Geographic information system-based mapping of air pollution & emergency room visits of patients for acute respiratory symptoms in Delhi, India (March 2018-February 2019)

Background & objectives: Studies assessing the spatial and temporal association of ambient air pollution with emergency room visits of patients having acute respiratory symptoms in Delhi are lacking. Therefore, the present study explored the relationship between spatio-temporal variation of particulate matter (PM)2.5 concentrations and air quality index (AQI) with emergency room (ER) visits of patients having acute respiratory symptoms in Delhi using the geographic information system (GIS) approach. Methods: The daily number of ER visits of patients having acute respiratory symptoms (less than or equal to two weeks) was recorded from the ER of four hospitals of Delhi from March 2018 to February 2019. Daily outdoor PM2.5 concentrations and air quality index (AQI) were obtained from the Delhi Pollution Control Committee. Spatial distribution of patients with acute respiratory symptoms visiting ER, PM2.5 concentrations and AQI were mapped for three seasons of Delhi using ArcGIS software. Results: Of the 70,594 patients screened from ER, 18,063 eligible patients were enrolled in the study. Winter days had poor AQI compared to moderate and satisfactory AQI during summer and monsoon days, respectively. None of the days reported good AQI (<50). During winters, an increase in acute respiratory ER visits of patients was associated with higher PM2.5 concentrations in the highly polluted northwest region of Delhi. In contrast, a lower number of acute respiratory ER visits of patients were seen from the ‘moderately polluted’ south-west region of Delhi with relatively lower PM2.5 concentrations. Interpretation & conclusions: Acute respiratory ER visits of patients were related to regional PM2.5 concentrations and AQI that differed during the three seasons of Delhi. The present study providessupport for identifying the hotspots and implementation of focused, intensive decentralized strategies to control ambient air pollution in worst-affected areas, in addition to the general city-wise strategies.

Association of Fluid Overload with Mortality in Critically-ill Mechanically Ventilated Children

Objectives: To study the association of fluid overload withmortality and morbidity in critically-ill mechanically ventilatedchildren.Design: Prospective observational study.Setting: Pediatric Intensive Care Unit (PICU) of a tertiary carehospital, New Delhi, India.Participants: 118 children (age 1 mo - 15 y) requiring mechanicalventilation.Outcome measures: Primary: Association of fluid overload withmortality. Secondary: Association of fluid overload withoxygenation, organ dysfunction, duration of mechanicalventilation and PICU stay.Results: Cumulative fluid overload of ?15% was observed in 74(62.7%) children. About 50% of these children reachedcumulative fluid overload of ?15% within the first 5 days of PICUstay. The mortality was 40.5% in those with ?15% cumulative fluidcompared to 34% in the rest [OR (95% CI): 1.02 (0.97, 1.07)]. Onmultivariate analysis, after adjusting for confounders, cumulativefluid overload ?15% was associated with higher maximumPELOD (pediatric logistic organ dysfunction) score (Median: 21vs. 12; P = 0.03), longer median duration of mechanicalventilation (10 vs. 4 d; P <0.0001) and PICU stay (13.5 vs. 6 d; P<0.0001). There was no significant association of fluid overloadwith oxygenation index (P=0.32).Conclusion: There is no association of fluid overload withmortality. However, it is associated with poor organ function,longer duration of mechanical ventilation and PICU stay incritically-ill, mechanically ventilated children.

Galactomannan Antigen Test for Early Diagnosis of Invasive Aspergillus Infection in Pediatric Febrile Neutropenia

Invasive aspergillosis is a major concern in neutropenic patients.We studied the utility of Galactomannan antigen detection test inserum using ELISA technique for early detection of invasiveaspergillosis. Diagnostic accuracy of Galactomannan index (GMI)test was maximum at a cut-off of > 1.5 with a negative predictivevalue of more than 95%

Vitamin D Deficiency and Parathyroid Response in Critically-ill Children: Association with Illness Severity and Clinical Outcomes.

