Complications during mechanical ventilation-A pediatric intensive care perspective.

Mechanical ventilation is a common procedure performed in pediatric intensive care units, with over 20% of patients requiring invasive ventilator support. The most common indication for endotracheal intubation and ventilation in the pediatric population is respiratory failure either due to respiratory embarrassment or neurologic pathology. Despite the use of ventilation modes that are lung protective in the pediatric population, complications of mechanical ventilation occur frequently. These include atelectasis, post-extubation stridor, perioral tissue damage, ventilator associated pneumonia, mucus plugging, pneumothorax, pneumomediastinum, and ICU neuromyopathy. The purpose of this review is to discuss the risk factors, presentation and management of complications associated with mechanical ventilation in the pediatric population.

COVID-19 in a mosaic trisomy 13 patient with polycystic kidney disease.

Presentation, management, and outcomes of COVID-19 infections among younger patients is an area of medicine with deficits in research, likely due to the lower incidence of severe COVID-19 disease among the younger population. Management can be challenging, and clinicians often guide their decision-making based on the ever-changing protocols that are tailored mostly to the elderly population. Even more underrepresented in COVID-19 research are patients with chromosomal abnormalities and trisomy syndromes, as they appear less frequently, but have risk of increased morbidity and mortality due to underlying medical conditions. We describe a case of severe COVID-19 infection in a young patient with mosaic trisomy 13 and pre-existing polycystic kidney disease, who developed severe acute hypoxic respiratory failure and acute chronic kidney injury. The patient was provided maximal pharmacological support and her clinical course helps to shape the understanding of COVID-19 infections in the setting of chromosomal abnormalities and complex medical history.

Viscerocutaneous Loxoscelism Manifesting with Myocarditis: A Case Report.

BACKGROUND Envenomation from the brown recluse spider (Loxosceles reclusa) is described to cause both local and systemic symptoms. We report a case of an adolescent boy who developed severe systemic loxoscelism, and his clinical course was complicated by myocarditis, which has not been previously reported in association with loxoscelism. CASE REPORT A 16-year-old boy presented with non-specific symptoms and forearm pain following a suspected spider bite, which subsequently evolved into a necrotic skin lesion. During his clinical course, he developed a characteristic syndrome of systemic loxoscelism with hemolysis, disseminated intravascular coagulopathy, and severe systemic inflammatory response syndrome, necessitating transfer to the Intensive Care Unit. The diagnosis was confirmed with an enzyme-linked immunosorbent assay that detected Loxosceles venom in the wound. Additionally, he developed pulmonary edema and cardiogenic shock secondary to myocarditis, which was confirmed with cardiac magnetic resonance imaging. Steroids and plasmapheresis were initiated to manage the severe inflammatory syndrome, and the myocarditis was treated with intravenous immunoglobulins, resulting in resolution of symptoms and improvement of cardiac function. CONCLUSIONS This is the first reported case of myocarditis associated with loxoscelism, providing evidence for Loxosceles toxin-associated cardiac injury, which has been previously described in animal models only. Furthermore, this case provides further support for the use of confirmatory testing in the clinical diagnosis of loxoscelism.

Successful use of inhaled epoprostenol as rescue therapy for pediatric ARDS.

Severe pediatric ARDS remains a significant challenge for clinicians, and management strategies are essentially limited to lung protective ventilation strategies, and adjunct approaches such as prone positioning, steroids, surfactant, and inhaled nitric oxide in unique situations. Inhaled nitric oxide produces pulmonary vasodilation in ventilated regions of the lung, shunting blood away from poorly ventilated areas and thus optimizing the ventilation perfusion ratio. A subset of patients with ARDS are known to be non-responders to nitric oxide, and selective pulmonary vasodilators such as Epoprostenol can be useful as rescue therapy in such cases. We describe a case of severe pediatric ARDS in the setting of pre-existing pulmonary hypertension and Trisomy 21, whose clinical course improved remarkably once inhaled Epoprostenol was initiated.

Favorable outcome with early initiation of VV-ECMO for unilateral lung disease in children.

