Acute kidney injury in pediatric hematopoietic cell transplantation: critical appraisal and consensus.

Hematopoietic cell transplantation (HCT) is a common therapy for the treatment of neoplastic and metabolic disorders, hematological diseases, and fatal immunological deficiencies. HCT can be subcategorized as autologous or allogeneic, with each modality being associated with their own benefits, risks, and post-transplant complications. One of the most common complications includes acute kidney injury (AKI). However, diagnosing HCT patients with AKI early on remains quite difficult. Therefore, this evidence-based guideline, compiled by the Pediatric Continuous Renal Replacement Therapy (PCRRT) working group, presents the various factors that contribute to AKI and recommendations regarding optimization of therapy with minimal complications in HCT patients.

Acalabrutinib in relapsed or refractory mantle cell lymphoma (ACE-LY-004): a single-arm, multicentre, phase 2 trial.

BACKGROUND: Bruton tyrosine kinase is a clinically validated target in mantle cell lymphoma. Acalabrutinib (ACP-196) is a highly selective, potent Bruton tyrosine kinase inhibitor developed to minimise off-target activity. METHODS: In this open-label, phase 2 study, oral acalabrutinib (100 mg twice per day) was given to patients with relapsed or refractory mantle cell lymphoma, until disease progression or unacceptable toxicity. The primary endpoint was overall response assessed according to the Lugano classification, and safety analyses were done in all participants. This trial is registered with ClinicalTrials.gov, number NCT02213926. FINDINGS: From March 12, 2015, to Jan 5, 2016, 124 patients with relapsed or refractory mantle cell lymphoma were enrolled and all patients received treatment; median age 68 years. Patients received a median of two (IQR 1-2) previous therapies. At a median follow-up of 15·2 months, 100 (81%) patients achieved an overall response and 49 (40%) patients achieved a complete response. The Kaplan-Meier estimated medians for duration of response, progression-free survival, and overall survival were not reached; the 12-month rates were 72% (95% CI 62-80), 67% (58-75), and 87% (79-92%), respectively. The most common adverse events were primarily grade 1 or 2 and were headache (47 [38%]), diarrhoea (38 [31%]), fatigue (34 [27%]), and myalgia (26 [21%]). The most common grade 3 or worse adverse events were neutropenia (13 [10%]), anaemia (11 [9%]), and pneumonia (six [5%]). There were no cases of atrial fibrillation and one case of grade 3 or worse haemorrhage. The median duration of treatment was 13·8 months. Treatment was discontinued in 54 (44%) patients, primarily due to progressive disease (39 [31%]) and adverse events (seven [6%]). INTERPRETATION: Acalabrutinib treatment provided a high rate of durable responses and a favourable safety profile in patients with relapsed or refractory mantle cell lymphoma. These findings suggest an important role for acalabrutinib in the treatment of this disease population. FUNDING: Acerta Pharma, a member of the AstraZeneca Group.

Hamman Syndrome with a Rare Feature of Pneumorrhachis - An Unusual Complication of Polysubstance abuse and e-vaping.

Hamman syndrome is defined as dissection of air in mediastinum and skin fascia usually due to increased intrathoracic pressure. The air leak tends to make its way into pleural and pericardial layers; however, in rare instances air can also dissect into epidural spaces, regarded as pneumorrhachis. We present a case of a young male with a history of polysubstance abuse and e-vaping, who presented with symptoms of altered mental status. Given the concerning physical examination, a computed tomography of the chest was undertaken, which showed pneumothorax, pneumomediastinum and pneumorrhachis. The patient was closely monitored in the intensive care unit and improved after symptomatic management. The symptoms of pneumorrhachis depend on the volume and location of air in intracranial and intraspinal space. Although asymptomatic in our case, it is crucial for clinicians to be aware that pneumorrhachis with Hamman syndrome can potentially cause neurological deficits and cardiopulmonary arrest in severe cases due to increased intraspinal and intracranial hypertension, emphasising the need for close monitoring. LEARNING POINTS: Elevated intrathoracic pressure generated by deep inhalation of an aerosolised product is one of the triggers of air dissection in pleural, pericardial, and mediastinal regions. In rare instances, air can also translocate into intracranial and intraspinal spaces, which is referred to as pneumorrhachis.Mostly asymptomatic, pneumorrhachis has the potential to develop acute neurological deficits due to increased intracranial and intraspinal pressure, validating the need for acute monitoring.Most cases of pneumorrhachis are managed conservatively. However, severe cases warrant decompression or high concentrations of oxygen administration to facilitate air absorption.

Outcome of Children with Severe Acute Malnutrition and Diarrhea: a Cohort Study.

PURPOSE: Severe acute malnutrition (SAM) is an important public health problem which contributes to significant number of under five deaths. Protocol based management significantly decreases risk of deaths in children with medical complications. METHODS: Outcome of children aged 2 months-5 years admitted and fulfilling definition of SAM having diarrhea (group A) was compared to children with SAM having medical complications other than diarrhea (group B). Both groups were managed according to standard recommended protocols and monitored and followed up for 12 weeks after discharge. RESULTS: The average weight gain, defaulter rate, primary failure, secondary relapse rate and readmission rate were similar in both groups. Length of stay in group A was three days longer (p-value=0.039). Discharge rate was comparable with overall 68% of children successfully discharged and 50% of children reaching weight/height >-2 standard deviation at follow-up of 12 weeks. CONCLUSION: The current management protocol is equally effective for managing children with SAM having diarrhea. Good adherence to management protocol of dehydration and timely modification of therapeutic feeds in children with persistent diarrhea results in satisfactory weight gain.

