Comparison of Pediatric Sequential Organ Failure Assessment and Pediatric Risk of Mortality III Score as Mortality Prediction in Pediatric Intensive Care Unit.

OBJECTIVE: To assess and compare the diagnostic accuracy of the Pediatric Risk of Mortality (PRISM) III score and Pediatric Sequential Organ Failure Assessment (p-SOFA) for the prediction of mortality in critically ill children. METHODOLOGY: This was a cross-validation study conducted at the Pediatric Intensive Care Unit (PICU) of the National Institute of Child Health Karachi from February 2021 to July 2021. Two hundred eighty-six critically ill children of age one month to 15 years of either gender staying in PICU for more than 24 hours were included. Within 24 hours of admission, the p-SOFA and PRISM III 24 scores were calculated for all eligible children. The outcome of the study was mortality within 30 days of PICU admitted children. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23. RESULTS: The median age was 24 months (range: 1-144 months). The 30-day mortality was estimated as 57%. The p-SOFA and PRISM scores were significantly greater in children who did not survive than survivors. The maximum p-SOFA score (area under the curve (AUC)=0.81, 95% CI=0.76-0.86, p=0.001) and PRISM III 24 score (AUC=0.75, 95% CI=0.69-0.81, p=0.001) had good discrimination for 30-day mortality. For the prediction of 30-day mortality at the cut-off value of p-SOFA>2, the sensitivity was 93.87%, specificity was 38.21%, and accuracy was 69.93%. Whereas at the cut-off value of PRISM III 24 score>8, the sensitivity was 55.83%, specificity was 77.24%, and accuracy was 65.03%. CONCLUSION: The p-SOFA score is a good predictor for 30-day mortality in critically ill children and had better accuracy than the PRISM III 24 score.

Pediatric Risk of Mortality III Score in Predicting Mortality Among Diabetic Ketoacidosis Patients in a Pediatric Intensive Care Unit.

Background Diabetic ketoacidosis (DKA) is one of the most common complications of type 1 diabetes. Mortality is not uncommon in DKA, mostly in younger children with severe DKA and those complicated with cerebral edema. Early identification of high-risk patients can help in timely interventions to improve the outcome of DKA. Pediatric Risk of Mortality (PRISM III) is a standard scoring system to objectively predict the prognosis and outcome of pediatric intensive care unit (PICU) patients. Objective To predict the need for inotrope and mechanical ventilation and mortality rate using PRISM III in DKA patients admitted to PICU. Methods A prospective observational study was conducted in the PICU of the National Institute of Child Health, Karachi, from February 2020 to September 2021 involving 114 children. PRISM III scoring protocol was applied. A PRISM III score of >8 predicted higher mortality risk.  Results The mean PRISM III score was 6.56 ± 3.18 with 30 (26.3%) children having a score >8. Of the 30 (26.31%) patients with >8 PRISM III scores, 14 (46.67%) needed inotropic support, 6 (20%) needed mechanical ventilation, and there were eight (26.67%) mortalities. There was no reported mortality among patients with a PRISM III score ≤8. All differences were statistically significant (p < .05). Conclusion PRISM III is a highly sophisticated scoring system that can aid clinicians in the early prediction of adverse clinical outcomes in patients with DKA. Robust scientific evidence supporting its clinical application can help practically improve the outcome of DKA in young patients.

Frequency of Drug Induced Acute Kidney Injury in Pediatric Intensive Care Unit.

