Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit

Objectives: To describe the spectrum of complications of Diabetic Ketoacidosis [DKA] observed in children admitted with severe DKA

Methods: Retrospective review of the medical records of all children admitted with the diagnosis of severe DKA in Pediatric Intensive Care Unit [PICU] of the Aga Khan University Hospital, from January 2010 to December 2015 was done. Data was collected on a structured proforma and descriptive statistics were applied

Results: Total 37 children were admitted with complicated DKA [1.9% of total PICU admission with 1.8% in 2010 and 3.4% in 2015]. Mean age of study population was 8.1 +/- 4.6 years and 70% were females [26/37]. Mean Prism III score was 9.4 +/- 6, mean GCS on presentation was 11 +/- 3.8 and mean lowest pH was 7.00 +/- 0.15. Complications observed included hyperchloremia [35.94%], hypokalemia [30.81%], hyponatremia [26.70%], cerebral edema [16.43%], shock [13.35%], acute kidney injury [10.27%], arrhythmias [3.8%], and thrombotic thrombocytopenic purpura [5.4%], while one patient had myocarditis and ARDS each. 13/37 children [35%] needed inotropic support, 11/37 [30%] required mechanical ventilation while only one patient required renal replacement therapy. Two patients [5.4%] died during their PICU stay

Conclusion: Hyperchloremia and other electrolyte abnormalities, cerebral edema and AKI are the most common complications of severe DKA

Frequency and outcome of meningitis in pediatric intensive care Unit of Pakistan

Meningitis is a leading cause of morbidity and mortality worldwide in intensive care settings. The aim of this study was to assess the frequency and outcome in children with meningitis through a retrospective chart review done in pediatric intensive care unit of a tertiary care hospital from January 2000 to December 2014. During these 14 years, 64 patients were admitted with meningitis in pediatric intensive care unit. Out of 64, 36 were diagnosed with pyogenic meningitis, 18 patients with viral meningitis, and 10 with tuberculous meningitis. Most complications were observed in the initial 48 hours. Most common presentation was altered level of consciouness in 50 [78.1%], seizure in 38 [59.4%], and shock in 23 [35.9%] patients. Ventilatory support was required in 30 [46.9%] patients and inotropic support in 26 [40.6%]. During stay in pediatric intensive care unit, there was 7.8% mortality. Although meningitis was an infrequent cause of hospitalization at the study centre, but it was an important infectious cause of mortality and morbidity in pediatric age group and associated with high neurological sequelae

Use of N-acetylcysteine in children with fulminant hepatic failure caused by acute viral hepatitis

To determine the efficacy of N-acetylcysteine [NAC] in children aged > 1 month to 16 years admitted with Fulminant Hepatic Failure [FHF] secondary to Acute Viral Hepatitis [AVH] in a tertiary care center of a developing country. Analytical study. Department of Paediatrics, The Aga Khan University Hospital, Karachi, Pakistan, from January 2007 to December 2011. Medical records of children [> 1 month - 16 years] with FHF admitted with AVH of known etiology who received NAC were reviewed retrospectively. Liver function tests [mean +/- SD] at baseline, 24 hours after NAC and before or at the time of discharge/death were recorded and compared via using repeated measures ANOVA[r-ANOVA]. Efficacy of NAC is defined in improvement in biochemical markers, liver function test and discharge disposition [survived or died]. Mortality associated risk factors were identified by using logistic regression analysis. P-value and 95% confidence interval were recorded. Forty children [mean age was 80 +/- 40 months] with FHF secondary to AVH received NAC. Majority were males [n=25; 63%]. Vomiting [75%] and jaundice [65%] were the main presenting symptoms, one-third had hypoglycemic, while 40% had altered sensorium at the time of admission. There was significant statistical difference in liver enzymes and prothrombin time on admission comparing at discharge in children received NAC [p < 0.001]. Fifteen [38%] children died. Severe vomiting [Odds Ratio [OR] 0.22, 95% Confidence Interval [CI] 0.05 - 0.8], jaundice [OR 9.3, CI 1.1 - 82.6], inotropic support [OR 20.6, CI 3.5 - 118.3] and mechanical ventilation [OR 4.3, CI 1.1 - 16.6] at the time of admission are associated with risk factors for mortality in children with FHF secondary to AVH. NAC used in children with FHF secondary to AVH is associated with markedly improved liver function tests and recovery. FHF with complications is high risk for mortality

Outcome of pediatric procedural sedation and analgesiain a tertiary care hospital in Pakistan

Background and Objective: Procedural sedation and analgesia [PSA] is pharmacologically induced state which allows patients to tolerate painful procedures while maintaining protective reflexes. It is the standard of care but there is limited data from Pakistan. Our objective was to assess the safety of the procedural sedation and analgesia in pediatric population at a tertiary care setting

