Hyperferritinemia in children hospitalized with scrub typhus.

BACKGROUND: Hyperferritinemia is increasingly associated with mortality in sepsis. Studies estimating the prevalence of hyperferritinemia in pediatric scrub typhus are limited. METHODS: This was a secondary analysis of a prospective observational study (FERRIS) from a tertiary care teaching hospital in North India where 72 children with confirmed scrub typhus, 4 (5.5%) PCR positive, 55 (76.4%)-IgM ELISA positive, and 13 (18.1%)-both PCR and ELISA positive, were analyzed. Serum ferritin was measured in 62 children to identify the prevalence of hyperferritinemia and determine its association with mortality. RESULTS: Hyperferritinemia (> 500 µg/L) was seen in 72.6% [n = 45] children; 26 (41.9%) were mild (500-2000 µg/L), 13 (21%) were moderate (2000-10,000 µg/L), and 6 (9.7%) were severe (> 10,000 µg/L). Early presentation to hospital (≤ 7 days of febrile illness) had more survivors than late presentation (> 7 days). Non-survivors had significantly higher PRISM III, PELOD-2, hyperlactatemia, hypoalbuminemia, organ dysfunction, need for mechanical ventilation, and need of RRT. Ferritin had poor sensitivity and specificity in predicting survival with AUC of 0.56. Organ dysfunction and risk scores as PRISM III, PELOD 2, and VIS at admission were better predictors with AUC (95% CI) of 0.72 (0.56, 0.89), 0.77 (0.63, 0.92), and 0.90 (0.78, 1.0) respectively. CONCLUSIONS: Hyperferritinemia is common in scrub typhus but it did not predict survival. Organ dysfunction and risk scores were better predictors of mortality than ferritin.

Bed Utilization and Overcrowding in a High-Volume Tertiary Level Pediatric Emergency Department.

OBJECTIVE: To measure bed utilization rate and overcrowding in a high-volume tertiary level pediatric emergency department (ED) and correlate with outcome. METHODS: All children beyond neonatal age attending the 22-bedded emergency were prospectively enrolled from February to December, 2019. Number of daily admissions, boarders, discharges, ward transfers, length of stay (LOS) and unfavorable outcomes (care discontinuation and deaths) were recorded. Daily bed occupancy rate (BOR) was calculated and correlated with unfavorable outcome. RESULTS: A total of 17,463 children visited the ED during the study period. The median (IQR) daily attendance and admission rate was 58 (51,65) and 22 (17,26) patients, respectively. The median (IQR) number of boarders and BOR was 48 (40-58) and 218% (181-263%), respectively. The median (IQR) LOS was 42.7 (23-71.4) hours. Unfavorable outcome correlated positively with number of boarders and BOR (P<0.001). CONCLUSIONS: Overcrowding of the ED was associated with increased frequency of care discontinuation and mortality. This data calls for systemic changes to tackle overcrowding.

Serum Ferritin Predicts Neither Organ Dysfunction Nor Mortality in Pediatric Sepsis Due to Tropical Infections.