Objective: To determine the prevalence of vitamin D deficiency in critically ill children, and to study its association with parathyroid response, severity of illness and clinical outcomes. Design: Prospective observational study. Setting: Medical Pediatric Intensive Care Unit of a tertiary care centre of Northern India. Participants: 154 children in-patients: August 2011-January 2013. Main outcome measures: Vitamin D deficient children were (serum 25-hydroxy vitamin D <20 µg/mL) divided into "parathyroid-responder" [serum parathyroid hormone >65 pg/mL with 25(OH)D<20 µg/mL and/or calcium corrected for albumin <8.5 mg/dL] and "non parathyroid-responder.’’ Illness severity was assessed by Pediatric Index of Mortality-2 (PIM-2) score at admission. Biochemical parameters, illness severity scores and clinical outcomes were compared between parathyroid-responders and non-parathyroid-responders. Results: Vitamin D deficiency and hypocalcemia were observed in 125 (83.1%) and 91 (59%) children, respectively at admission. There were no differences in illness severity score at admission, mortality rate and length of stay between vitamin D-deficient children and 19.8% of non-vitamin D-deficient children. Among Vitamin D-deficient children, parathyroid-responders had higher PIM-2 score at admission compared to non-parathyroid-responder [12.8 (7.4,20.6) vs. 6.5 (2.5,12.2), P=0.01]. However, there were no differences in other clinical outcomes between two groups. Conclusion: Critically ill children have high prevalence of vitamin D deficiency. Parathyroid gland response secondary to hypocalcemia or vitamin D defiency is impaired in critical illness.

ADRB2 Polymorphism and Salbutamol Responsiveness in Northern Indian Children with Mild to Moderate Exacerbation of Asthma.

Objectives: The primary objective was to determine the association between beta-2 adrenergic receptor (ADRB2) gene polymorphism (rs1042713, c.46A>G, p.Arg16Gly) and the response to inhaled salbutamol in North Indian children aged 5 to 15 years, with mild to moderate exacerbation of asthma. Methods: This cross-sectional study was done at a tertiary-care hospital in Northern India from June 2011 to May 2013. 120 children with asthma with mild to moderate exacerbation underwent spirometry at baseline and after administration of three doses of salbutamol. An increase in FEV1 ³15% was considered as positive response. Blood samples from these children were analysed for ADRB2 polymorphism (p.Arg16Gly). 94 non-asthmatic adult controls were also studied to determine the prevalence of ADRB2 polymorphism. Results: In asthmatic children, the frequency of AA, GG, AG genotypes were 24.2%, 24.2% and 51.7% compared to 20.2%, 20.2 % and 59.6%, respectively in the non-asthmatic adults. Salbutamol responsiveness showed no correlation with the studied ADRB2 polymorphism (p= 0.55). A trend towards greater bronchodilator responsiveness amongst AA genotype, compared to GG genotype was observed (Median change in percent predicted FEV1 14.5% and 7.5%, respectively). Conclusions: No correlation was found between salbutamol responsiveness and ADRB2 genotype in Northern Indian children with asthma with mild-to moderate exacerbation.

Slower Rise of Exhaled Breath Temperature in Cystic Fibrosis.

Objective: To measure exhaled breath temperature in patients with cystic fibrosis. Methods: 17 patients (6-18 years) with cystic fibrosis and 15 age- and gender-matched healthy controls were recruited in this cross sectional study. Exhaled breath temperature was measured in subjects recruited in both the groups with a device X-halo and analyzed as plateau temperature achieved and rate of temperature rise. Results: Patients with cystic fibrosis showed no significant difference in plateau temperature [34.4(32.3-34.6) versus 33.9 (33.0- 34.4)oC; P=0.35] while mean (SEM.) rate of temperature rise was significantly less in patients [0.09 (0.01) versus 0.14 (0.02) ΔºC/s ; P=0.04] as compared to controls. Conclusion: There was a slower rise of exhaled breath temperature in patients with cystic fibrosis whereas plateau temperature was not significantly different from controls.

Fractional Exhaled Nitric Oxide in Children with Acute Exacerbation of Asthma.

Objective: To determine whether fractional exhaled nitric oxide (FENO) has a utility as a diagnostic or predictive maker in acute exacerbations of asthma in children. Design: Analysis of data collected in a pediatric asthma cohort. Setting: Pediatric Chest Clinic of a tertiary care hospital Methods: A cohort of children with asthma was followed up every 3 months in addition to any acute exacerbation visits. Pulmonary function tests (PFT) and FENO were obtained at all visits. We compared the FENO values during acute exacerbations with those at baseline and those during the follow up. Results: 243 asthmatic children were enrolled from August 2009 to December 2011 [mean (SD) follow up - 434 (227) days]. FENO during acute exacerbations was not different from FENO during follow up; however, FENO was significantly higher than personal best FENO during follow up (P < 0.0001). FENO during acute exacerbation did not correlate with the severity of acute exacerbation (P=0.29). The receiver operating characteristics curve for FENO as a marker for acute exacerbation had an area under the curve of 0.59. Cut-off of 20 ppb had a poor sensitivity (44%) and specificity (68.7%) for acute exacerbation. Conclusions: FENO levels during acute exacerbation increase from their personal best levels. However, no particular cut off could be identified that could help in either diagnosing acute exacerbation or predicting its severity.

