Hypoglycemia with insulin in post-transplant diabetes mellitus.

INTRODUCTION: To prevent hypoglycemic episodes, the management of insulin therapy against post-transplant diabetes mellitus (PTDM) is important. We compared glargine (long-acting insulin) versus NPH isophane (intermediate-acting insulin) as an armamentarium against PTDM. Indeed, the study evaluated PTDM patients with hypoglycemic episodes treated with isophane or glargine. MATERIAL AND METHODS: We evaluated a total number of 231 living-donor renal transplant recipients with PTDM of age ≥ 18 years admitted to the hospital between January 2017 and September 2021. However, patients taking hypoglycemic agents before transplantation were excluded from this study. Out of 231 patients, 52 (22.15%) suffered from PTDM out of whom 26 were treated with glargine or isophane. RESULTS: After applying exclusion criteria, out of 52 PTDM patients 23 were included in the study: 13 PTDM patients were treated with glargine, whereas 10 PTDM patients with isophane. Our analysis revealed 12 episodes of hypoglycemia in glargine-treated PTDM patients compared to 3 in isophane-treated PTDM patients (p = 0.056). Clinically, 9 out of 15 hypoglycemic episodes were nocturnal (60%). Furthermore, no other risk factors were observed in our study population. Detailed analysis showed that both groups had equivalent doses of immunosuppressants and oral hypoglycemic agents. The odds ratio for hypoglycemia in the group treated with isophane compared to that treated with glargine was 0.224 (95% CI, 0.032-1.559). Glargine users recorded significantly lower blood sugar levels before lunch, dinner and at bedtime with p-values of 0.001, 0.009 and 0.001 respectively. A better hemoglobin A1c (HbA1c) level was seen in the glargine vs. isophane group (6.98 ± 0.52 vs. 7.45 ± 0.49, p-value 0.03). CONCLUSION: The study shows better blood sugar control with long-acting insulin analog, glargine, than with intermediate-actin analog, isophane. Overall, a higher number of hypoglycemic episodes was nocturnal. Long term safety of long-acting insulin analogs needs to be further studied.

Etio-Hematological Profile and Clinical Correlates of Outcome of Pancytopenia in Children: Experience From a Tertiary Care Center in North India.

Introduction Pancytopenia is a clinical entity encountered in pediatric practice as a feature of various benign and malignant disorders. It describes the simultaneous presence of anemia, leucopenia and thrombocytopenia. Attempts to identify the correct etiology and gauging the severity of pancytopenia will help to determine the management and prognosis of the patients. Objectives To study etio-hematological profile, clinical correlates and outcome of pancytopenia in Indian children Methods This prospective observational study of children with pancytopenia was conducted at a tertiary care center from August 2015 to July 2016. Clinical, hematological and bone marrow studies were performed and patients were followed for one year. The collected data were statistically analyzed. Results Out of 84 cases, the mean age at diagnosis was 70 (70.77±4.8) months. Bone marrows showed aplastic changes in 37% and hyperplasia in 14% of patients. In our study, most common causes were aplastic anemia, acute leukemia and nutritional anemia. During the first year of follow-up, 67% pancytopenics survived and 12% succumbed (rest discontinued treatment) with ~26% of aplastic anemia (7/27 cases) and 9% of acute leukemia (2/22 cases) not surviving. Anthropometric status of patients and severity in aplastic anemia were significantly associated (p < 0.05) with outcome. Conclusion The data gathered support a complex picture for pancytopenia in our study population since both benign nutritional deficiencies and malignant hematological neoplasms were common. Bone marrow studies seem to be of salient use in delineating etiology. As the outcome is multifactorial, factors like anthropometry, hematological parameters have a bearing on prognosis.

Demographics and Outcome of Philadelphia-positive ALL in a Pediatric Population in North India: a Single-center Experience.

