High-flow nasal oxygen in infants and children for early respiratory management of pneumonia-induced acute hypoxemic respiratory failure: the CENTURI randomized clinical trial.

Objective: To compare the effectiveness of early high-flow nasal cannula (HFNC) and low-flow oxygen support (LFOS) in children under 5 years with acute hypoxemic respiratory failure (AHRF) due to severe community-acquired pneumonia in low-middle-income countries. Methods: An open-label randomized clinical trial enrolled children aged 2-59 months with AHRF due to severe community-acquired pneumonia and randomized into HFNC and LFOS. In the LFOS group, the patient received cold wall oxygen humidified by bubbling through sterile water administered through simple nasal prongs at a fixed flow rate of 2 L/min. In the HFNC group, the patient received humidified, heated (37 °C), high-flow oxygen at a flow rate assigned based on weight range, with a titratable oxygen fraction. The primary outcome was treatment failure in 72 h (escalating the respiratory support method using any modality other than primary intervention). Results: Data was analyzed intention-to-treat (HFNC = 124; LFOS = 120). Median (IQR) age was 12 (6-20) and 11 (6-27) months, respectively. Treatment failure occurred in a significantly lower proportion in the HFNC group (7.3%, n = 9/124) as compared to the LFOS group (20%, n = 24/120) (relative risk = 0.36, 95% CI 0.18 to 0.75; p = 0.004; adjusted hazard ratio 0.34, 95% CI 0.16 to 0.73; p = 0.006). The intubation rate was significantly lower in the HFNC group (7.3%, n = 9/124 vs. 16.7%, n = 20/120; relative risk = 0.44, 95% CI 0.21 to 0.92, p = 0.023). There were no significant differences noted in other secondary outcomes. No mortality occurred. Conclusion: High-flow nasal cannula oxygen therapy used as early respiratory support in children under 5 years with acute hypoxemic respiratory failure due to severe community-acquired pneumonia was associated with significantly lower treatment failure compared with standard low-flow oxygen support. Trial registration: CTRI/2016/04/006788. Registered 01 April 2016, https://ctri.nic.in/Clinicaltrials/advsearch.php. Supplementary Information: The online version contains supplementary material available at 10.1007/s44253-024-00031-8.

Stress and stressors experienced by the parents of high-risk neonates admitted in neonatal intensive care unit: Systematic review and meta-analysis evidence available from India.

The aim of the systematic review and meta-analysis is to determine the stress and stressors experienced by the parents of high-risk neonates admitted to the neonatal intensive care unit (NICU) in India. We included both quantitative and qualitative studies. The Joanna Briggs Institute Critical Appraisal Checklist and Critical Appraisal Skill Programme checklist were used to assess the quality of included studies. A systematic search was conducted in PubMed, EMBASE, SCOPUS, EBSCOhost, Web of Science, ProQuest, Microsoft Academic, DOAJ, Indian Citation Index, and J-Gate to identify relevant studies. Additionally, online hand searching was performed on Indian websites of relevant institutions, women and child health departments, repositories, registries, and paediatric journals. Twelve of the 21 quantitative studies found that maternal stress was higher than fathers due to the separation from their babies and the medical condition of the neonate. One qualitative study reported that financial burden, alterations in the parenting role, and concern over domestic issues are significant causes of fathers' stress. A meta-analysis of the included studies assessed the prevalence of maternal, paternal, and parental stress and reported that mothers experienced higher stress levels than fathers across all subscales. The most typical stressors for parents were changes in neonatal looks, behaviour, and altered parental roles. Beyond the immediate NICU care and interactions, other triggering factors of stress among parents must be considered to design multicomponent interventions in a local (Indian) context. Moreover, parental psychological support and regular counselling can be incorporated into the standard neonatal intensive care policy.

Broad and narrow complex tachycardia resulting in cardiorespiratory arrest in a child: what is the optimal treatment strategy?