Management of Acute Lung Injury/ARDS.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are disorders of pulmonary inflammation characterized by hypoxemia and respiratory failure. Children have varying incidence of ALI/ARDS from 2.2 to 16 per 100,000 pediatric population associated with high morbidity, mortality, and financial burden. The diagnostic criteria include: acute onset, severe arterial hypoxemia resistant to oxygen therapy alone (PaO2/FIO2 ratio ≤200 for ARDS and ≤300 for ALI), diffuse pulmonary inflammation (bilateral infiltrates on chest radiograph) and No evidence of left atrial hypertension. Management includes ventilatory therapy including lower tidal volume, relatively high PEEP and supportive care. Guidelines for diagnosis, ventilator management, rescue therapies and supportive care are being discussed in the protocol.

Benign superior mediastinal syndrome due to intrathoracic tuberculosis in a child-association with endobronchial tuberculosis.

A 5-year-old boy presented with fever, cough, breathlessness and facial swelling. He was pale with distended veins over neck and chest, cervical and axillary lymphadenopathy and bilateral expiratory wheeze. Chest radiographs showed superior mediastinal widening. A computed tomography scan of the chest revealed mediastinal lymph nodes compressing superior vena cava and trachea. Bronchoscopy revealed nodular lesions in trachea and bronchi and compression of trachea. Broncho-alveolar lavage revealed acid fast bacilli. Diagnosis of superior mediastinal syndrome (SMS) secondary to tuberculosis was made and child was treated with antitubercular treatment along with oral prednisolone with good response.

'Primary cutaneous mucormycosis during induction chemotherapy in a child with acute lymphoblastic leukemia'.

We report a child with acute lymphoblastic leukemia who developed primary cutaneous mucormycosis at the site of lumbar puncture during induction chemotherapy. Though high mortality rates are reported with invasive mucormycosis, prompt biopsy, early identification and antifungal therapy using a combination regime of amphotericin-B and rifampicin along with extensive surgical debridement led to complete cure of the lesions in the index case.

Use of different primer directed sequence amplification by polymerase chain reaction for identification of Pneumocystis jirovecii in clinical samples.

BACKGROUND: Pneumocystis carinii pneumonia (PCP), caused by opportunistic agent Pneumocystis jirovecii (formerly, Pneumocystis carinii is one of the most serious respiratory infection in immunocompromised patients. AIM: The present study was conducted to compare polymerase chain reaction (PCR) assays targetting three different genes of Pneumocystis to study their application in its diagnosis. METHODS: One hundred and eighty (n = 180) clinical samples from 145 immunocompromised patients with clinical suspicion of PCP and 35 samples from control group of 30 immunocompetent individuals with respiratory infections other than PCP were prospectively examined for the presence of Pneumocystis jirovecii (P. jirovecii). All the samples were subjected to microscopic examination, one single [major surface glycoprotein, (MSG)] and two nested [mitochondrial large subunit ribosomal ribonucelic acid, (mtLSU rRNA) and internal transcribed spacer (ITS) region], polymerase chain reaction assays. RESULTS: Microscopic examination was positive in only six (n = 6) patients, whereas single round MSG PCR detected P. jirovecii deoxyribonucleic acid (DNA) in 16 cases. When the clinical samples were tested by mtLSU rRNA and ITS nested PCR assays, it was possible to detect seven additional cases of PCP, making it to a total of 23 cases. None of the clinical specimens in control group (n = 30) were positive by any of the above-mentioned techniques. Amongst the 81 bronchoalveolar lavage (BAL) samples tested, 16 were positive by MSG PCR, while 20 were positive by both nested, i.e., mtLSU rRNA and ITS PCR assays. Similarly, out of 50 sputum samples, only three were positive by MSG, seven by mtLSU rRNA and six by ITS nested PCR assays. CONCLUSION: It has been observed that MSG is relatively more sensitive when single round PCR assay is used for detection of human Pneumocystosis compared to the first (single) rounds of either ITS or mtLSU rRNA nested PCRs. However, the two nested PCRs using ITS and mtLSU rRNA have been found to be more sensitive. On comparison of two nested PCR assays, the results have been more or less comparable.

Unusual lymphocytosis with systemic lupus erythematosus.

A 15-year-old boy with systemic lupus erythematosus, who on a follow up visit complained of recurrent episodes of fever, easy fatiguability, and seizures. Investigations revealed lymphocytosis (95%), anemia, and a positive PCR for cytomegalovirus (CMV). Electron microscopy of the lymphocytes revealed intranuclear inclusion bodies supporting the diagnosis of CMV infection. The child was treated with ganciclovir and discharged. At discharge the child was afebrile. However, lymphocytosis persisted even after 9 months of discharge. Repeated screening for possible lymphoreticular malignancy was negative. It is likely that lymphocytosis in this child was due to persistence of CMV infection in host cells leading to continued provocation of the host immune system.