Prevalence and Outcomes of Carbapenem-resistant Bloodstream Infection in Children With Cancer.

INTRODUCTION: Carbapenem-resistant (CR) infections cause major morbidity and mortality. Data on CR infections in children with cancer are scarce, especially from the developing world. The aim of this study was to evaluate the characteristics and outcomes of bacteremia with CR organisms (CRO) compared with bacteremia with Carbapenem-sensitive organisms in children with cancer. METHODS: This retrospective observational study was conducted in a tertiary pediatric oncology center in South India. Data on all bloodstream infections with Gram-negative organisms (CRO and Carbapenem sensitive-organisms) in children with malignancy ≤14 years of age from August 2017 to July 2021 were retrieved. The outcome was determined as survival and all-cause death 28 days after the date of Bloodstream infection (BSI) onset. RESULTS: Sixty-four Gram-negative BSI were identified, with 24% (n=15) in the Carbapenem-Resistant Bloodstream Infection (CR-BSI) group and 76% (n=49) in the Carbapenem-sensitive-Bloodstream Infection group. The patients included 35 males (64%) and 20 females (36%), with ages ranging from 1 year to 14 years (median age: 6.2 y). The most common underlying disease was hematologic malignancy (92.2%, n=59). Children with CR-BSI had a higher incidence of prolonged neutropenia, septic shock, pneumoniae, enterocolitis, altered consciousness, and acute renal failure and were associated with 28-day mortality in univariate analysis. The most common carbapenem-resistant Gram-negative bacilli isolates were Klebsiella species (47%) and Escherichia coli (33%). All carbapenem-resistant isolates were sensitive to colistin, and 33% were sensitive to Tigecycline. The case-fatality rate was 14% (9/64) in our cohort. The overall 28 days mortality was significantly higher in patients with CR-BSI than in those with Carbapenem-sensitive Bloodstream Infection (28-day mortality: 43.8% vs. 4.2%, P =0.001). CONCLUSIONS: Bacteremia with CRO has higher mortality in children with cancer. Prolonged neutropenia, pneumoniae, septic shock, enterocolitis, acute renal failure, and altered consciousness were predictors of 28-day mortality in carbapenem-resistant septicemia.

Surgical management of chronic osteomyelitis: Organisms, recurrence and treatment outcome.

PURPOSE: The study aimed to identify the risk factors of recurrence in chronic osteomyelitis (COM) and to document the microbiological patterns pre- and intra-operatively and at recurrence, if any. METHODS: We performed retrospective review on COM patients treated with surgical debridement and a 6-week course of antibiotics. The patients with symptoms of osteomyelitis for at least 6 weeks, present or past episodes of discharging sinus, documentation of bone sequestration in operative notes or preoperative images were included in the study. Patients with symptoms of osteomyelitis < 6 weeks, lack of history of discharging sinus or lack of evidence of sequestration in preoperative images or intraoperative notes were excluded. Logistic regression models were used to assess the impact of risk factors of recurrence. Cohen-Kappa scores were derived to see the concordance between pre-operative and intra-operative isolates and at recurrence. RESULTS: Totally, 147 COM patients (115 males and 32 females, mean age (33 ± 19) years) were included in this study. Recurrence was noted in 28 patients (19.0%). Polymicrobial growth and extended spectrum beta-lactamase producing Enterobacteriaceae increased the chance of recurrence. Cierny-Mader stage-1, hematogenous aetiology and negative intraoperative culture reduced the chance of recurrence. Concordance between pre-operative and intra-operative cultures was 59.85% (Kappa score 0.526, p < 0.001) and between index surgery and at recurrence was 23.81% (Kappa score 0.155, p < 0.001). Lack of knowledge of causative organism preoperatively did not affect outcome. At mean follow-up (42 ± 15) months, all patients were apparently infection free for at least 1 year. CONCLUSION: Polymicrobial growth and multi-drug resistant organisms increase the risk of recurrence in COM. Patients' age, gender, diabetes mellitus, previous failed treatment, duration of symptoms, haemoglobin, white cell count, C-reactive protein and erythrocyte sedimentation rate at presentation did not have any impact on the recurrence of infection. Pre-operative isolation of organism is of questionable value. Recurrences of infections do occur and are more of re-infections than relapses. Diligent isolation of organism must be attempted even in re-debridements. Even patients with recurrences do well with appropriate debridement and antibiotic therapy.