BACKGROUND: Acute kidney injury (AKI) is known to complicate one-third of cases in pediatric intensive care units (PICU), and almost one-fourth of these are due to nephrotoxic drugs (NTDs). Although stopping NTDs seems the most obvious option, it is not practically applicable. Many NTDs are the only existing option, and their potential benefits outweigh the risk of drug-induced AKI. OBJECTIVES: To assess the proportion of children receiving NTDs in the PICU and highlight the children who developed AKI. METHODS: A prospective observational study was conducted in the PICU of the National Institute of Child Health, Karachi. All children admitted to the PICU for at least 72 hours not diagnosed with any acute or chronic kidney disease were included. Serum creatinine (SCr) was done at admission and then after 72 hours. Data was entered and analyzed using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. RESULTS: Of 99 children, 53 (53.5%) were male. NTD exposure was positive in 97 (97.9%), and 72 (72.7%) had high exposure (≥3 NTDs). Drug-induced AKI was diagnosed in 46 (46.5%). It was significantly related to high SCr even at admission and high NTDs exposure. The mortality rate in the AKI group was 17% compared to 4% in the non-AKI (p=0.02). CONCLUSION: Almost half of all PICU admissions were infants. Almost all patients were exposed to NTDs, and three-fourth experienced high exposure. AKI developed in 46% of patients and may be predicted by raised creatinine at the time of admission. Children exposed to ≥3 NTDs had a higher chance of drug-induced AKI.

Correlation Between the Ratio of Oxygen Saturation to Fraction of Inspired Oxygen and the Ratio of Partial Pressure of Oxygen to Fraction of Inspired Oxygen in Detection and Risk Stratification of Pediatric Acute Respiratory Distress Syndrome.

OBJECTIVE: To measure the correlation between the ratio of oxygen saturation to fraction of inspired oxygen [SpO2/FiO2 (SF)] and the ratio of partial pressure of oxygen to fraction of inspired oxygen [PaO2/FiO2 (PF)] among children diagnosed with acute respiratory distress syndrome (ARDS). METHODOLOGY:  A cross-sectional study was conducted at the pediatric intensive care unit (PICU), National Institute of Child Health (NICH), Karachi, a tertiary care government hospital, from November 2020 to July 2021. One hundred twenty children (of either gender) having the age range of 2 months to 16 years, admitted to PICU with acute onset of respiratory distress, were included in the study. We measured SpO2, PaO2, FiO2 and calculated SF and PF ratios. SPSS (version 23) (Armonk, NY: IBM Corp) was used to analyze data, and the Spearmen's correlation test was applied to measure the relationship between SF and PF ratios. RESULTS: A total of 120 children were included, the mean age was 40.58±38.88 months and 67 (55.8%) were males. The mean FiO2 was 76.33%, the mean PaO2 and SpO2 were 100.35 mmHg and 94.37%, respectively. The mean PF ratio was 156.34, and the mean SF ratio was 156.45. There was a strong correlation between the SF ratio and the PF ratio (r=0.688; p=0.001). CONCLUSION: This study has shown that there is a strong correlation between the SF and PF ratios, and a statistically substantial agreement has been observed.

The Spectrum of Pediatric Cardiac Procedures and Their Outcomes: A Six-month Report from the Largest Cardiac Facility in Sindh, Pakistan.

Introduction Congenital heart disease (CHD) is the most common birth defect globally, with low-to-middle income Asian countries registering the highest incidence. Every year, 60,000 babies are born with varying severity of CHD in Pakistan. But the country has only three pediatric intensive care units (PICU) fully dedicated to child cardiac surgery patients. The focus of this study is to analyze the spectrum of pediatric cardiac surgical procedures performed for the management of CHD and their outcomes in a cardiac PICU in Pakistan. Methods In this analysis, all surgical records of children admitted to the PICU of National Institute of Cardiovascular Diseases (NICVD), Karachi, from October 2018 to March 2019 were included. It is a 14-bed, state-of-the-art cardiac PICU, which provides high-quality care to critical post-surgical patients. Results The surgical records of 537 patients were extracted for the purpose of our study, which accounted for 89.5 of post-operative patients admitted in the PICU per month and three per day. Tetralogy of Fallot (TOF) was the most commonly treated anomaly (n = 161; 29.9%) in the facility, followed by ventricular septal defect (n = 107; 19.9%). The overall mortality rate was 5.4% (n = 29), out of which 27.5% (n = 8) were TOF-related. Conclusions There is a very high burden of patients on the cardiac PICUs in low-to-middle income Asian countries. Despite the lack of resources, the high- quality care provided by pediatric cardiac critical-care specialists at these PICUs has ensured favorable outcomes and a mortality rate as low as that in any of the developed countries.