Philadelphia-positive (Ph+) acute lymphoblastic leukemia (ALL) in children had a worse outcome before the use of tyrosine kinase inhibitors. We have evaluated the demographics and outcome of Ph+ ALL patients treated with imatinib without blood marrow transplantation. Of the 206 children with ALL registered for treatment, the demographic data of 15 Ph+ ALL patients were compared with the remaining Ph- patients. Imatinib (340 mg/m) was started on day 5 (D5) of induction in Ph+ patients, and their overall survival was compared with Ph- high-risk patients treated on similar protocols. Statistical analysis was carried out by the Fisher exact test and the t test. The Kaplan-Meier test was used for survival analysis. Philadelphia positivity noted in 15/206 (7.28%) ALL patients was higher than reported earlier. Median initial total leukocyte count and central nervous system positivity were significantly higher in Ph+ patients. Myeloid markers, CD13 and CD33, were also positive in 33.3% Ph+ patients. D15 and D35 marrow showed remissions in a larger proportion of Ph+ ALL, as compared with Ph- patients, but chemotherapy interruptions and neutropenic deaths were significantly higher after starting imatinib, as compared with Philadelphia high-risk patients. Overall survival was similar in Ph+ and Ph- high-risk ALL patients. Ph+ ALL, noted in 7.28%, presented with high initial white blood cell counts, high central nervous system positivity, poor steroid response, and higher induction deaths, as compared with high-risk Ph- ALL, and raised the question about the appropriate dose and time of introduction of imatinib to prevent toxicity.

A Comparative Evaluation of Presepsin with Procalcitonin and CRP in Diagnosing Neonatal Sepsis.

The objectives of this study were to study the clinical and biochemical profile of neonates with sepsis and to evaluate the diagnostic role of presepsin and its comparison with C-reactive protein (CRP) and Procalcitonin (PCT). This study was conducted from March 2015 through October 2016 in Neonatal intensive care unit (NICU) at S N Medical College, Agra. Neonates with ≥1 clinical features of sepsis and/or two risk factors were included. A total of 41 cases and 41 controls were taken. Blood sample was taken for all investigations. ROC curve analysis was performed. Out of 41 cases, 19 were blood culture positive, majority were males (68.3%), low birth weight (LBW: 70.7%) and preterms (53.6%). At chosen cut-off values, sensitivity of CRP, PCT and presepsin was 80.5%, 80.5%, 97.6% and specificity was 97.5%, 80.5%, 95.1% respectively. PCT and CRP were comparable as diagnostic markers of neonatal sepsis. Presepsin, in comparison with CRP and PCT has better sensitivity and negative predictive value (NPV).

Clinical Profile and Outcome of Influenza A/H1N1 in Pediatric Oncology Patients During the 2015 Outbreak: A Single Center Experience from Northern India.

BACKGROUND: Owing to their immunocompromised status, childhood cancer patients on chemotherapy are at a greater risk for Influenza infection and its associated complications. There is limited data available on the clinical profile and outcome of Influenza A/H1N1 in this subset of patients. METHODS: A retrospective study was performed of Influenza A/H1N1 cases diagnosed between January 2015 to December 2015 in the in-patients of Pediatric Oncology unit of a tertiary care hospital from Northern India. RESULTS: In total, 16 children were diagnosed with laboratory confirmed H1N1. Most frequent symptoms were fever and cough. Oseltamivir was administered to all patients. Complications encountered were delay/interruption of antineoplastic therapy (9), need for respiratory support (5), and air leaks (1). Prolonged viral shedding was encountered in 50% of patients who were retested for H1N1 in their throat swabs. There were 2 deaths, 1 in a child of Acute Lymphoblastic Leukemia on induction therapy and another in a child with anaplastic Wilms tumor. CONCLUSIONS: Childhood cancer patients infected with Influenza A/H1N1 are at risk of serious illness and higher mortality. Delay of anticancer treatment is a concern in these infected children. Prompt initiation of antivirals and an optimum duration of treatment are warranted to reduce the morbidity and mortality.

