Procalcitonin versus C-Reactive Protein as a Biomarker for Prediction of Bacterial Infection in Children with Febrile Neutropenia in Acute Leukemia.

Febrile neutropenia (FN) is a frequently occurring treatment-related complication with significant morbidity and mortality for childhood acute leukemia. Early diagnosis and assessment of severity are essential steps for early comprehensive treatment to reduce FN-related morbidity and mortality. Biomarkers like C-reactive protein (CRP) and procalcitonin (PCT) can be used to assess and predict the bacterial infection in children with febrile neutropenia. The objective of the study was to determine the role of procalcitonin and CRP as a biomarker for prediction of bacterial infection in children with FN in acute leukemia. This prospective observational study was conducted in the Department of Pediatric Hematology and Oncology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from August 2020 to July 2021. Total 58 Children with acute leukemia aged 1 to <18 years with FN were analyzed in this study. A proper history and thorough physical examination were carried out. The blood sample was sent for biomarkers (Procalcitonin and CRP) within 24 hours of the onset of FN and other investigations, such as Complete blood count, Blood C/S, Urine R/E and C/S. Metabolic workup (SGPT, Serum Creatinine, Serum Electrolytes, Serum Ca+) was also done in every patient. Stool R/E & C/S, Chest X-ray, Wound swab for C/S were done when the patient presented with diarrhoea, cough, respiratory distress and focal sepsis respectively. In this study, the mean age of the patients was 6.62±4.07 years (1.10-16.0 years) and 34 patients (58.6%) were male. In 65.5% of patients, localizing signs of infection were not identified. Of the 58 patients, 12 patients (20.7%) showed positive blood culture and 2 patients (3.4%) showed positive urine culture. Klebsiella spp (41.0%) was the most frequent organism isolated followed by Acinetobacter (17.0%), Pseudomonas (17.0%) and E. coli (17.0%). The median PCT levels were significantly higher in patients with bacterial infection than patients without bacteremia (26.10µg/l versus 0.78µg/l, p=0.002) and PCT level >2µg/l was significantly associated with bacteremia. The median CRP levels in the bacteremia and without-bacteremia patients were 137.4mg/L and 54.17mg/L, respectively (p=0.036). In direct comparisons, PCT showed better overall performance than CRP with the AUC being 0.797 (95% CI 0.651-0.943) for PCT and 0.697 (95% CI 0.54-0.855) for CRP in predicting the bacterial infection. PCT and CRP both are useful biomarkers for the prediction of bacteremia, but PCT may be a superior early biomarker as compared to CRP to predict bacterial infection in children with febrile neutropenia in acute leukemia.

Acute lymphoblastic leukaemia presenting with severe hypercalcaemia.

Acute lymphoblastic leukaemia (ALL) is the most common malignancy in children. Usually ALL children present with pallor, fever, bleeding, infection, lymphadenopathy and hapatosplenomegaly. Very rarely ALL patients may present with hypercalcaemia and osteolytic lesions. A five year old boy was referred and transferred to the paediatric ward of Bangabandhu Sheikh Mujib Medical University, Dhaka with the complaints of pain in the hip joint, generalized pain all over the body and very high calcium level. He was severely pale, the total leukocyte count was normal with normal distribution. Platelet count was also normal. There were some atypical lymphocytes. Radiology showed extensive osteolytic lesions. Considering all these findings, a bone marrow study was done, which was compatible with ALL. Flow-cytometry was also done and it confirmed the diagnosis as common ALL.

Mineral homeostasis in children with acute lymphoblastic leukemia before and after chemotherapy.

A prospective study was carried out in the Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh to evaluate the pattern of mineral changes in children treated for acute lymphoblastic leukemia (ALL) before and after induction chemotherapy. A total number of 32 children aged 1-14 years of both sexes were evaluated. Serum calcium, phosphate, alkaline phosphatase, albumin and creatinine and urinary creatinine and calcium were estimated in cases and control. The mean calcium level at presentation and post induction was 9.50±1.48 mg/dl and 9.08±1.30 mg/dl. Serum phosphate was higher in preinduction mean of 4.83±2.71 mg/dl than post induction value of 4.75±1.38 mg/dl and it was statistically significant. Serum alkaline phosphatase was higher in the post induction period. It was 324.8±128.17 U/L in pre induction and 331.59±93.97 u/l in post induction period. It was not statistically significant. No statistically significant difference was found in pre and post induction urinary calcium and creatinine.

Ondansetron versus granisetron in the prevention of chemotherapy induced nausea and vomiting in children with acute lymphoblastic leukemia.

Effect of ondansetron and granisetron were evaluated in sixty (60) children (age 4-11 years) irrespective of sex, diagnosed case of acute lymphoblastic leukemia (ALL) who received high dose methotrexate and did not receive any antiemetic 24 hours prior to HDMTX. This was a prospective, randomized, double-blind, single center study. Of 60 children, 30 received oral ondansetron (4mg) and rest 30 granisetron (1mg) half an hour before therapy. Drugs were randomly allocated with appropriate code. The patients were followed up from day 1 to day 5 of therapy. Episodes of nausea and vomiting were recorded and scorings was done every 24 hours following chemotherapy. No significant difference was found between two groups according to acute emesis (Day-1) (p=0.053). In day two and day three it was significant (p<0.05). In day four it was significant (p=0.002). Early chemotherapy induced nausea and vomiting (CINV) were controlled 90% in children who received granisetron and 70% in children who received ondansetron. Delayed (Day 2-4) CINV were controlled in 80% of children who received granisetron and 43.4% who received ondansetron (p<0.05). Granisetron group required additional doses only 3.3% cases and ondanseton group 30% cases on the second day (p<0.05). Result was significant between two groups. About 36.7% patients had episodes of nausea on day four of chemotherapy in ondansetron group and it was only 3.3% in granisetron group due to adverse effects of antiemetic drug itself (p=0.001). Maximum episodes of vomiting were found on the second day in ondansetron group 33.3% and in granisetron group 3.3% (p=0.003). Though adverse effects like headache, constipation, abdominal pain and loose motion were common in both group of children but their number was much less in children who received granisetron. On second day of therapy score of nausea and vomiting was maximum in ondansetron and minimum in granisetron treated on day 4 and the result was significant. So, to prevent acute and delayed CINV in children with ALL, oral graniseteron can be considered as more effective and well tolerated with minimum adverse effects compared with ondansetrons.