Unilateral lung diseases such as unilateral pneumonia, trauma or pulmonary hemorrhage can cause profound hypoxemic respiratory failure necessitating mechanical ventilation. These disorders are characterized by marked asymmetry in lung mechanics, with the affected lung having a lower compliance compared to the healthier lung, and management involves complex strategies such as simultaneous independent lung ventilation. However, such strategies can be challenging in pediatric populations due to technical limitations, and also lead to ventilator induced lung injury. We report two unique cases that support the use of venovenous extracorporeal membrane oxygenation as an alternative strategy for management of unilateral lung disease in children.

Zinc supplementation leads to immune modulation and improved survival in a juvenile model of murine sepsis.

Children with severe sepsis are known to have altered zinc homeostasis and decreased circulating zinc levels, suggesting a role for zinc supplementation to improve outcomes. We tested the hypothesis that zinc supplementation would improve survival in a juvenile model of polymicrobial sepsis. Juvenile (13-14-d-old) C57BL/6 mice were treated with 10 mg/kg of zinc via i.p. injections (or vehicle) for 3 d prior to induction of polymicrobial sepsis via i.p. cecal slurry injections. Survival after sepsis was followed for 3 d, and bacterial clearance, ex vivo phagocytosis, systemic inflammatory markers and neutrophil extracellular trap (NET) formation were quantified. We found a significant survival benefit and decreased bacterial burden among zinc supplemented mice when compared with the control group. Zinc supplementation also resulted in enhanced phagocytic activity, greater neutrophil recruitment in the peritoneal cavity and NET formation, suggesting a possible mechanism for improved bacterial clearance and survival. We also noted decreased serum cytokine levels and decreased myeloperoxidase activity in lung tissue following zinc supplementation, suggesting attenuation of the systemic inflammatory response. In conclusion, zinc supplementation improves bacterial clearance, and hence survival, in juvenile mice with polymicrobial sepsis.

Effect of case management on neonatal mortality due to sepsis and pneumonia.

BACKGROUND: Each year almost one million newborns die from infections, mostly in low-income countries. Timely case management would save many lives but the relative mortality effect of varying strategies is unknown. We have estimated the effect of providing oral, or injectable antibiotics at home or in first-level facilities, and of in-patient hospital care on neonatal mortality from pneumonia and sepsis for use in the Lives Saved Tool (LiST). METHODS: We conducted systematic searches of multiple databases to identify relevant studies with mortality data. Standardized abstraction tables were used and study quality assessed by adapted GRADE criteria. Meta-analyses were undertaken where appropriate. For interventions with biological plausibility but low quality evidence, a Delphi process was undertaken to estimate effectiveness. RESULTS: Searches of 2876 titles identified 7 studies. Among these, 4 evaluated oral antibiotics for neonatal pneumonia in non-randomised, concurrently controlled designs. Meta-analysis suggested reductions in all-cause neonatal mortality (RR 0.75 95% CI 0.64- 0.89; 4 studies) and neonatal pneumonia-specific mortality (RR 0.58 95% CI 0.41- 0.82; 3 studies). Two studies (1 RCT, 1 observational study), evaluated community-based neonatal care packages including injectable antibiotics and reported mortality reductions of 44% (RR = 0.56, 95% CI 0.41-0.77) and 34% (RR = 0.66, 95% CI 0.47-0.93), but the interpretation of these results is complicated by co-interventions. A third, clinic-based, study reported a case-fatality ratio of 3.3% among neonates treated with injectable antibiotics as outpatients. No studies were identified evaluating injectable antibiotics alone for neonatal pneumonia. Delphi consensus (median from 20 respondents) effects on sepsis-specific mortality were 30% reduction for oral antibiotics, 65% for injectable antibiotics and 75% for injectable antibiotics on pneumonia-specific mortality. No trials were identified assessing effect of hospital management for neonatal infections and Delphi consensus suggested 80%, and 90% reductions for sepsis and pneumonia-specific mortality respectively. CONCLUSION: Oral antibiotics administered in the community are effective for neonatal pneumonia mortality reduction based on a meta-analysis, but expert opinion suggests much higher impact from injectable antibiotics in the community or primary care level and even higher for facility-based care. Despite feasibility and low cost, these interventions are not widely available in many low income countries. FUNDING: This work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to Saving Newborn Lives Save the Children, through Save the Children US.