Improving the Quality and Intelligibility of Electrolaryngeal Speech during Mobile Communication with Landline Analogous Bandpass Filtering.

The normal functioning of the larynx or voicebox gives humans the ability to converse with others effortlessly. However, if the larynx is permanently removed due to injury or illness, speech cannot be produced. The electrolarynx, a noninvasive device used to produce speech for such persons, has a motor-induced hum which hinders telephone-based communication among electrolaryngeal speakers. This adversely affects the morale of electrolarynx users, leading to abandonment of technology, psychological issues and decreased quality of life. This paper examines a technique based on bandpass filtering of electrolaryngeal speech which has the potential of increasing the quality and intelligibility of speech produced by means of an electrolarynx. Finite impulse response and infinite impulse response filtering with bandpass frequencies analogous to telephone landline and wideband filtering were investigated. Objective testing and subjective testing of quality and intelligibility of electrolaryngeal speech have been performed in each phase of the work. Statistical analysis based on one-way analysis of variance (ANOVA) has been conducted after each round of subjective testing. Results indicate that the quality as well as intelligibility of electrolaryngeal speech can be improved with the help of bandpass filtering.

Displaced midshaft clavicle fractures in adults - is non-operative management enough?

INTRODUCTION: Displaced fractures of middle third of clavicle are traditionally managed non-operatively. Recently, the trend is towards surgical management considering functional deficits in some of the non-operatively managed patients. The purpose of the study was to examine the functional outcome of non-operative treatment in these injuries, while identifying the factors responsible for less than ideal outcome and determine the guidelines for patient counselling. PATIENTS AND METHODS: One hundred patients with displaced fractures of middle third of clavicle were prospectively evaluated clinico-radiologically for one year from injury. Risk factors for non-union were determined using Fisher's exact test. Logistic regression was used to identify factors contributing to functional outcome. Threshold values for the radiological displacements were estimated with the smooth threshold regression using the logistic transition function. RESULTS: Ninety-four out of 100 fractures united. The factors associated with non-union were: smoking, diabetes and poor soft tissue condition over the fracture. Ninety-two out of 94 patients who had their fractures united achieved "good" (Constant Score above 70) or "very good" (Constant Score above 85) functional outcome at one year, out of which only 49 belonged to "very good" category. The most important factors influencing functional outcome were fracture angulation and clavicular shortening. From the model, it was estimated that with one unit increase in degree of angulation or 1 mm increase in shortening, the odds of scoring above 85 reduces by around 14%. Based on this, an equation and a probability calculator were developed from which the probability of achieving a Constant Score above 85 can be calculated. Threshold analysis yielded 22.8° for angulation and 16.8 mm for shortening at which the probability of achieving "very good" function is only 0.23. CONCLUSION: Displaced midshaft clavicular fractures with the intent of achieving "good" outcome must be managed non-operatively. If the patient expectation is not to accept even minor functional deficits, the treatment objective must be raised to achieve a minimum Constant score of 86. Substituting the radiological displacements in the equation, the probability of the patient achieving this objective can be calculated. Non-operative management is offered if this probability figure is acceptable to the patient, otherwise counselled for surgery. Non-operatively managed patients with coexisting diabetes, smoking or poor soft tissue condition must be watched for the possibility of going for non-union.

Treatment of acute avulsion of posterior cruciate ligament of left knee with bony fragment by Siddha Varmam therapy and traditional bone setting method.

A 42-year-old man with the complaints of left knee swelling, severe pain, difficult to stand was reported to Siddha Varmam division after a road accident. He was diagnosed as acute avulsion of Posterior cruciate ligament (PCL). It was diagnosed based on the history of trauma, knee pain and swelling after trauma, positive posterior drawer test and avulsion fracture shown by radiograph. He was treated with Siddha Varmam therapy and traditional bone setting. After a month of treatment, the PCL avulsion fracture got healed without any surgical interventions and patient able to walk normally. This case report summarises the novel Siddha Varmam therapy and traditional bone setting treatments for acute avulsion of PCL with bony fragment.