Correlation of serum parathormone level with biochemical parameters in chronic renal failure.

A prospective study was carried out to assay the level of serum intact parathormone and its correlation with biochemical parameters in patients with chronic renal failure (CRF). The study included 64 children (44 with CRF, and 20 age and sex matched controls). Serum intact parathormone (iPTH), serum creatinine, urea, calcium, inorganic phosphate and alkaline phosphatase were estimated. Creatinine clearance (Ccr) was estimated by Schwartz formula. Patients with CRF were divided into four groups based on their Ccr (mild CRF with mean Ccr 59.17 +/- 1:18.53 mL/min/1.73 m2 (n = 6) moderate CRF with mean Ccr 34.98 +/- 7.75 mL/min/1.73 m2 (n = 7); severe CRF with mean Ccr 17.71 +/- 5.40 mL/min/1.73 m2 (n = 15); and end-stage renal disease with mean Ccr 6.46 +/- 1.71 mL/min/1.73 m2 (n = 16). Mean serum iPTH levels were 93.00 +/- 46.62 pg/mL in CRF and 16.52 +/- 9.35 pg/mL in controls. Groupwise mean serum (iPTH) levels were 48.50 +/- 4.76, 67.29 +/- 7.91, 82.42 +/- 9.67 and 130.66 +/- 58.74 pg/mL in mild, moderate, severe CRF and endstage renal failure respectively. Mean serum iPTH level of CRF (93.00 +/- 46.42 pg/mL) negatively correlated with mean Ccr (22.02 +/- 18.53 mL/min/l.73 m2) (P < 0.001) and mean serum calcium (7.30 +/- 1.02 mg/dL) (P < 0.001) and positively correlated with mean inorganic phosphate (5.76 +/- 1.1 mg/dL) (P < 0.05) and mean alkaline phosphatase (355.14 +/- 185.53 UL) (P < 0.001). We conclude that increased iPTH level occur even early in the course of CRF and progressive hypocalcemia and hyperphosphatemia are the initiating factors for the development of hyperparathyroidism.

Attitude of the parents seeking service from the paediatricians.

The overuse of antibiotics and other medicines have been standing a dangerous proposition and researchers are coming in fore front analyzing and assessing the aftermath of years of misperceptions and inappropriate usage of drugs prescribed by the pediatricians. Two hundred and two parents from the community as well as from the outpatient department of medical college hospitals were interviewed, to study their attitude while seeking for the health service for their children. Data were collected through a face-to-face interview using a structured questionnaire. One hundred and ninety nine (82.7%) of the parents interviewed were mothers and only 3 (1.5%) were fathers. One hundred and sixty-seven (82.7%) parents were from the urban population and the rest 35 (17.3%) were from rural areas. The mothers mean stay in the educational institution was 11.8 years and that of the father's was 13.1 years. About 34.7% parents had to seek for doctor's advice at least once or twice a month and around 43% had to visit doctor's clinic. Most (66.8%) of the parents were from the family earning tk.6000 to tk.20000 a month, 19.8% and 13.4 % were from the families earning below tk.6000 and above tk.20000 respectively. A vast majority of the parents expressed their preference for advice to medicines. Among the medicines they like antibiotics more than vitamins. Majority of the parents showed their interest to spend more time and to have less medicine. For anorexic children parents preferred advice to medicines. An overwhelming majority (98%) of the parents was interested to get advice and ORS for diarrhea. For ARI also a larger number (56.1%) of parents opted for advice only and no medicine at all but 37.1% kept their option for both. A large majority of the parents were preferring more frequent visit and having fewer medicines than the conditions of more medicines with less frequented visits.

Iron status and infants feeding practice in children with anaemia.

A cross sectional study was carried out in the then IPGM&R now (Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh) to detect the pattern of feeding practice among the anemic children who were below 2 years of age and to find out a relationship between feeding practice and iron status. Hemoglobin was measured on finger prick blood samples using Haemoglobinometer. A peripheral blood film, and serum-ferritin was estimated by micro particle enzyme-immonoassay (MEIA). A dietary questionnaire was completed with particular emphasis on the type of feeding, breast and formula and at which age the weaning was introduced. 140 clinically suspected anemic patients were selected randomly for this study. Among them 111 (79.3%) patient had hemoglobin value ranging between 7.2-6.4 gm and their serum-ferritin level at or below 12 ngm/ml. It was observed that female children were predominantly affected and incidentally all patients were malnourished. In this study it was found that babies with an exclusive diet of breast milk were mildly anemic and not deficient in iron. On the contrary infants with mixed feeding habits or prolonged breast-feeding without weaning at all or babies devoid of any breast milk had moderate to severe anaemia and all were deficient in iron.