Methods: A retrospective notes and record review was conducted at the Aga Khan University Hospital, Karachi over 4 years from April 2010 to August 2014. Patients were between ages 6 months to 16 years and were in low risk category. The combination of Ketamine and Propofol were used. Data collected on the standardized hospital PSA form. All procedures were performed by two trained persons

Results: A total of 3489 diagnostic and therapeutic procedures were performed. Satisfactory level of sedation was achieved for 3486 [99%] of procedures. Adverse events occurred in 21 [0.6%] patients including: 12 [0.3%] episodes of hypoxia, 07 [0.2%] episodes of apnea, 02 [0.06%] episodes of post sedation hallucination. No major events were noted

Conclusion: Procedural sedation and analgesia for children using Propofol and Ketamine is found safe and effective in our setting

Breast Carcinoma masquerading as granulomatous mastitis on fine needle aspiration cytology lessons to learn!

Chronic granulomatous mastitis is not an uncommon entity. It mimics breast carcinoma on physical, gross and microscopic examinations; both on histopathological and fine needle aspiration cytology. At other times invasive ductal carcinoma may suggest granulomatous mastitis. A case is presented here where ductal carcinoma was misinterpreted as granulomatous mastitis on fine needle aspiration cytology smears in a 48 yr old woman who presented with large painful lump in her left breast. The mass was subsequently excised and the histopathological examination revealed infiltrating ductal carcinoma. Reexamination of the cytology smears did show some atypical cells commensurate with the ductal carcinoma. We here discuss various reasons and factors responsible for over and under interpretation of cytological atypia

Granuloma formation in discoid lupuserythematosus: a novel microscopic feature

Lupus erythematosus is an autoimmune disease with marked pleotropism. If several systems are involved then the disease is named as systemic lupus erythematosus [SLE] and if skin is exclusively involved the term discoid lupus erythematosus [DLE] is used. One of the several histopathological features of DLE includes periappendageal inflammation. This may at times ; completely wipe out sebaceous glands forming sebaceous granulomas. To determine the frequency of sebaceous granulomas formation in discoid lupus erythematosus. In this prospective observational study was conducted at the Departments of Dermatology and Pathology, Pakistan Institute of Medical Sciences, Islamabad. 100 cases of DLE spanning over two years and with the age range of 3 years to 70 years were examined for the presence of sebaceous granuloma. Other features of DLE like hyperkeratosis, follicular plugging, epidermal atrophy, basal layer vacuolization, basement membrane deposits, pigmentary incontinence, perivascular inflammation, periappendageal inflammation, and collagen damage were also noted., Out of these 100 cases, 8 cases contained sebaceous granulomas. These granulomas were,, . composed of epithelioid cells, foreign body giant cells containing partially digested sebaceous material and a few lymphoctytes. Sebaceous granulomas formation was seen in 8% cases of DLE cases. This feature must be recognized both by dermatologists and pathologist so that diagnosis of DLE may not be distracted and erroneous diagnosis due to presence of granulomas may not be rendered

Experience of pediatric rapid response team in a tertiary care hospital in Pakistan.

Objective. To report our experience before and after implementation of pediatric rapid response team (RRT) in pediatric wards of a tertiary care hospital in Pakistan. Methods. An audit of RRT activity from December 2007 to August 2008 was conducted and reviewed patient diagnoses at the time of call placement, interventions done and post-intervention clinical outcomes. Clinical Outcomes in the nine months before RRT implementation were compared with those in the first operational nine months after RRT. Results. Eighty-three calls were generated during the post-intervention study period of 9-month (21 calls/1000 admissions). The median age of patients was 27 months; 37% calls were for infants. The majority of patients were under care of medical services (93% vs 7% under care of surgical services). Greater numbers of calls were made during 0800-1600 hours (45%). Respiratory issues were the most common reason for activation of RRT. Because of early interventions, majority (61%) of patients avoided unnecessary PICU stay and expenditure; only 17% required mechanical ventilation in PICU. The code rate per 1000 admissions decreased from 5.2 (pre-RRT) to 2.7 (post-RRT) (p=0.08; OR 1.88(95%CI 0.9 -3.93). The mortality rate of patients admitted in PICU from wards decreased from 50% to 15% (p=0.25; OR 1.64 (95%CI 0.63 – 4.29). Conclusion. Our experience with implementation of RRT was associated with reduction in cardiorespiratory arrest, mortality and saved a lot of PICU resource utilization. It is an excellent patient-safety initiative especially in resource-constrained countries by bringing PICU reflexes outside the PICU.