Role of broad-spectrum sunscreen alone in the improvement of melasma area severity index (MASI) and Melasma Quality of Life Index in melasma.

BACKGROUND: Sunscreens have long been an indispensable part in treating melasma as ancillary agents. None of previous studies have evaluated the role of sunscreens alone in the improvement of melasma. AIMS: Our objective was to study the role of broad-spectrum sunscreen with sun protection factor 19 and PA+++ as the sole agent for improvement of melasma. METHODS: A total of 100 patients with melasma were included in the study. Following proper method of application of 3 mL sunscreen, thrice daily, Melasma Area Severity Score (MASI) and Hindi language version of the MELASQOL scale (Hi-MELAQOL) was done at baseline and 12 weeks. RESULTS: The mean MASI in the study group at the beginning and at the end of the study was 12.38 ± 14.7 and 9.15 ± 4.7, respectively, whereas the mean value of Hi-MELASQOL at the beginning and at the end of the study was 47.2 ± 14 and 38.1 ± 14.2, respectively. The differences of both were statistically significant. Spearman's correlation between MASI and Hi-MELASQOL before and after the study was positive but insignificant. CONCLUSION: There was both an objective and subjective improvement in melasma after 12 weeks of sunscreen use in terms of both MASI, showing an objective improvement of melasma after using sunscreens alone and also in Hi-MELASQOL showing that use of sunscreens significantly improved quality of life of melasma patients. In our study, we have attempted to re-instate the importance of sunscreens to patients and dermatologists who are inclining more toward various skin lightening agents for treatment of melasma, which have many side effects.

Determinants of Stunting, Wasting, and Underweight in Five High-Burden Pockets of Four Indian States.

OBJECTIVES: Prevalence of under-nutrition is very high in India. Under-nutrition is a result of interplay between different immediate, underlying, and basic causes. The study was conducted with the objective to identify significant predictors of stunting, wasting, and underweight. METHODS: Cross-sectional studies with 2299 children from five high-burden pockets of four Indian states were conducted. Primary data on their anthropometric measurements along with their households' demographic and socioeconomic characteristics were collected. Binary logistic regression analyses were performed to examine the predictors of stunting, wasting, and underweight. RESULTS: Results show very high prevalence of stunting, wasting, and underweight in all five regions covered in the study. Multivariate analyses show that food security, use of toilets, and low body mass index status of mothers were the major predictors of stunting and underweight among children. Acute respiratory infection disease was the major predictor of underweight and diarrhea was the major predictor of stunting. Younger children (<24 months) had lower odds of underweight and stunting compared to older children (24-59 months). The analyses showed higher odds of wasting among male children. Regional variations were also seen in the study with higher odds of underweight and wasting in Khuntpani block and higher odds of stunting in Naraini block. CONCLUSION: The above findings indicate that for comprehensively addressing child under-nutrition, it is very important to address maternal nutrition, improve food security, and reduce poverty status, provide better water and sanitation facility to the community, control infections, and address regional disparity.

Comparison between Weight-for-Height Z-Score and Mid Upper Arm Circumference to Diagnose Children with Acute Malnutrition in five Districts in India.

BACKGROUND: The World Health Organization recommends weight-for-height Z-score (WHZ) or mid-upper arm circumference (MUAC) and bilateral pitting edema to diagnose acute malnutrition among children aged 6-59 months. WHZ and MUAC identify different sets of children with acute malnutrition, and overlap between their prevalence varies greatly among countries. OBJECTIVE: The objective of the study was to determine the degree of overlap and agreement between WHZ and MUAC to diagnose children with acute malnutrition in India. METHODS: Five nutrition surveys using Standardized Monitoring and Assessment of Relief and Transitions methodology were conducted in four Indian states. A total of 2127 children aged 6-59 months were analyzed. All anthropometric indices were calculated using emergency nutrition assessment software and analyzed in Epi-Info 3.5.4. RESULTS: Of total global acute malnutrition (GAM) cases, 96% and 28.4% cases were diagnosed with WHZ and MUAC, respectively. Similarly, of total severe acute malnutrition (SAM) cases, 95.1% were identified using WHZ and 30% using MUAC. The proportion of overlap between the two criteria for GAM and SAM cases was 24.5% and 25.2%, respectively. The analysis showed that MUAC was comparatively more sensitive to identify acute malnutrition among 6-23-month aged children and females. CONCLUSION: One-fourth of GAM and SAM cases were identified with both criteria. MUAC identified approximately 30% of the total SAM cases which was lower than other countries. MUAC identified more number of females and younger children, who may have higher mortality risk and would result significantly smaller caseload (68% smaller) that requires intervention compared to when using WHZ.