Outcome of extraocular retinoblastoma in a resource limited center from low middle income country.

Retinoblastoma (RB) is the most common ocular malignancy in children, and is managed by multimodal treatment. There is a paucity of data regarding the clinical profile and outcome of children with extraocular retinoblastoma from Low Middle Income Countries (LMIC) including India. Case records of children with newly diagnosed extraocular RB from January 2013 to August 2016 treated at our unit were analysed for clinical profile, treatment, and outcome. Over the 44 month study period, 91 children were diagnosed with RB, out of which 41 had extraocular disease. While 26 children had extraocular spread limited to orbit (IRSS stage III), 15 had a distant spread to brain (IRSS stage IV). Median lag period for diagnosis was eight months. Treatment abandonment rates were 38.5% and 46.6% in International Retinoblastoma Staging System (IRSS) stage III and IV respectively. With a median follow up of 31.5 months, the projected overall survival for IRSS III at one, two, and three years was 87.5%, 55.6%, and 39.7%. All patients with stage IV disease died after a median follow up duration of three months. High treatment abandonment rates and limited availability of resources lead to suboptimal survival in children with extraocular RB from LMIC. Initiatives aimed at improving early diagnosis, so that the disease is detected in the intraocular stage, are critical to improve the survival in children with RB.

Peritoneal dialysis in children with acute kidney injury: a developing country experience.

BACKGROUND: Peritoneal dialysis (PD) is the preferred and convenient treatment modality for acute kidney injury (AKI) in children and hemodynamically unstable patients. METHODS: The outcome of acute PD was studied in 57 children (39 boys) with AKI, aged 1 month to 12 years, at a tertiary care center of a teaching hospital in India. RESULTS: Hemolytic uremic syndrome (36.8%) was the most common cause of AKI, followed by septicemia (24.6%) and acute tubular necrosis (19.3%). Treatment with PD was highly effective in lowering retention markers (p < 0.001). Overall mortality was 36.8%. The risk of mortality by multi-variate analysis was higher when patients were anuric [odds ratio (OR): 8.2; 95% confidence interval (CI): 1.3 to 49; p < 0.05], had septicemia (OR: 3.79; 95% CI: 1.55 to 25.8; p < 0.05), or severe infectious complications (OR: 8.2; 95% CI: 1.5 to 42.9; p < 001). CONCLUSIONS: Because of its simplicity and feasibility, acute PD is still an appropriate treatment choice for children with AKI in resource-poor settings. Septicemia and severity of AKI are contributory factors to high mortality in pediatric acute kidney injury.

Antioxidant status of children with acute renal failure.

The production of free radicals can cause renal injury and play a role in the pathogenesis of acute renal failure (ARF). The indirect markers of reactive oxygen species (ROS) were evaluated in children with ARF and controls. Forty patients with ARF aged 0-10 years were selected. Twenty age- and gender-matched healthy children were included as controls. Plasma malondialdehyde, protein carbonyl, nitrite, copper, ascorbic acid, zinc, and ceruloplasmin levels were estimated in patients with ARF and controls. The plasma malondialdehyde (p < 0.01), copper (p < 0.001), ascorbic acid (p < 0.05), and ceruloplasmin (p < 0.001) levels were significantly raised in ARF patients in comparison with controls. Significantly higher levels of plasma malondialdehyde (p < 0.01), nitrite (p < 0.001), copper (p < 0.001), and ceruloplasmin (p < 0.001) and lower plasma zinc (p < 0.01) were found in ARF nonsurvivors in comparison with survivors. The cutoff levels of plasma nitrite and ceruloplasmin were found to be most accurate in predicting mortality in ARF patients and had maximum sensitivity (100%) and specificity (60.7%) among the parameters studied. In conclusion, the increased levels of oxidants and antioxidants suggest the production of ROS and their possible role in ARF pathogenesis. Plasma nitrite and ceruloplasmin concentrations demonstrated predictive ability in relation to mortality.