plastics and pesticides. Phosgene remains one of the most dangerous of today's high-volume chemicals, as evidenced by the deaths and widespread evacuations caused by its release in industrial accidents. The respiratory system is most severely harmed by exposure to phosgene. CASE PRESENTATION: A 39-year-old male patient arrived feeling short of breath, nauseous, and tachypnoeic after being exposed to triphosgene gas at work. Upon examination, the patient's oxygen saturation (spo2) was 72% without oxygen, 95% on 15 L of oxygen (o2), hemodynamically unstable, and transferred to the intensive care unit (ICU) for additional care. A ventilator was started in non-invasive mode, and antibiotics were administered based on an initial CT scan of the chest that revealed bilateral fluffy alveolar deposits. The same course of treatment was continued on day two. Chest X-ray shadows improved starting on day three. Saturation is 95% after weaning off Niv support and placing 5 L of o2. He was discharged with oral medications once he was hemodynamically stable. CONCLUSION: An incidental phosgene poisoning is described in detail here, along with its clinical symptoms and treatment. It is critical to suspect phosgene gas exposure and monitor such patients to save lives.

Knowledge, Awareness, and Understanding of Pediatric Triage Among Nursing Officers in India: A Multicenter Study.

INTRODUCTION:  Triage is crucial in patient screening within emergency departments (EDs) worldwide. It is one of the essential and standard medical practices in many developed countries. However, in India, there is a need for improvement in triage utilization, as it is predominantly performed by resident doctors or medical officers, leading to an uneven distribution of clinical skills among healthcare providers (HCPs). A comprehensive analysis incorporating literature review and data collection revealed that while mandatory screening is conducted in most Indian EDs, the formal implementation of standardized triage protocols remains limited. Like in developed countries, registered nurses or nursing officers (NOs) can be effectively trained and directed to play the role of dedicated triage personnel in EDs of most of the healthcare facilities in India. METHOD AND MATERIALS:  This study aimed to examine the current state of triage utilization and its impact on the distribution of responsibilities among HCPs in Indian EDs. Through this online survey, the investigators assessed the knowledge and practical understanding of clinical triaging among NOs, working at various hospitals nationwide. RESULTS:  The participants included 5,029 NOs working in various parts of India, predominantly nursing graduates (82.52%), the majority being employed in government healthcare settings (84.01%) and most having over five years of cumulative working experience in the ED (70.77%). Nurses showed inadequate knowledge and awareness about the Pediatric Assessment Triangle (PAT) used for quick initial evaluation (62.18% among all participants). Concerning the complete triage process applicable, especially in pediatric ED settings, they had even less satisfactory knowledge and understanding, e.g., identifying primary (28.27%) and secondary (22.69%) survey components via focused history and examination, properly using temperature assessment (23.32%) and instant blood glucose level assessment (22.95%) in triage, and knowing various types of internationally accepted triage systems for ED-based health facilities such as the Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), and Australasian Triage Scale (ATS) (15.87%). ANOVA and post hoc analysis revealed that the intergroup performance of the study participants with maximum correct responses to the knowledge-determining specified subset of the questionnaire depicts the significantly higher role of graduate nursing degree over diploma such as General Nursing and Midwifery (GNM)/Auxiliary Nursing and Midwifery (ANM) qualification, working in government hospital versus private setup, and ED working experience of >5 years over that of <5 years. CONCLUSIONS:  Of the participants in the study, 50% were not evaluated for cognitive or psychomotor domains during their assessment examinations. The research illuminated a significant disparity in knowledge and proficiency levels among Indian nurses concerning pediatric triage, especially with the ability to effectively apply the PAT for initial patient evaluations, discern components of primary and secondary surveys, and comprehend various triage systems. This study underscores the importance of comprehensive reform in the Indian healthcare system and teaching curriculum by emphasizing clinical triage training and interprofessional collaboration, and establishing guidelines and regulations to ensure consistent and standardized triage practices across all EDs.

A Comparative Study on Safety and Efficacy of Desvenlafaxine Versus Sertraline in Depression.

Background Depression is one of the most predominant mental health issues that are prevalent now. Therefore, many clinical trials were being conducted to find the safest, most effective, and tolerable anti-depressant. This study aims to compare desvenlafaxine and sertraline regarding their safety and efficacy in treating depression. Methodology The patients who were diagnosed with depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria were included in the study and were divided into two groups. The severity of depression in these patients was evaluated using Beck Depression Inventory and Hamilton depression scale (HAM-D) before and after the treatment (four weeks). Results About 64% of the study sample were males, and 36% were females, with 77% of the patients in the desvenlafaxine group taking 100 mg dosage and about 74% patients taking 50 mg dosage in the sertraline group. The patients in both groups showed statistically significant (p < 0.00001) improvement after using these drugs. Conclusion Both desvenlafaxine and sertraline showed their efficacy in treating depression by improving the clinical outcome in patients. Sertraline was marginally better in clinical results. Finally, it is advisable to carry out more randomized trials to improve the patient's quality of life.

Assessment of the Impact of COVID-19 on Drug Store Management in a Tertiary Care Teaching Hospital of Central India.

INTRODUCTION: One-third of the annual hospital budget is spent on the purchase of medicines, materials, and supplies. Drug store management is a complex but critical process within the healthcare delivery system. Health supply chains, the import of active pharmaceutical ingredients, transportation, procurement, finished products have been disrupted by COVID-19. MATERIALS & METHODS: A retrospective, observational study was carried out at the Department of Hospital Administration, All India Institute of Medical Sciences (AIIMS), Raipur. Quantitative data about the pattern of consumption of 20 most commonly used drugs (10 antibiotics, three analgesics, three antipyretics, two anticoagulants, and two steroids), and 20 most frequently used consumables were sourced from existing records of the Central Pharmacy for 24 months between 1st January 2019 to 31st December 2020. RESULTS: A significant rise in the consumption pattern was seen in 25 drugs and consumables out of 40 total selected drugs and consumables. The maximum increase was observed in antibiotics followed by antipyretics, and the least increase was observed in analgesics followed by anticoagulants. Tablet Azithromycin 500 mg was the most frequently used antibiotic during the COVID-19 Period as compared to the Pre-COVID-19 period followed by injection Piperacillin + Tazobactam. The only antibiotic having a decline in consumption and also with the lowest consumption was tablet Metronidazole 400 mg. The highest increase in consumables occurs by 10088% in N95 Masks, followed by 573% in shoe covers, and 153% in face masks (three-layers), respectively. CONCLUSION: This study will enhance education to the pharmaceutical industries, policymakers to the Government, and other hospitals on how to better manage drug stores in future pandemic-like situations. Proper drug store management played a crucial role in medication usage that improved patient outcomes and prevented the misuse of medications. The pattern of changes in the consumption of drugs and consumables in the present study can be utilized by other hospitals in the third wave of the pandemic.