Upper gastrointestinal bleed in a toddler - an unusual encounter revealing foreign body ingestion.

Foreign body (FB) ingestion is common in children; however, management varies based on the object ingested, its location and clinical presentation. Urgent intervention is needed if any warning signs are present. We describe the case of a four-year-old child who presented with acute onset of life-threatening upper gastro intestinal bleeding. He had no other significant previous or present complaint, and results of lab workup were inconclusive. Endoscopic evaluation revealed a sharp and hard object which was removed. Post-operative period, duration of hospitalization and subsequent follow up were uneventful. Through this report, we wish to draw the attention of healthcare providers to the dangerous effects of FB ingestion and also emphasise that FB ingestion should be considered in differential diagnosis when unexplained upper GI haemorrhage symptoms occur acutely.

MHC class I D(k) expression in hematopoietic and nonhematopoietic cells confers natural killer cell resistance to murine cytomegalovirus.

NK cell-mediated murine cytomegalovirus (MCMV) resistance (Cmv(r)) is under H-2(k) control in MA/My mice, but the underlying gene(s) is unclear. Prior genetic analysis mapped Cmv(r) to the MHC class I (MHC-I) D(k) gene interval. Because NK cell receptors are licensed by and responsive to MHC class I molecules, D(k) itself is a candidate gene. A 10-kb genomic D(k) fragment was subcloned and microinjected into MCMV-susceptible (Cmv(s)) (MA/My.L-H2(b) x C57L)F(1) or (B6 x DBA/2)F(2) embryos. Transgenic founders, which are competent for D(k) expression and germline transgene transmission, were identified and further backcrossed to MA/My.L-H2(b) or C57L mice. Remarkably, D(k) expression delivered NK-mediated resistance in either genetic background. Further, NK cells with cognate inhibitory Ly49G receptors for self-MHC-I D(k) were licensed and critical in protection against MCMV infection. In radiation bone marrow chimeras, NK resistance was significantly diminished when MHC-I D(k) expression was restricted to only hematopoietic or nonhematopoietic cells. Thus, MHC-I D(k) is the H-2(k)-linked Cmv(r) locus; these findings suggest a role for NK cell interaction with D(k)-bearing hematopoietic and nonhematopoietic cells to shape NK-mediated virus immunity.

Impact assessment of Intensified Malaria Control Project in transitioning a high malaria-endemic district to a low-endemic district: an epidemiological aspect.

Intensified Malaria Control Project (IMCP) was implemented in 2005 to control malaria in all North-Eastern and Odisha states of India. The present study aimed to investigate the impact of IMCP in reducing the malaria burden in Udalguri district, Assam state of North-East India. Malaria epidemiological data were obtained for IMCP intervention (Udalguri) and nonintervention district (West Singhbhumi, Jharkhand state). IMCP activities include introducing bi-valent rapid diagnostic kits (RDTs), Artemether-Lumefantrine drug in North-East India, long-lasting insecticidal nets (LLINs) distribution, and creating awareness programs about malaria in an intensified mode. The data revealed a significant decline in annual parasite incidence (API) from 14.94 (2005) to 2.61 (2018), -37% (95%CI: -57%, -19%, p = 001) after using LLINs in 2009 and -64% (95%CI: -116%, -14%, p = 013) after the introduction of RDTs in district Udalguri. Whereas control district showed a -28% (95%CI: -63%, 6.3%, p = 0.051) decrease in API using LLINs and a 10% (95%CI: -7.6%, 28%, p = 0.122) increase after the introduction of RDTs. Plasmodium falciparum (Pf) and P. vivax (Pv) were the major malarial parasites in Udalguri. Pv-malaria was much higher (71%) than Pf-malaria (29%) during the study period. An increasing trend of Pf cases was observed in Udalguri. Udalguri and Khoirabari BPHCs showed an overall reduction of 94% (95%CI: -143%, -45%, p = 0.001) and 84% (95%CI: -126%, -39%, p = 0.003), respectively; however, only a 10% (95%CI: -65%, -41%, p = 0.360) reduction in API was observed in Orang BPHC. An overall decrease in malaria indicates the effective implementation of vector and disease control strategies in the Udalguri district.

Moderate Rainfall and High Humidity During the Monsoon Season, Negligence in Using Malaria Protection Methods and High Proportion of Mild Symptomatic Patients Were the Driving Forces for Upsurge of Malaria Cases in 2018 Among Tea Tribe Populations in Endemic Dolonibasti Health Sub-center, Udalguri District, Assam State, North-East India.