Sebaceous granulomas: a novel feature of discoid lupus erythematosus

To determine the frequency of sebaceous granulomas formation in discoid lupus erythematosus, Retrospective observational study. Departments of Dermatology and Pathology, Pakistan Institute of Medical Sciences, Islamabad. 100 cases of Discoid Lupus Erythematosus [DLE] spanning over two years and with the age range of 3 years to 70 years were examined for the presence of Sebaceous Granuloma. Other features of DLE like hyperkeratosis, follicular plugging, epidermal atrophy, basal layer vacuolization, basement membrane deposits, pigmentary incontinence, perivascular inflammation, periappendigeal inflammation, and collagen damage were also noted. Lupus erythematosus is an immune complex, type Ill hypersensitivity disease where antibodies are formed against native Deoxyribose Nucleic Acid [DNA]. The immune compexes are deposited in various organs and various sites causing marked pleotropism. If several systems are involved then the disease is named Systemic Lupus Erythematosus [SLE] and if skin is exclusively involve the term Discoid Lupus Erythematosus [DLE] is used. One of the several features of DLE includes periappengeal inflammation. This may at times completely wipe out sebaceous glands forming sebaceous granulomas. Out of these 100 cases 8 cases contained sebaceous granulomas. These granulomas were composed of epithelioid cells, foreign body giant cells containing partially digested sebaceous material and a few lymphoctytes. Sebaceous granulomas formation was seen in 8% cases of discoid lupus erythematosus. This feature must be recognized both by dermatologists and pathologist so that diagnosis of DLE may not be distracted and erroneous diagnosis due to presence of granulomas may not be rendered

Corruption in the government hospitals

Corruption in Government Hospitals is very common; particularly in the third world countries. Corruption starts from the top places. Corrupt elements in the Governments of powerful countries, World Health Organization [WHO], Local Governments, Ministry of Health, Multinational Companies, Non Governmental Organizations, Secret Organizations and powerful Media; all play their role in misdirecting the health budget of Government Hospitals toward rich and powerful and away from the poor and weak. They snatch away the big chunk of whatever little health budget is destined for the poor patients. Corrupt society leads to the appointments and assignments of dishonest, crooked, incompetent and impotent people who destroy the systems through their actions and inactions. Corruption in the Government Hospitals ravages and desolates the Pathology Department affecting its all activities! In order to have sound and blissful healthy systems there is dire need to fight materialism and greed by all sane and honest people of the society. This requires active and rapid instillation of high moral and ethical values at all levels and in all spheres of the society. This can be achieved in very short span time if we use the divine teachings particularly the last and the final eternally preserved book in its original language i.e. Quran. Whenever people had held this book firmly journey of millennium had been travelled in few years. The 23 Prophetic life of the Prophet Mohammad [PBUH] directly lead to the most glittering human civilization with foundation of all modern sciences, institutions and achieving highest degree of human values as well as prosperity and peace. Certainly it was the propelling force pulling Europe out of dark ages, creating renaissance and bringing industrial revolution. Today too this will Insha Allah happen again if we did the same! It can quickly and rapidly eliminate corruption in all its forms and shades at all levels in the Government Hospitals

Venoarterial PCO[2] difference: a marker of postoperative cardiac output in children with congenital heart disease

To determine the relationship between venoarterial carbon dioxide gradient [delta pCO[2]] and central venous oxygen saturation [ScvO[2]] in children after cardiac surgery. A cohort study. The Paediatric cardiac intensive care unit of the Aga Khan University Hospital, Karachi, from June 2006 to May 2007. All children admitted in the paediatric cardiac intensive care after complete repair of congenital heart defect using cardiopulmonary bypass were included in the study. Simultaneous arterial and central venous blood gas samples were obtained from a catheter placed in the artery [either radial or femoral] and superior vena cava respectively. Linear regression analysis was performed between ScvO[2] and delta pCO[2]. Fifty seven children aged from 5 days to 14 years were included and 272-paired simultaneous arterial and central venous samples were analyzed. Mean venous pCO2 was 47.82 +/- 9.03 mmHg and mean arterial pCO[2] was 40.50 +/- 9.06 mmHg. One hundred seventy four samples had ScvO[2] > 70% with mean delta pCO[2] of 5.44 +/- 2.55 mmHg and 98 samples had ScvO2 < 70% with mean delta pCO2 of 9.07 +/- 3.90 mmHg. With ScvO[2] < 70%, 77 samples had delta pCO[2] of > 6 mmHg while only 21 samples had delta pCO2 of < 6 mmHg [p < 0.001]. On the contrary with ScvO[2] > 70%, 71 samples had delta pCO[2] of > 6 mmHg and 103 samples had delta pCO[2] of < 6 mmHg. Coefficient of correlation [R[2]] between 0.340 was ScvO[2] and delta pCO[2]. Elevated delta pCO[2] is practical and can be utilized as a useful adjunct to low ScvO[2] in the assessment of low cardiac output syndrome in children after cardiac surgery