Objective: To evaluate serial ferritin levels measured in the initial 72 h of admission as a biomarker for new and progressive multi organ dysfunction syndrome (NPMODS) and mortality (unfavorable outcomes) in critically ill children with sepsis due to tropical infections. Material and Methods: In this prospective observational study from a tertiary care teaching hospital in India, children 3 month to 12 years with a diagnosis of acute febrile illness and any two features suggesting tropical infections [cytopenia (platelet count <1,00,000/cu.mm, total leucocyte count <4,000/cu.mm), hepatomegaly and/or splenomegaly, lymphadenopathy, systemic signs (rash, edema), respiratory distress, and encephalopathy not accounted by localized infection] were eligible for inclusion. Children with known or suspected disorder of iron metabolism were excluded. Primary outcome was to determine the association of serial ferritin levels with mortality and NPMODS. Secondary outcomes included estimation of the prevalence of hyperferritinemia and comparison of risk prediction scores with serial ferritin measurement in predicting unfavorable outcomes. Measurements and Main Results: In the 202 children enrolled, diagnosis could be established in 133 (65.8%) children. Scrub typhus and dengue were the most common infections. Median (IQR) ferritin measured at admission (n = 183) and on day 3 (n = 120) of hospital stay were 798 (378, 3,205) µg/L and 429 (213,680) µg/L, respectively. Majority (n = 180, 89.1%) had MODS at admission defined as per International pediatric sepsis consensus conference. NPMODS occurred in 47 (23.3%) children of whom 37 (18.3%) died. Children with three or less organ dysfunctions had lower mortality. Neither admission ferritin values nor the percentage change over 72 h was different between children with favorable and unfavorable outcomes. Pediatric Risk of Mortality (PRISM-III) and daily Pediatric Logistic Organ Dysfunction score (dPELOD2 score) were significantly different in those with unfavorable outcomes. Admission ferritin levels and percentage change in 72 h had poor discriminatory power for mortality with AUC of 0.53 (0.53, 0.67) and 0.50 (0.50, 0.64), respectively. dPELOD2 had the best discriminatory power for mortality with AUC of 0.89 (0.89, 0.95). Conclusions: Serial ferritin estimation predicted neither organ dysfunction nor mortality in pediatric sepsis with tropical infections. dPELOD-2 and PRISM-III predicted unfavorable outcomes better than ferritin. The current diagnostic criteria for MODS overestimated organ dysfunctions in tropical infections and hence may need modification with further validation in this epidemiological cohort.

Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions.

BACKGROUND: Acute stroke patients are usually transported to the nearest hospital regardless of their required level of care. This can lead to increased pressure on emergency departments and treatment delay. OBJECTIVE: The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions. METHODS: Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service area in Southend-on-Sea was conducted. Emergency patients categorized as code stroke and headache were included from June 5, 2018, to December 18, 2018. Rate of avoided admission to the accident and emergency (A&E) department, rate of admission directly to target ward, and stroke management metrics were assessed. RESULTS: In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to 8 of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, 1 patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 min (interquartile range, 40-60). CONCLUSION: This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&E departments.

Clinical profile and juvenile arthritis damage index in children with juvenile idiopathic arthritis: A study from a tertiary care center in south India.

AIM: This study was designed to determine the clinical profile of juvenile idiopathic arthritis (JIA) and its morbidity using the juvenile arthritis damage index (JADI) score at a tertiary care center in northern Kerala and to compare with data from India and abroad. METHODS: A hospital-based cross-sectional study was carried out over a period of one and half years from January 2011 to July 2012. Clinical and laboratory profiles and morbidity were assessed. RESULTS: There were 62 children (mean age 8.9 ± 3.8 years) with JIA during this period with a median duration of disease of 24 months (2-151 months). The most common subgroup was polyarticular JIA (n = 26; 41.9%) followed by systemic JIA (sJIA) (n = 20; 32.3%), oligoarticular JIA (n = 15; 24.2%) and enthesitis-related arthritis (n = 1; 1.6%). The most common joints involved at presentation were the knee (38.7%) followed by the ankle (25.8%). Weights and heights were less than the fifth centile in 25.8% and 11.3%, respectively, being most affected in sJIA. The frequencies of articular and extra-articular morbidities were highest in sJIA and showed negative correlation with age at onset and positive correlation with the duration of illness. Macrophage activation syndrome was diagnosed in 50% of sJIA with a mortality of 33.3%. We experienced lower frequency of articular (30.6% vs. 60.7%) and extra-articular damage (24.2% vs. 39.3%), growth failure (19.3% vs. 68.5%) and pubertal delay (4.8% vs. 20.2%) compared to another study from north India. CONCLUSIONS: Our study shows lower frequency of morbidity in JIA; probably related to a better healthcare system facilitating early diagnosis and treatment in this part of the country.