Neonatal infections in the developing world.

An estimated one million newborns die from infections in developing countries. Despite the huge burden, high-quality data from community-based epidemiologic studies on etiology, risk factors, and appropriate management are lacking from areas in which newborns experience the greatest mortality. Several planned and ongoing studies in South Asia and Africa promise to address the knowledge gaps. However, simple and low-cost interventions, such as community-based neonatal care packages supporting clean birth practices, early detection of illness through use of clinical algorithms, and home-based antibiotic therapy in areas in which hospitalization is not feasible are already available and have the potential to bring about a drastic reduction in global neonatal mortality due to infections if they are scaled up to national level. Concerted collaborative action by national governments, health professionals, civil society organizations, and international health agencies is required to reduce neonatal mortality due to infections.

International perspective on early-onset neonatal sepsis.

Infections are a major cause of neonatal death in developing countries. High-quality information on the burden of early-onset neonatal sepsis and sepsis-related deaths is limited in most of these settings. Simple preventive and treatment strategies have the potential to save many newborns from sepsis-related death. Implementation of public health programs targeting newborn health will assist attainment of Millennium Development Goals of reduction in child mortality.

Prevalence and predictors of depression among an elderly population of Pakistan.

OBJECTIVE: To assess the magnitude and risk factors of the problem of depression in an elderly population of Pakistan. METHOD: A cross-sectional study was conducted using a sample of 402 people aged 65 and above visiting the Community Health Center of the Aga Khan University, Karachi. Questionnaire based interviews were conducted for data collection and the 15-Item Geriatric Depression Scale was used to screen for depression. Univariate and multivariate logistic regression analyses were performed to identify factors associated with depression. RESULTS: Of the 402 participants; 69.7% (95% CI=+/-4.5%) were men, 76.4% (95% CI=+/-4.2%) were currently married, 36.8% (95% CI=+/-5%) had received 11 or more years of education and 24.4% (95% CI=+/-4.2%) were employed. The mean age was 70.57 years (SD=+/-5.414 years). The prevalence of depression was found to be 22.9% (95% CI=+/-4.1%) and multiple logistic regression analysis indicated that higher number of daily medications (p-value=0.03), total number of health problems (p-value=0.002), financial problems (p-value<0.001), urinary incontinence (p-value=0.08) and inadequately fulfilled spiritual needs (p-value = 0.067) were significantly associated with depressive symptoms. CONCLUSION: We have identified several risk factors for depression in the elderly which need to be taken into account by practicing family physicians and health care workers.

Body Dysmorphic Disorder: gender differences and prevalence in a Pakistani medical student population.

BACKGROUND: Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a preoccupation with an imagined or slight defect which causes significant distress or impairment in functioning. Few studies have assessed gender differences in BDD in a non clinical population. Also no study assessed BDD in medical students. This study was designed to determine the point prevalence of BDD in Pakistani medical students and the gender differences in prevalence of BDD, body foci of concern and symptoms of BDD. METHODS: The medical students enrolled in a medical university in Karachi, Pakistan filled out a self-report questionnaire which assessed clinical features of BDD. BDD was diagnosed according to the DSM-IV criteria. RESULTS: Out of the 156 students, 57.1% were female. A total of 78.8% of the students reported dissatisfaction with some aspect of their appearance and 5.8% met the DSM-IV criteria for BDD. The male to female ratio for BDD was 1.7. Regarding gender differences in body foci of concern, the top three reported foci of concern in male students were head hair (34.3%), being fat (32.8%), skin (14.9%) and nose(14.9%), whereas in females they were being fat (40.4%), skin (24.7%) and teeth (18%). Females were significantly more concerned about being fat (p = 0.005). Male students were significantly more concerned about being thin (p = 0.01) and about head hair (p = 0.012). CONCLUSION: BDD is fairly common in our medical student population, with a higher prevalence in males. Important gender differences in BDD symptomatology and reported body foci of concern were identified which reflected the influence of media on body image perception. The impact of cultural factors on the prevalence as well as gender differences in BDD symptomatology was also established.