Background: We describe a child with a broad and narrow complex tachycardia causing haemodynamic collapse. Case summary: A 9-year-old girl (weight 26 kg, height 114 cm) with a 5-year history of refractory 'epilepsy' presented with cardiorespiratory arrest and tonic-clonic seizure, witnessed by her mother. Electrocardiogram documented recurrent episodes of simultaneous broad and narrow tachycardias associated with haemodynamic compromise. Diagnostic electrophysiologic study (EPS) confirmed a dual tachycardia mechanism. The challenge in selecting the optimal treatment strategy is discussed. A diagnosis of dual tachycardia was made with catecholaminergic polymorphic ventricular tachycardia (CPVT) and simultaneous focal atrial tachycardia. Discussion: Bidirectional ventricular tachycardia (VT) induced by isoproterenol in this clinical scenario is strongly suggestive of CPVT. Diagnostic EPS can be useful in challenging clinical situations to understand the mechanism of arrhythmias and to tailor the most appropriate treatment strategy. Combination therapy with nadolol and flecainide is highly effective in ventricular arrhythmia control. Implantable cardioverter defibrillator implantation is not without risk in CPVT as there is a potential of electrical storm driven by shock therapy that increases adrenergic drive. Cervical sympathectomy may be considered if further VTs occur in future despite optimum medical therapy.

Exercise dose-response relationship with heart rate variability in individuals with overweight and obesity: protocol for a systematic review and meta-analysis of randomised controlled trials.

INTRODUCTION: Obesity is a chronic relapsing disease process and serious public health concern that can lead to chronic diseases, medical complications and a higher risk of disability. Another significant feature of obesity is dysfunction in cardiac autonomic function, which leads to changes in parasympathetic and sympathetic regulation, which can be measured using heart rate variability (HRV). The objective of this review is to estimate the extent to which exercise doses impacts on HRV among individuals living with overweight and obesity class I and II. METHODS AND ANALYSIS: A systematic literature search will be performed using PubMed/Medline, Scopus, EMBASE, ProQuest, CINAHL, Web of Science and the Cochrane Library for articles dating from 1965 to December 2021. Inclusion criteria include studies designed as parallel-arm randomised trials, enrolling adolescent and adult individuals with overweight (body mass index, BMI≥25 to ≤29.9) and obesity (class I BMI: 30-34.9 and class II BMI: 35-39.9) undergoing aerobic or resistance training or concurrent exercise training. For data synthesis, sensitivity analysis, subgroup analysis and risk of bias assessment, Stata V.13.0 software will be used. ETHICS AND DISSEMINATION: Formal ethical approval is not required. This systematic review will be submitted to a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42019104154.

Outcomes From Pediatric Ablation: A Review of 20 Years of National Data.

OBJECTIVES: This study set out to examine outcomes from pediatric supraventricular tachycardia ablations over a 20-year period. This study sought to examine success rates and repeat ablations over time and to evaluate whether modalities such as 3-dimensional (3D) mapping, contact force, and cryotherapy have improved outcomes. BACKGROUND: Ablation of supraventricular tachycardia in pediatric patients is commonly performed in most congenital heart centers with excellent long-term results. METHODS: Data were retrieved from the NICOR (National Institute of Clinical Outcomes Research) database in the United Kingdom. Outcomes over time were evaluated, and procedure-related details were compared. RESULTS: There were 7,069 ablations performed from January 1, 1999, to December 31, 2018, at 10 centers. Overall, ablation success rates were 92% for accessory pathways, 97% for atrioventricular node re-entry tachycardia, and 89% for atrial tachycardia. There was an improvement in procedural success rates over time (p < 0.01). The use of 3D mapping did not alter success or need for repeat ablation but was associated with a higher proportion of lower fluoroscopy cases; 55% of 3D mapping cases used <5 min of fluoroscopy (p < 0.01). Patients needing a repeat ablation were 341 (12%) for accessory pathways, 128 (7%) for atrioventricular node re-entry tachycardia, and 35 (7%) for atrial tachycardia. Overall, the risk of complete heart block was low (n = 12, <0.01%). The use of cryotherapy was associated with an increased risk of needing a repeat ablation. CONCLUSIONS: Overall success rates from pediatric ablations are excellent and compare favorably to other registries. Introduction of newer technologies have likely made procedures safer and reduced radiation exposure, but they have not changed success rates or the need for a repeat procedure.

HPV related cloacogenic carcinoma of the anal canal with divergent histomorphology.

Cloacogenic carcinoma also known as basaloid squamous cell carcinoma is a rare anorectal tumor presenting with varied histomorphology. In this case report, we describe a case of 58-year-old man presenting with bleeding per rectum and pain. A polypoidal tumor was noted in anal canal which on microscopy was diagnosed to be cloacogenic carcinoma with transitional carcinoma-like, basaloid and mucinous patterns. An unusual finding in the present case was the presence of signet ring cells in the mucinous areas. A thorough knowledge of the wide histomorphological spectrum of the tumor and a limited IHC panel are crucial for the diagnosis. Here, we also present a review of literature and describe in detail the origin and histopathological features of the tumor.

