Clinical and Laboratory Profile of Macrophage Activation Syndrome in Kawasaki Disease: A Single Centre Cross-Sectional Study.

OBJECTIVE: To study the prevalence of Macrophage Activation Syndrome (MAS) in children with Kawasaki disease (KD) and to devise a classification tree for predicting MAS in early KD based on easily available clinical and laboratory information using artificial intelligence (AI) technology. METHODS: A prospective cross-sectional observational study was conducted (March 2020 - October 2021) during which hospitalized children aged 1-18 years with KD were consecutively enrolled. Those with positive RTPCR test or IgM/IgG serology for COVID-19 were excluded. The clinical and laboratory profiles of children with and without MAS were studied. A multivariable logistic regression (LR) model was developed utilizing backward elimination method to determine the relationship between select candidate predictor variables and MAS in patients with KD. A classification tree was created based on these using artificial intelligence algorithms. RESULTS: Sixty-two children were diagnosed with KD during the study period, of these, 42 children with KD were included; 14 (33.3 %) were diagnosed with MAS. The median (IQR) duration of fever (days) was significantly more in MAS than those without MAS [7 (5, 15) vs 5 (5, 9), P < 0.05]. Serum albumin (g/dL) was significantly lower in those with MAS [2.3 (2.2, 2.7) vs 2.8 (2.3, 3.1), P = 0.03]. The classification tree constructed by the AI-based algorithm predicted that in children with KD who had myocardial dysfunction, serum albumin ≤ 2.8 g/dL and fever > 6 days duration at admission had increased likelihood of developing MAS. In children without myocardial dysfunction, alanine transaminase (ALT) levels > 70 U/L and fever > 5 days were equally predictive of MAS. CONCLUSION: Nearly one-third of the children with KD had MAS. Clinicians should consider screening all children with KD for MAS at admission. A classification tree based on the presence of myocardial dysfunction, duration of fever > 6 days, ALT levels and hypoalbuminemia can identify MAS in the course of KD.

Is Atopic Dermatitis a Risk Factor for Thyroid Autoimmunity? - A Cross-Sectional Study from a Tertiary Care Center in India.

Background: Because of the counter-regulation of Th1 and Th2 cells, Th1-type autoimmune diseases like thyroid autoimmunity and Th2-mediated allergic diseases like atopic dermatitis (AD) should occur in mutually exclusive populations. However, thyroid autoimmunity has been associated with chronic urticaria, and atopy is considered a cause of both AD and urticaria. Objectives: To assess the frequency of thyroid autoimmunity in children with AD and to study the correlation between the clinical severity of AD using the SCORing Atopic Dermatitis (SCORAD) score, and biochemical parameters of serum immunoglobulin E (IgE), absolute eosinophil count, and vitamin D levels. Materials and Methods: A hospital-based cross-sectional study was conducted, recruiting children (0-18 years) with AD. Patients on drugs affecting thyroid dysfunction and those with sick euthyroid syndrome or an immunodeficiency disorder were excluded. Clinical severity was assessed using SCORAD, and the thyroid profile, anti-thyroid peroxidase antibodies, antinuclear antibody (ANA), absolute eosinophil count, serum IgE, and vitamin D levels were measured. Results: Thyroid autoimmunity was diagnosed in 18.9% (10/53) of children. There was a significant correlation between SCORAD and serum IgE (r = 0.432, P = 0.002) and absolute eosinophil count (r = 0.575, P = <0.001). There was a negative correlation between SCORAD and vitamin D levels (r = -0.373, P = 0.006). Conclusions: Thyroid autoimmunity may be associated with AD, and a high index of suspicion is essential. Vitamin D also should be supplemented in children with AD as it is frequently found to be low, especially in severe cases. Multi-center case-control studies are required to determine the prevalence of thyroid autoimmunity in children with AD.

Diagnosis of bacterial infection in children with relapse of nephrotic syndrome: a personalized decision-analytic nomogram and decision curve analysis.