Malaria elimination is a global priority, which India has also adopted as a target. Despite the malaria control efforts like long-lasting insecticidal nets distribution, rounds of indoor residual spray, the introduction of bi-valent rapid diagnostic tests and artemisinin combination therapy, malaria remained consistent in Dolonibasti sub-center of Orang block primary health center (BPHC) under the district Udalguri, Assam state followed by abrupt rise in cases in 2018. Therefore, we aimed to investigate the factors driving the malaria transmission in the outbreak area of Dolonibasti sub-center. Malaria epidemiological data (2008-2018) of Udalguri district and Orang BPHC was collected. The annual (2011-2018) and monthly (2013-2018) malaria and meteorological data of Dolonibasti sub-center was collected. An entomological survey, Knowledge, Attitude and Practices study among malaria cases (n = 120) from Dolonibasti was conducted. In 2018, 26.1 % (2136/ 8188) of the population of Dolonibasti were found to be malaria positive, of which 55% were adults (n = 1176). Majority of cases were from tea tribe populations (90%), either asymptomatic or with fever only, 67.5 % (81/120) had experienced malaria infection during past years. The outbreak was characterized by a strong increase in cases in June 2018, high proportion of slide falciparum rate of 26.1% (other years average, 15.8%) and high proportion of P. falciparum of 81.2 % (other years average, 84.3%). Anopheles minimus s.l. was the major vector with 28.6% positivity and high larval density in paddy fields/ drainage area. Annual relative humidity was associated with rise in malaria cases, annual parasite incidence (rs = 0.69, 90%CI; p = 0.06) and slide positivity rate (rs = 0.83, 95%CI; p = 0.01). Older people were less educated (rs = -0.66; p < 0.001), had lesser knowledge about malaria cause (rs = -0.42; χ2=21.80; p < 0.001) and prevention (rs = -0.18; p = 0.04). Malaria control practices were followed by those having knowledge about cause of malaria (rs = 0.36; χ2 = 13.50; p < 0.001) and prevention (rs = 0.40; χ2 = 17.71; p < 0.001). Altogether, 84.6% (44/52) of the respondents did not use protective measures. We described a sudden increase in malaria incidence in a rural, predominantly tea tribe population group with high illiteracy rate and ignorance on protective measures against malaria. More efforts that are concerted needed to educate the community about malaria control practices.

Development and On-Field Deployment of a Mobile-Based Application 'MoSQuIT' for Malaria Surveillance in International Border Districts of Northeast India-Challenges and Opportunities.

The conventional paper-based system for malaria surveillance is time-consuming, difficult to track and resource-intensive. Few digital platforms are in use but wide-scale deployment and acceptability remain to be seen. To address this issue, we created a malaria surveillance mobile app that offers real-time data to stakeholders and establishes a centralised data repository. The MoSQuIT app was designed to collect data from the field and was integrated with a web-based platform for data integration and analysis. The MoSQuIT app was deployed on mobile phones of accredited social health activists (ASHA) working in international border villages in the northeast (NE) Indian states of Assam, Tripura and Arunachal Pradesh for 20 months in a phased manner. This paper shares the challenges and opportunities associated with the use of MoSQuIT for malaria surveillance. MoSQuIT employs the same data entry formats as the NVBDCP's malaria surveillance programme. Using this app, a total of 8221 fever cases were recorded, which included 1192 (14.5%) cases of P. falciparum malaria, 280 (3.4%) cases of P. vivax malaria and 52 (0.6%) mixed infection cases. Depending on network availability, GPS coordinates of the fever cases were acquired by the app. The present study demonstrated that mobile-phone-based malaria surveillance facilitates the quick transmission of data from the field to decision makers. Geospatial tagging of cases helped with easy visualisation of the case distribution for the identification of malaria-prone areas and potential outbreaks, especially in hilly and remote regions of Northeast India. However, to achieve the full operational potential of the system, operational challenges have to be overcome.

Pneumomediastinum in COVID-19 patients: a case series of a rare complication.

Pneumomediastinum is a rare clinical finding, but one which can be the source of significant concern for clinicians. By presenting 3 such cases, we highlight that pneumomediastinum can complicate the course of a severe coronavirus disease 2019 infection but emphasize that conservative management is the first-line method of treatment, with gradual resorption of the air from the tissues. It is important to be alert to the development of pneumothorax, which will require drainage.

SARS-CoV-2 isolation from an appendix.