Isolated parapharyngeal cold abscess in a 9-year-old boy.

Tuberculous adenitis presenting as an isolated cold abscess in the parapharyngeal space is very uncommon and has not been reported in the paediatric age group; presentation as a retropharyngeal abscess, however, is well known. Nine-year-old boy with a progressively increasing swelling on the right side of the neck for 2 months was referred with a clinical diagnosis of neuroblastoma. Surgical exploration of the parapharyngeal space by needle aspiration yielded a cheesy material and Mycobacterium tuberculosis was detected by DNA TB PCR. Tuberculosis should always be considered in the differential diagnosis of a cervical swelling in a child.

Can Chaotic Analysis of Electroencephalogram Aid the Diagnosis of Encephalopathy?

Chaotic analysis is a relatively novel area in the study of physiological signals. Chaotic features of electroencephalogram have been analyzed in various disease states like epilepsy, Alzheimer's disease, sleep disorders, and depression. All these diseases have primary involvement of the brain. Our study examines the chaotic parameters in metabolic encephalopathy, where the brain functions are involved secondary to a metabolic disturbance. Our analysis clearly showed significant lower values for chaotic parameters, correlation dimension, and largest Lyapunov exponent for EEG in patients with metabolic encephalopathy compared to normal EEG. The chaotic features of EEG have been shown in previous studies to be an indicator of the complexity of brain dynamics. The smaller values of chaotic features for encephalopathy suggest that normal complexity of brain function is reduced in encephalopathy. To the best knowledge of the authors, no similar work has been reported on metabolic encephalopathy. This finding may be useful to understand the neurobiological phenomena in encephalopathy. These chaotic features are then utilized as feature sets for Support Vector Machine classifier to identify cases of encephalopathy from normal healthy subjects yielding high values of accuracy. Thus, we infer that chaotic measures are EEG parameters sensitive to functional alterations of the brain, caused by encephalopathy.

Jehovah's Witness and consent for blood transfusion in a child: The Indian scenario.

In India, the clinical guidelines and laws governing consent for blood transfusion in a minor are meager and vague. In an elective situation, whether the parents can make a decision for the child on his/her behalf or whether the doctor has the right to make the decision in the best interests of the child is not clear. We present the case scenario of a child belonging to Jehovah's Witness denomination diagnosed with Burkitt lymphoma. His parents were in a dilemma whether to opt for blood transfusion or not. In the absence of laws and guidelines in this context, and considering the complications that he developed during the treatment period, it was very challenging for us to manage the situation both medically and medico-legally. This situation highlights the need for framing consensus guidelines/laws regarding elective blood transfusion in a minor to make health-care delivery, smooth, transparent and flawless.

Impact of care at foster homes on the health-related quality of life of HIV-infected children and adolescents: a cross-sectional study from India.

PURPOSE: To assess the impact of care at foster homes on the health-related quality of life (HRQOL) of children living with HIV (CLHIV), attending a referral ART Centre, and to compare their HRQOL with children living in their own homes. METHODS: A cross-sectional study was conducted in 144 CLHIV between 5 and 18 years of age, attending a referral ART Centre in South India to assess their HRQOL using the standard PedsQL™ 4.0 questionnaire. Data were then analysed to compare the HRQOL of children living in foster homes to those children living in their own homes. The child report and the parent proxy-report on the child's HRQOL were also compared to see for any differences in their perspectives. RESULTS: 56.25% CLHIV were brought up in different foster homes. In the child's self-report, the mean HRQOL was higher for children living in foster homes [physical score (76.54 ± 12.40), psychosocial score (71.41 ± 12.40) and total score (73.20 ± 11.13)] when compared to children living in their own homes [physical score (75.09 ± 14.76), psychosocial score (70.60 ± 13.48) and total score (72.17 ± 12.00)]. There was no statistically significant difference in the HRQOL between these two groups (p > 0.05). In the parent proxy-report also, there was no statistically significant difference in the HRQOL in all the three scores. The child self-report depicted a significantly higher HRQOL in all the domains compared to the parent proxy-report (p < 0.05). CONCLUSIONS: HRQOL of children living in foster homes is at par with the quality of life enjoyed by children living in their own homes. Foster care manages to provide a reasonable HRQOL in CLHIV, and has become an inseparable component of quality health care delivery for these children.