BACKGROUND: Infections associated with nephrotic relapses (NR) are often managed according to physician preferences. A validated prediction tool will aid clinical decision-making and help in rationalizing antibiotic prescriptions. Our objective was to develop a biomarker-based prediction model and a regression nomogram for the prediction of the probability of infection in children with NR. We also aimed to perform a decision curve analysis (DCA). METHODS: This cross-sectional study included children (1-18 years) with NR. The outcome of interest was the presence of bacterial infection as diagnosed using standard clinical definitions. Total leucocyte count (TLC), absolute neutrophil count (ANC), quantitative C-reactive protein (qCRP), and procalcitonin (PCT) were the biomarker predictors. Logistic regression was used to identify the best biomarker model, followed by discrimination and calibration testing. Subsequently, a probability nomogram was constructed and DCA was done to determine the clinical utility and net benefits. RESULTS: We included 150 relapse episodes. A bacterial infection was diagnosed in 35%. Multivariate analysis showed the ANC + qCRP model to be the best predictive model. This model displayed excellent discrimination (AUC: 0.83), and calibration (optimism-adjusted intercept: 0.015, slope: 0.926). A prediction nomogram and web-application was developed. The superiority of the model was also confirmed by DCA in the probability threshold range of 15-60%. CONCLUSIONS: An ANC-based and qCRP-based internally validated nomogram can be used for the prediction of probability of infection in non-critically ill children with NR. Decision curves from this study will aid in the decision-making of empirical antibiotic therapy, incorporating threshold probabilities as a surrogate of physician preference. A higher resolution version of the Graphical abstract is available as Supplementary information.

Impact of structured verbal feedback module in medical education: A questionnaire- and test score-based analysis.

INTRODUCTION: Feedback is a divalent bond between the supplier (teacher) and the recipient (student). The strength of the bond depends on the instructional design of the feedback. Feedback is central to medical education in promoting self-directed learning in students. In the present study, a structured verbal feedback module was prepared, implemented, and evaluated. METHODS: The study was done on 280 students from four consecutive batches (2011 to 2014) of the 1(st) year MBBS students exposed to different types and modes of feedback. Analysis was done using student feedback questionnaire for the perception of students to verbal feedback. Quantitative analysis using post hoc test and ANOVA for the impact of type of feedback (verbal or written) and effect of modes (individual or group) of verbal feedback on test score performance were done. RESULT: In this study, ≥95% of the students preferred verbal feedback of both positive and negative attributes in student questionnaires. It was observed that verbal feedback sessions made a difference of up to 2-2.4 grade points in the mean score of batch when compared to the written feedback. The initial mean test score (T1) of 2011 + 2012 and 2013 + 2014 was not statistically significant (P = 0.113). But, in all subsequent tests (T2, T3, and T4), there was a statistically significant difference in the mean test scores (P = 0.000). CONCLUSION: (1) Students prefer verbal one-to-one feedback over written feedback. (2) Verbal feedback changes learning process and causes sustained improvement in learning strategies.

Unfamiliar Manifestations of Anti-tubercular Therapy.

Cutaneous drug reactions are frequent in hospitalized patients and vary from simple manifestations like rash and erythema to severe life threatening conditions like angio-oedema, erythroderma, Stevens-Johnson syndrome and toxic epidermal necrolysis. However drug eruptions with antitubercular drugs are largely unknown except few case reports. We highlight here one similar case which presented with pleomorphic cutaneous manifestations after taking anti tubercular therapy and closely mimicked vasculitis. But when the offending drugs were stopped the lesions disappeared and the patient improved.

Meningitis due to Neisseria meningitidis serogroup B in India.