"But doctor, I googled it!": The "three Rs" of managing patients in the age of information overload.

Managing patient interactions in the age of the Internet can be particularly difficult due to the vast amount of information available. Dermatologists should be able to identify relevant patient concerns to adequately address them. We discuss the ethical issues involved in interacting with patients who use the Internet for medical knowledge, and we suggest a method, using the "three Rs" (reassure, redirect, refer), to conduct these interactions. Appropriate evaluation and categorization of patients with regard to their concerns and needs can help guide physicians on how to use the three Rs in managing patient care and expectations.

Hansen's Neuritis Revisited - A Clinicopathological Study.

INTRODUCTION: Leprosy affecting the nerve solely or with concomitant skin lesions is not an uncommon condition in clinical practice. It is responsible for extensive morbidity and often poses a diagnostic challenge. This study aims to highlight the clinicopathological features of Hansen's neuritis (HN). MATERIALS AND METHODS: In this retrospective study, cases of histologically diagnosed HN, from January 2010 to July 2017, were reviewed in the light of clinical features, treatment history, and outcome. RESULTS: There were 18 cases of HN which accounted for 3.97% of total nerve biopsy samples (n = 453) and 0.02% of total histopathology samples (n = 81,013). The male: female ratio was 5:1 in the cases of HN. Age range was 20-79 years with a mean age of 42.4 years (standard deviation: ±14.03). Among the HN cases, there were 13 cases of pure neuritic leprosy (61.1%). Mononeuritis multiplex was the most common finding in the nerve conduction study. Six (33.3%) cases exhibited histological features of borderline tuberculoid leprosy, followed by five (27.8%) cases of mid-borderline features, three (16.7%) cases each of borderline lepromatous and burnt-out HN, and one (5.6%) case of polar tuberculoid leprosy. Lepra bacilli were detected on Fite-Faraco stain in 44.4% cases. CONCLUSION: Diagnosis of HN depends on astute search for skin lesions, nerve thickening or tenderness, sensory or motor symptoms, histopathological examination, and demonstration of lepra bacilli.

Low Altitude Solar Magnetic Reconnection, Type III Solar Radio Bursts, and X-ray Emissions.

Type III solar radio bursts are the Sun's most intense and frequent nonthermal radio emissions. They involve two critical problems in astrophysics, plasma physics, and space physics: how collective processes produce nonthermal radiation and how magnetic reconnection occurs and changes magnetic energy into kinetic energy. Here magnetic reconnection events are identified definitively in Solar Dynamics Observatory UV-EUV data, with strong upward and downward pairs of jets, current sheets, and cusp-like geometries on top of time-varying magnetic loops, and strong outflows along pairs of open magnetic field lines. Type III bursts imaged by the Murchison Widefield Array and detected by the Learmonth radiospectrograph and STEREO B spacecraft are demonstrated to be in very good temporal and spatial coincidence with specific reconnection events and with bursts of X-rays detected by the RHESSI spacecraft. The reconnection sites are low, near heights of 5-10 Mm. These images and event timings provide the long-desired direct evidence that semi-relativistic electrons energized in magnetic reconnection regions produce type III radio bursts. Not all the observed reconnection events produce X-ray events or coronal or interplanetary type III bursts; thus different special conditions exist for electrons leaving reconnection regions to produce observable radio, EUV, UV, and X-ray bursts.

Expected Sonographic Appearance of the Spleen in Children and Young Adults With Sickle Cell Disease: An Update.