Sudden, new-onset aortic regurgitation during off pump coronary bypass surgery.

During off pump coronary artery bypass grafting surgery, it is common to observe mitral or tricuspid regurgitation due to heart displacement. But it's very unusual to notice new onset aortic regurgitation in OPCABG.

Augmenting ENT surgery outside the medical school curriculum: the role of a 1-day otolaryngology course.

BACKGROUND: ENT is highly under-represented in the saturated UK medical school curriculum, comprising less than 1 per cent of the curriculum. A 1-day course was implemented in order to raise awareness of ENT among medical students, educate them in the specialty and teach a basic skill. METHODS: The skills day comprised lectures by consultants followed by a consultant-led workshop teaching tracheostomy. Pre- and post-course questionnaires assessed perceptions of ENT, confidence performing tracheostomy and interest in ENT as a career. RESULTS: Perceptions of ENT as a specialty were improved by up to 80 per cent (p < 0.01). There was improved understanding of and confidence in performing tracheostomies. Interest in a career in ENT was increased by 77 per cent (p < 0.01). CONCLUSION: A 1-day course run by a student body can be a powerful adjunct to the medical school curriculum, in terms of educating undergraduates in ENT and inspiring the pursuit of ENT as a career.

Guillain-Barré syndrome after cardiac surgery: diagnostic dilemma.

Guillain-Barré Syndrome after cardiac surgery is very uncommon. Mechanism remains elusive although immunological reaction post surgery has been postulated. This disease can potentially increase the morbidity of the postoperative patients and generally cannot be explained by the cardiac disease or interventions. It is very much essential to diagnose the condition as appropriate management can substantially and profoundly change the course of treatment.

A curious case of raised gradient across mitral bioprosthetic valve.

High Doppler valve gradient is generally suggestive of valve thrombosis. However, it should be corroborated with the finding of restricted leaflet movement to confirm the diagnosis. In the present case, abnormally high gradient was not associated with limited leaflet movements or any valve thrombus.

Correlation of biochemical constituents of seminal plasma with semen quality in Teddy goat (Capra hircus) bucks.

This study was planned to determine the relationship between semen quality parameters and the levels of biochemical constituents of seminal plasma of Teddy (Capra hircus) buck semen. For this purpose, semen ejaculates were collected from five mature healthy Teddy bucks. All the experimental bucks were kept under natural environmental conditions. Semen was collected twice in a week for the duration of 6 weeks by Artificial Vagina (AV) in the breeding season (February-April). Two successive ejaculates of single buck were pooled at time of collection, and a total of 60 semen samples were processed for semen analysis. Sperm per cent motility, sperm concentration, dead sperm percentage, morphological abnormal spermatozoa, plasma membrane integrity were correlated with biochemical constituents of seminal plasma. The mean per cent motility (89.18% ± 0.37%), sperm concentration (1.86 ± 0.04 × 109 /ml), dead sperm percentage (8.08% ± 0.29%), morphological abnormal spermatozoa (6.05% ± 0.29%) and plasma membrane integrity (88.22% ± 0.34%) were recorded. The seminal plasma contained Na+ (144.12 ± 1.59 mEq/L), K+ (27.38 ± 0.49 mEq/L), Cl- (65.73 ± 0.45 mEq/L), Ca++ (9.34 ± 0.22 mg/dl), P (19.32 ± 0.97 mg/dl), aspartate aminotransferase (AST; 26.48 ± 1.30 IU/L), alanine aminotransferase (ALT; 168.47 ± 5.18 IU/L), lactate dehydrogenase (LDH; 215.98 ± 6.06 IU/L), albumin (1.90 ± 0.10 g/dl), globulins (2.08 ± 0.11 g/dl) and total protein (3.98 ± 0.20 g/dl). The collected data were analysed by applying Pearson's correlation coefficients. Dead sperm percentage had negative correlation with sodium (r = -.278, p < .05), albumin (r = -.294, p < .05), globulin (r = -.266, p < .05) and total protein (r = -.295, p < .05). Phosphorus was negatively associated with sperm concentration (r = -.262, p < .05). AST was negatively correlated with plasma membrane integrity (r = -.292, p < .05). It was concluded that most of the semen quality parameters of Teddy bucks were positively correlated with biochemical constituents, but opposite trends were found in case of dead sperm percentage. The seminal biochemical constituents dynamically interact with each other.