Treatment of tumor lysis syndrome in children with leukemia/lymphoma in resource-limited settings-Efficacy of a fixed low-dose rasburicase.

Rasburicase is a novel drug used during the management of tumor lysis syndrome. In countries with limited resources, it is frequently given at a lower dose and only for the treatment of established tumor lysis syndrome and not as prophylaxis. A retrospective study was conducted in the department of pediatric oncology at a tertiary referral oncology center in south India to analyze the use of rasburicase over the past 3 years. Data of all the 18 children (< 14 years of age) who were given rasburicase for the management of hyperuricemia were collected and analyzed. With a mean rasburicase dose of 0.085 mg/kg, hyperuricemia was managed efficiently without the need for a hemodialysis in 16 children (88.8 %). The fall in mean serum uric acid levels after the administration of a single dose of rasburicase at 4, 24, and 48 hours was 31.18 %, 64.8 %, and 74.5 %, respectively. Rasburicase efficiently decreases the uric acid levels to a normal level within a short period. In resource-limited settings, rasburicase at a lower dose is a promising option for managing hyperuricemia in the event of a tumor lysis syndrome.

Awareness, attitudes and practices of first aid among school teachers in Mangalore, south India.

INTRODUCTION: Circumstances requiring medical attention are common at schools. Teachers are often the first individuals to witness and handle situations requiring first aid and medical emergencies. AIM: To determine awareness, attitudes and practices of school teachers and the facilities available at schools with respect to administration of first aid. METHODS: Data were obtained from 146 teachers in nine schools in Mangalore, India, using a self-administered questionnaire. The schools were also inspected for first aid equipment and facilities. RESULTS: Only 69 (47%) teachers had received first aid training previously. Poor and moderate knowledge of first aid was observed among 19 (13%) and 127 (87%) teachers, respectively. Only eight teachers knew the correct procedure for cardiopulmonary resuscitation. Most teachers 96 (66%) were willing to administer first aid if provided with the required training. A total of 74 teachers reported having practised first aid in response to a situation arising at their school. Wounds (36%) and syncopal attack (23%) were among the commonly encountered situations requiring first aid management at schools. Teachers' confidence level in administering first aid was significantly associated with prior training in first aid (p=0.001). First aid kits were available in only five of the nine schools surveyed. DISCUSSION: The current competency level among teachers in Mangalore to administer first aid is inadequate. Measures need to be taken at schools to ensure initiation of first aid training followed by periodic training for teachers in first aid.

Evidence-based National Vaccine Policy.

India has over a century old tradition of development and production of vaccines. The Government rightly adopted self-sufficiency in vaccine production and self-reliance in vaccine technology as its policy objectives in 1986. However, in the absence of a full-fledged vaccine policy, there have been concerns related to demand and supply, manufacture vs. import, role of public and private sectors, choice of vaccines, new and combination vaccines, universal vs. selective vaccination, routine immunization vs. special drives, cost-benefit aspects, regulatory issues, logistics etc. The need for a comprehensive and evidence based vaccine policy that enables informed decisions on all these aspects from the public health point of view brought together doctors, scientists, policy analysts, lawyers and civil society representatives to formulate this policy paper for the consideration of the Government. This paper evolved out of the first ever ICMR-NISTADS national brainstorming workshop on vaccine policy held during 4-5 June, 2009 in New Delhi, and subsequent discussions over email for several weeks, before being adopted unanimously in the present form.

An unusual sequel of submandibular gland calculus-A case report.

Sialolithiasis in sub-mandibular gland is a common condition. Sub-mandibular fistula as a sequel of sub-mandibular sialolithiasis is a rare entity. We report a case of an unusually large sub-mandibular gland calculus causing a cutaneous fistula.

Holmium laser cystolithotripsy in children: initial experience.