OBJECTIVES: To update the imaging literature regarding spleen appearances in young patients with sickle cell disease (SCD). METHODS: We conducted a retrospective study and included 112 patients age 0 to 21 years with SCD who had at least 1 abdominal sonogram at our institution between 1999 and 2011. Radiologic findings were compared between risk groups by χ(2) analysis. Findings were correlated with other imaging modalities when available. RESULTS: In our cohort, 35.7% of patients had autosplenectomy, and 8.0% had undergone surgical splenectomy. Only 5.0% of individuals age 0 to 5 years had autosplenectomy. In those who had not undergone surgical splenectomy or autosplenectomy, 76.2% had echogenic spleens, heterogeneous-appearing spleens, or both, and patients with the homozygous sickle cell anemia (HbSS) genotype were more likely to have an abnormal spleen echo texture. Patients treated with transfusions had echogenic spleens and had a higher frequency of splenic regeneration nodules. Most patients (80%) with splenomegaly did not require surgical splenectomy after 5.7 years of follow-up. CONCLUSIONS: Twenty years ago, children with HbSS SCD were expected to have autosplenectomy by age 5 years. There have been changes in the radiologic appearance of the spleen in patients with SDC, likely due to improved supportive care and the use of acute and chronic transfusion therapy. We found that autosplenectomy is rare by age 5 years, and during childhood and adolescence, the spleen typically appears echogenic, heterogeneous, or both, depending on disease severity.

Implications of radiologic-pathologic correlation for gallbladder disease in children and young adults with sickle cell disease.

The purpose of this study is to describe gallbladder imaging findings in patients with sickle cell disease, and to determine how they correspond with occurrence of complications, need for cholecystectomy, and surgical pathology. This study is IRB approved and HIPAA compliant. Informed consent requirements were waived. We reviewed records of 77 children with sickle cell disease ages 0-18 years at the time of their first gallbladder imaging study. Demographics, hospital courses, and radiologic and pathologic reports were collected. Two pediatric radiologists independently and retrospectively reviewed the imaging studies. Statistical analysis was performed using kappa statistic, chi-squared test, and ANOVA F-test. Continuous variables were described with mean, median, variance, and range. Patients who underwent cholecystectomy (N = 25) were more likely than the patients who did not undergo cholecystectomy (N = 52) to have gallstones or sludge (100 versus 36.5 %, p = <0.0001) or other gallbladder or biliary abnormality (70.8 versus 1.9 %, p = <0.0001). Patients who did not undergo cholecystectomy more frequently had normal-appearing gallbladders and biliary tracts (63.5 versus 0 %, p = <0.0001). Ninety-two percent of patients with cholecystectomy had chronic cholecystitis on pathology, and 96 % had a complication, including chronic cholecystitis and sequelae of biliary obstruction. Young patients with sickle cell disease, cholelithiasis, and any other biliary imaging abnormality will almost certainly require cholecystectomy, and many will experience complications. The most common surgical pathologic diagnosis in this group is chronic cholecystitis, which has a variable radiologic appearance. Our findings support recommendations to perform elective cholecystectomy for children and young adults with sickle cell disease and cholelithiasis or gallbladder sludge.

Comparison of effectiveness of acupuncture therapy and conventional drug therapy on psychological profile of migraine patients.

Migraine is a painful condition in which patients suffer from recurrent episodes of disabling pain, which could be very severe and can lead to grave psychological disturbances. There is no curative treatment for migraine, but there are various treatment modalities, though, with conflicting reports on their efficacy. This study was conducted to compare the effectiveness of electro acupuncture therapy and the conventional drug therapy on the psychological profile of migraneurs based on the assessment of quality of life and disability parameters. Migraneurs (n = 60) were recruited from the Psychiatry and Neurology OPD, Guru Tegh Bahadur Hospital, Delhi. Following a written consent, migraneurs were randomly allocated into 2 study groups--Group A received 10 sittings of electro acupuncture on selected acupuncture points over a period of 30 days, while for the same duration the Group D received a conventional drug therapy in the form of oral flunarizine 20 mg OD along with paracetamol 500 mg SOS. The patients were assessed twice, before and after completion of the treatment programme (30 days). The quality of life was assessed with WHOQOL BREF (WHO Quality of Life Biomedical Research and Education Foundation) questionnaire and the disability was assessed with MIDAS (Migraine Disability Assessment) questionnaire. Statistical analysis was performed using repeated measure's ANOVA with Tukey's test. Migraneurs were found to have lower quality of life and higher disability scores but following the treatment regimes, the 2 study groups showed a significant improvement in both the parameters studied. It was however observed, that the acupuncture group showed a better response and was thus found to be more effective as compared to the drug group (P = 0.005 to 0.000). We thus conclude that acupuncture is a better treatment option than the conventional drug therapy in not only relieving the pain of migraine but in also improving the psychological profile in migraneurs. Hence its use should be encouraged as an alternative/adjunct treatment for migraine.