Dhoti cancer: a waistline skin cancer with review of literature.

Skin cancers account for less than 1 % of all malignancies in India. Squamous cell carcinomas occurring over the waistline due to tying of cotton cloth called dhoti in males and sarees in females are predominantly seen in traditional Indian population. On wearing of these clothes for years, there is a constant irritation which produces depigmentation, glazing of the skin, acanthosis, scar formation, and later on malignant transformation. Presenting a case of a 65-year-old male with 7 × 5 cm ulceroproliferative growth over the right waistline with a history of prolonged use of dhoti. Wide local excision of the growth with 2-cm margin and primary closure of wound by mobilizing the skin was carried out. Histopathology showed well-differentiated squamous cell carcinoma. The patient is clinically disease free after postoperative follow-up of 1 year.

Monitoring polio supplementary immunization activities using an automated short text messaging system in Karachi, Pakistan.

PROBLEM: Polio remains endemic in many areas of Pakistan, including large urban centres such as Karachi. APPROACH: During each of seven supplementary immunization activities against polio in Karachi, mobile phone numbers of the caregivers of a random sample of eligible children were obtained. A computer-based system was developed to send two questions--as short message service (SMS) texts--automatically to each number after the immunization activity: "Did the vaccinator visit your house?" and "Did the enrolled child in your household receive oral polio vaccine?" Persistent non-responders were phoned directly by an investigator. LOCAL SETTING: A cluster sampling technique was used to select representative samples of the caregivers of young children in Karachi in general and of such caregivers in three of the six "high-risk" districts of the city where polio cases were detected in 2011. RELEVANT CHANGES: In most of the supplementary immunization activities investigated, vaccine coverages estimated using the SMS system were very similar to those estimated by interviewing by phone those caregivers who never responded to the SMS messages. In the high-risk districts investigated, coverages estimated using the SMS system were also similar to those recorded--using lot quality assurance sampling--by the World Health Organization. LESSONS LEARNT: For the monitoring of coverage in supplementary immunization activities, automated SMS-based systems appear to be an attractive and relatively inexpensive option. Further research is needed to determine if coverage data collected by SMS-based systems provide estimates that are sufficiently accurate. Such systems may be useful in other large-scale immunization campaigns.

Lsr2 of Mycobacterium leprae and its synthetic peptides elicit restitution of T cell responses in erythema nodosum leprosum and reversal reactions in patients with lepromatous leprosy.

The Lsr2 protein of Mycobacterium leprae and its synthetic peptides have been shown to elicit lymphoproliferation and gamma interferon (IFN-γ) release by peripheral blood mononuclear cells (PBMCs) of patients with lepromatous leprosy (M. Chaduvula, A. Murtaza, N. Misra, N. P. Narayan, V. Ramesh, H. K. Prasad, R. Rani, R. K. Chinnadurai, I. Nath, Infect. Immun. 80:742-752, 2012). PBMCs from 16 patients with lepromatous leprosy who were undergoing erythema nodosum leprosum (ENL) (type 2) and 5 patients with reversal reactions (RR) (type 1) were stimulated with M. leprae, recombinant Lsr2, and six end-to-end synthetic peptides (A through F) spanning the Lsr2 sequence. During the reaction all patients with ENL showed lymphoproliferation (stimulation index, >2) in response to peptides A and F, with other peptides eliciting responses in 75 to 88% of the subjects. In PBMC cultures, both lymphoproliferation and IFN-γ release for peptide E were significantly higher than for peptides B and C and recombinant Lsr2 (P < 0.05, Wilcoxon signed-rank test). Five patients with RR also showed enhanced lymphoproliferative responses and IFN-γ release in response to Lsr2, M. leprae, and peptide E. Six months postreaction, 14 patients with ENL continued to exhibit responses to Lsr2 and its peptides, with the highest responses being elicited by peptide E. However, 5 subjects showed no lymphoproliferation and had reduced IFN-γ release in response to Lsr2 peptides (P < 0.001, Kruskal-Wallis test) but responded to recombinant Lsr2. Six patients with ENL had HLA-A*68.01, which the STFPEITHI program showed to have high peptide-binding scores of 20 to 21 for peptides E, B, and C. Eleven patients had HLA-DRB1*1501 and HLA-DRB1*1502, which had high binding scores for peptides C and E. Thus, Lsr2 and its peptides are recognized in leprosy reactions during and well after the subsidence of clinical signs.