INTRODUCTION: Management of vesical calculi in children poses an interesting challenge to the urologist. The treatment options currently available include open surgery, transurethral pneumatic cystolithotripsy, percutaneous suprapubic cystolithotomy and shockwave lithotripsy (SWL). Holmium: YAG (Ho: YAG) laser cystolithotripsy represents a novel modality of treatment that is minimally invasive. MATERIALS AND METHODS: From July 1999 to January 2003 we treated 23 children with vesical calculi using transurethral Ho: YAG laser lithotripsy. The indications for cystolithotripsy were stone size < or = 4 cm (N=19), or multiple stones with combined stone burden < or = 4 cm (N=4). The mean patient age was 7.8 (range 2-12) years and the mean stone size was 2.7 (range 0.9-4) cm. Access was obtained with an 8F ureteroscope and holmium laser energy (0.6-1.8 J/pulse at 5-12 Hz) was applied through a 550-mum. end-firing fibre under video guidance. The calculi were pulverized to tiny fragments about 2-3 mm in size. An 8F urinary catheter was placed for one night in all patients. Post-operatively the children were evaluated at 3 and 18 months with radiological imaging and uroflowmetry to confirm stone-free status and exclude urethral stricture formation. RESULTS: The mean duration of the endoscopic procedure was 38 (range 19-62) minutes while the mean length of hospital stay was 2.2 (range 2-3) days. All the children were rendered stone-free following a single operative session. Laser-induced major complications were not observed in any of the children. At the mean follow-up of 42 (range 26-69) months none of the children developed stone recurrence, urinary tract infections or urethral strictures. CONCLUSIONS: Transurethral Ho: YAG laser lithotripsy was found to be an efficient and safe modality for the treatment of vesical calculi in children.

Transverse aortic arch aneurysms--a challenge ahead.

Deep Hypothermia and Circulatory Arrest (DHCA) is widely used to repair complex congenital heart lesions in children. We report our experience of DHCA in seven patients of transverse aortic arch aneurysm repair. Anaesthesia consisted of Nitrous Oxide, Oxygen, morphine 1 to 1.5 mg kg-1, halothane and pancuronium. Core cooling on cardiopulmonary bypass was used. At 19 +/- 0.64 degrees C (rectal) temperature, Total Circulatory Arrest (TCA) was established. Thiopentone 30 mg.kg-1 and hydrocortisone hemisuccinate 400 mg was administered before arrest. Head was packed with ice during cooling and patients were placed in steep Trendelenberg's position before opening the aneurysm sac. Mean cardiopulmonary bypass time was 151.4 +/- 8.7 minutes. Mean duration of circulatory arrest was 38.6 +/- 6.9 minutes (range, 15 to 77 minutes). Permanent neurological deficit was found in two patients. Tracheostomy was performed in one of these patients for prolonged ventilation. Two patients died of persistent bleeding, low cardiac output and hypoxia due to right lung collapse.

Macro and microscopical studies on vanaharidra curcuma aromatica salisb.

The drug Vanaharidra is used in various kinds of diseases like Kusta, Kasa, etc., Pharmacognosy of the root and rhizome of Vanaharidra is presented in this paper.

PHARMACOGNOSTICAL STUDIES ON THE ROOT OF SAHACHARA NILGIRIANTHUS HEYNEANUS (Nees) Bremek - (ACANTHACEAE).

Nilgirianthus heyneanus is widely used in South India in place of Sahachara (Barleria prionitis L) and is considered as an important Vatahara drug. Detailed pharmacognosy of the root of N. heyneanus commonly known as Karim Kurinji (Malayalam) in Kerala has been carried out. Some of the diagnostic features of the drug are pigmented cystoliths in the cortex and pith region; yellow colour cell contents in the cortex region; thick walled and oval-elongated stone cells in the cortex region.

Medico - botany of andaman and nicobar islands - iv (ayurvedic drugs - 2).

Details on 33 plants / drugs belonging to 30 genera and 22 families are provided in this paper; ayurvedic drug name, botanical sources in the island, short description of the species occurring in the islands, chemical constituents, ayurvedic preparations and therapeutic properties are elucidated.

Studies on some South Indian market samples of ayurvedic drugs - v.

The South Indian market samples of drugs Chavya, Gajapippali and Hrivera are evaluated. The accepted source, botanical identification of the market samples, ayurvedic synonyms, therapeutic properties, major preparations and diseases along with a short botanical description for the market samples are provided. Suitable photographs of the market samples are also included.