Efforts to recognize SARS-CoV-2 infection have focused on respiratory symptoms such as cough and shortness of breath. Although it is also well known that SARS-CoV-2 infection can cause gastrointestinal symptoms such as abdominal pain, nausea, vomiting and diarrhoea, there are emerging reports of SARS-CoV-2 infection causing surgical pathology. We present the first case report of SARS-CoV-2 infection directly causing acute appendicitis, first suspected due to highly atypical histological features and later confirmed as polymerase chain reaction positive appendicular tissue sample.

Frequency of Exposure of Nephrotoxic Drugs and Drug-Induced Acute Kidney Injury in Pediatric Intensive Care Unit: A Retrospective Review From a Tertiary Care Centre in Pakistan.

Introduction Acute kidney injury (AKI) is one of the most common problems seen in the pediatric intensive care unit (PICU), with an overall 27% incidence. Besides many other factors, nephrotoxic medications (Nephrotoxins; Ntx) are also responsible for a large proportion of potentially avoidable pediatric AKI, directly accounting for 16% of AKI events. Objective To assess potential associations between nephrotoxic drugs and the risk of developing AKI in children admitted in PICU. Material and methods This is a retrospective cross-sectional study. Children (aged 1 month - 18 years) admitted to the PICU, with a length of stay >24 hours, were included. AKI was defined as according to KDIGO (Kidney Disease Improving Global Outcomes) criteria. Mild AKI was defined as a rise in creatinine value of 0.3 mg/dl from presenting value at a 24-hour interval. Patients were grouped according to the presence or absence of AKI. All medications administered in the ICU were assessed for nephrotoxicity through a review of adverse reactions mentioned in the Pediatric Dosage Handbook, along with consultation with a clinical pharmacist. Results Among 752 patients, the mean age was 4.8 years ± 4.37. There were 57.3% male and 42.7% female children. Among the exposed children, 37.4% received one drug, 32.4% received two drugs and 12.1% had high nephrotoxin exposure. The most commonly used drug was vancomycin (16.8%), as a single Ntx; vancomycin/colistin (12.9%), in dual nephrotoxic combination; and vancomycin/colistin/amphotericin (2.9%) in highly exposed children (i.e., with equal or more than three). Overall, the incidence of AKI was 14.9%. Conclusion Nephrotoxins are potentially avoidable risk factors in critically ill children. Whenever a combination of medications is required, it's advisable to review all medications for better protection of kidneys and preventing of acute kidney injury.

Frequency of Pediatric Acute Respiratory Distress Syndrome Based on Oxygen Saturation Index in Pediatric Intensive Care Unit of a Developing Country.

Objectives To determine the frequency of pediatric acute respiratory distress syndrome based on oxygen saturation index in pediatric intensive care unit of a developing country. Methods We conducted a retrospective study of all children admitted in pediatric intensive care unit (PICU) of Aga Khan University Hospital, Karachi from July 2017 to June 2018 with respiratory rate >40 breaths/minute, shortness of breath, and bluish discoloration of skin and mucous membranes. The diagnosis of acute respiratory distress syndrome (ARDS) was made on the basis of standard operational definitions as mentioned (fulfilling criteria for ARDS). Results During the one-year study period 150 patients with age range of one month to 16 years were admitted fulfilling the inclusion criteria. Mean age was 38.27 ± 53.13 months, and 92 (61.33%) were male with male to female ratio of 1.6:1. Mean duration of symptoms was 1.23 ± 0.42 days. Frequency of pediatric acute respiratory distress syndrome using oxygen saturation index admitted in a pediatric ICU was 23 (15.33%) patients. Conclusion This study has shown that the frequency of pediatric acute respiratory distress syndrome is quite high.

Normal development and function but impaired memory phenotype of CD8⁺ T cells in transgenic mice expressing HIV-1 Nef in its natural target cells.

We studied the impact of HIV Nef on CD8(+) T cells in a mouse model of AIDS, the CD4C/HIV(Nef) transgenic (Tg) mice. We found that negative and positive thymic selections of CD8(+) T cells proceeded normally in Nef Tg mice bred respectively with HY or OT-1 TCR Tg mice. Tg peripheral CD8(+) T cells showed an activated phenotype and enhanced cell division in vivo and proliferated efficiently when stimulated in vitro with antigenic peptide. When challenged with LCMV(Armstrong), Nef Tg mice developed a strong acute CD8(+) T cell response and cleared the virus as efficiently as wild-type mice. However, maintenance of LCMV-specific CD8(+) memory T cells was impaired in Nef Tg mice, a defect partially rescued by adoptive transfer of non-Tg naïve CD4(+) T cells. Thus, despite severe abnormalities of their precursors, the double-positive CD4(+)CD8(+) thymocytes, Tg CD8(+) T cells have conserved important functions.