Lsr2 peptides of Mycobacterium leprae show hierarchical responses in lymphoproliferative assays, with selective recognition by patients with anergic lepromatous leprosy.

Lsr2 protein of Mycobacterium leprae was shown earlier to elicit B and T cell responses in leprosy patients (20, 28). Lymphoproliferation to M. leprae and Lsr2 antigens was observed in >70% of tuberculoid (T) patients and in 16 and 34% of lepromatous (L) patients, respectively. We focused on the M. leprae nonresponders in the lepromatous group using 22 synthetic Lsr2 peptides (end-to-end peptides A to F and overlapping peptides p1 to p16) in in vitro T cell responses. A total of 125 leprosy and 13 tuberculosis patients and 19 healthy controls from the area of endemicity (here, healthy controls, or HC) were investigated. The highest responses were observed (67 to 100%) in HC for all peptides except p1 to p3, and the lowest was observed in tuberculosis patients. Significant differences in lymphoproliferation were observed in T, L, and HC groups (analysis of variance [ANOVA], P = 0.000 to 0.015) for all end-to-end peptides except B and for p5 and p7 to p10. Hierarchical recognition between lepromatous and tuberculoid leprosy was noted for p8 (P < 0.05) and between the HC and L groups for p7 to p10, p15, and p16 (P < 0.005 to P < 0.02). Significant lymphoproliferation was observed to peptides A to F and p1 to p9, p11, p12, p15, p16 (P = 0.000 to 0.001) with 40% responding to peptides C and p16 in L patients. Lepromatous patients also showed significantly higher levels of a gamma interferon (IFN-γ) response to peptide C than to other peptides (P < 0.05). Major histocompatibility complex (MHC) class II bias for peptide recognition was not observed. These studies indicate that Lsr2 has multiple T cell epitopes that induce in vitro T cell responses in the highly infective lepromatous leprosy patients.

Effects of feeding different dietary protein and energy levels on the performance of 12-15-month-old buffalo calves.

The study investigated the performance response of different dietary protein and energy levels of Nili-Ravi buffalo calves. Sixty buffalo calves of 12-15 months of age and similar body weight (140 ± 14 kg) were divided in to 12 groups, five animals in each group, according to 4 × 3 factorial arrangements. Twelve rations were formulated containing four levels of crude protein (CP; 10.5%, 12.20%, 13.80%, and 15.55%) each with three levels (1.72, 2.11, and 2.5 Mcal/Kg) of metabolizable energy (ME). Experiment lasted for 100 days; first 10 days were given for dietary adaptation. Daily feed consumption in calves fed all experimental diets were statistically significant (p<0.05) across all treatments. Higher feed intake was observed in buffalo calves fed diets containing 12.20% and 13.85% CP with 2.11 Mcal/kg ME. Results of dry matter (DM) digestion were significantly different (p<0.05) across all treatments. There was a quadratic (p<0.05) response of DM digestibility for levels of dietary protein while, curvilinear (p<0.05) trend with respect to dietary energy levels. Daily weight gain of buffalo calves did not show any treatment effect. The outcome of the present study indicate that 12-15-month-old buffalo calves perform adequately well when fed on diets containing 12.2% CP and 2.10 ME Mcal/Kg.

Case of unusual foreign body in the rectum.

A 44-year-old male patient with a foreign body in rectum (beverage bottle), introduced as sexual perversion, is presented with literature review. The management emphasis is on transanal retrieval and ruling out of the rectal and colonic perforation and the requirement for postremoval psychiatric treatment.