Morphological spectrum of vascular changes in glioblastoma multiforme

To determine the frequency of various vascular changes and their associated effects in Glioblastoma Multiforme [GBM]. It was a descriptive study.Pathology Department, Pakistan Institute of Medical Sciences. Islamabad. 30 diagnosed cases of glioblastoma multiforme were analyzed in the study from July 2005 to September 2006. The slides were evaluated for various vascular patterns like vascular proliferation, endothelial proliferation, glomeruloid bodies, necrosis of vessel wall and fibrin thrombi. More than l/3rd blood vessels were blocked by fibrin thrombi in 70% of cases. Vascular occlusion by thrombi involving more than 50% of diameter was seen in 57% of cases. 64% of cases showed endothelial proliferation in the form of glomeruloid bodies, while rest of the cases showed mild to moderate endothelial proliferation. 86% of cases exhibited necrosis whereas pseudopalisaded necrosis was observed in 60% cases. Most of the cases showed edema and extravasation of red blood cells in more than 2/3rd of slide area. All cases of glioblastoma multiforme showed vascular thrombi resulting in destruction as well as leading to endothelial cell damage and proliferation. The resultant vascular damage causes exudation of plasma and extravasation of red blood cells leading to significant cerebral edema

impact of intratumoral hemorrhage in producing arrays of morphological features in schwannomas

To study and evaluate the impact of intratumoral hemorrhage in producing wide spectrum of morphological features including Antoni A and Antoni B areas in Schwannomas. Observational study. Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad from 1st April 2005 to 31st October 2006. The total number of cases was 30 selected through convenience non-probability method. All diagnosed cases of Schwannomas were included in this study and were later reviewed by a final year FCPS student and a senior pathologist. A criterion was set for examining each slide. Percentage of hypercellular, hypo cellular or mixed areas was estimated in each slide. Verocay bodies were graded as 3 [well formed], 2 [moderately formed] and 1 [Schwann cells aggregates with suggestion of Verocay bodies]. Number of blood vessels was graded as 3, 2 and 1 if these constituted > 50%, 25-50% or < 25% of the area in the slide respectively. Hyalinization of blood vessels was graded as: grade 3 for the wall thickness double the lumen diameter, grade 2 for wall thickness equal to the lumen diameter, grade 1 when lumen diameter was greater than wall thickness and 0 when no hyalinization was noted. Number of extravasated RBCs was graded from 3 to 0 depending upon extravasation seen in > 50%, 25-50%, <25% and none respectively. All the data was entered in SPSS version 10 and frequencies calculated. Impact scores of various parameters in predominantly hyper and hypocellular areas were also calculated. There was marked impact of intratumoral hemorrhage in creation of all sorts of morphological pictures in schwannomas. In about 47% cases hemorrhage was mild while in about 43% cases it was quite significant giving rise to dominant hypocellular areas, marked extravasation of red blood cells and hyalinization of blood vessels. Verocay bodies were well formed in 47% cases and these became ill defined with increased severity of hemorrhages. Intratumoral hemorrhages produce wide arrays of morphological changes in Schwannomas that have resulted not only in division of Antoni A and Antoni B areas but also giving bewildering morphological patterns, lack of familiarity of which may cause difficulty in recognition of the entity. On the other hand future research towards elimination or minimization of hemorrhages may help in reducing the bulk of the tumors thus avoiding pressure complications and facilitating their easy removal

Morphological aspects of thromboembolic phenomenon in skin biopsies

To determine the frequency-based value of various histological features seen in skin biopsies of patients with vessel thrombosis or embolism. This was a descriptive study; carried out in the Department of Pathology Pakistan Institute of Medical Sciences. The duration of study was 2 years. The total number of cases was 20, selected by convenience non-probability sampling. Skin biopsies of subjects suspected of thromboembolic disorder were collected and reviewed. A fixed scoring criterion ranging from 0 to 4 was used to score the degree of damage to the various components of skin and vessel involvement. Thrombosis of small vessels in the skin resulted in damage to the collagen and atrophy of the skin and later its ulceration. These changes correlated well with the degree of blockage of the vessels and degree of ischemia. Thromboembolic conditions may lead to formation of thrombi or shower of emboli in the microvessels of skin which may lead to discoloration, petichea, or even ulceration of the skin. Clinically, when the coagulation profile of the patient is not done or it is normal such lesions may be confused by the dermatologists with other dermatological diseases and the lesions may be biopsied.The biopsy of such lesions can reveal an underlying thromboembolic phenomenon and a high index of suspicion may lead to early diagnosis of such cases and in turn institution of prompt management. Epidermal atrophy, ulceration and/or collagen damage progressing towards necrosis are the features which can alert the pathologist of such a condition. Meticulous examination of the microvasculature of the skin biopsy is essential to not miss these conditions