Invasive meningococcal disease has a fulminant course and high mortality. Neisseria meningitidis serogroup A is predominantly responsible for meningococcal disease in India and the developing countries. Group B meningococcus, which is prevalent in the developing world is uncommon in India. We herein report the second case of group B meningococcal infection from the country, two decades after the reporting of the first case. Ineffective vaccines against serogroup B warrant the need for close surveillance of this disease.

Giant liver abscess with bilateral pleural effusion: An unfamiliar association.

Amoebic liver abscess is a common problem in tropical countries. However, its protean manifestations sometimes pose diagnostic dilemma leading to delay in starting appropriate therapy. We report here one interesting case of an amoebic liver abscess where the patient developed some uncommon features like bilateral pedal edema and bilateral pleural effusion. Although unilateral effusion is well known in such patients, the cause of bilateral involvement of pleura in this patient remained largely unknown. The cause of edema turned out to be compression of inferior vena cava by the large-sized abscess, rather than any cardiopulmonary abnormality. This case has global relevance because many of the migrant populations from tropical countries are settled all over the world, particularly in Europe and America. It would only be appropriate that the treating physicians are aware of this unfamiliar association.

Risk factors for the development of retroperitoneal hematoma after percutaneous coronary intervention in the era of glycoprotein IIb/IIIa inhibitors and vascular closure devices.

OBJECTIVES: We sought to determine the incidence, clinical features, and risk factors for retroperitoneal hematoma (RPH) after percutaneous coronary intervention (PCI). BACKGROUND: Little is known about the clinical features, outcomes, and determinants of this serious complication in the contemporary era of PCI. METHODS: A retrospective analysis yielded 26 cases of RPH out of 3,508 consecutive patients undergoing PCI between January 2000 and January 2004. Cases were compared with a randomly selected sample of 50 control subjects without RPH. RESULTS: The incidence of RPH was 0.74%. Features of RPH included abdominal pain (42%), groin pain (46%), back pain (23%), diaphoresis (58%), bradycardia (31%), and hypotension (92%). The mean systolic blood pressure nadir was 75 mm Hg. The hematocrit dropped by 11.5 +/- 5.1 points from baseline in RPH patients, as compared with 2.3 +/- 3.3 points in controls (p < 0.0001). The mean hospital stay was longer in RPH patients (2.9 +/- 3.8 days vs. 1.7 +/- 1.5 days, p = 0.06). The following variables were found to be independent predictors of RPH: female gender (odds ratio [OR] 5.4, p = 0.005), low body surface area (BSA <1.73 m(2); OR 7.1, p = 0.008), and higher femoral artery puncture (OR 5.3, p = 0.013). There was no association between RPH and arterial sheath size, use of glycoprotein IIb/IIIa inhibitors, or deployment of a vascular closure device. CONCLUSIONS: Female gender, low BSA, and higher femoral artery puncture are significant risk factors for RPH. Awareness of the determinants and clinical features of RPH may aid in prevention, early recognition, and prompt treatment.

Long-term effects of polymer-based, slow-release, sirolimus-eluting stents in a porcine coronary model.

BACKGROUND: Stent-based delivery of sirolimus (SRL) has shown reduction in neointimal hyperplasia and restenosis. The purpose of this study was to evaluate the chronic vascular response and the expression of cell cycle regulators after SRL-eluting stent implantation in a porcine coronary model. METHODS: Forty-nine pigs underwent placement of 109 oversized stents (control, n=54, SRL (140 microg/cm(2)), n=55) in the coronary arteries with histologic analysis and Western blot (PCNA, p27(kip1), CD45, MCP-1, IL-2, IL-6, TNF-beta) at 3, 30, 90 or 180 days. RESULTS: At 3 days, the mean thrombus area was similar for control (0.38+/-0.19 mm(2)) and SRL (0.29+/-0.09 mm(2)) stents. After 30 days, the mean neointimal area was significantly less for the SRL (1.40+/-0.35 mm(2)) versus the control stents (2.94+/-1.28 mm(2), p<0.001). At 90 and 180 days, the mean neointimal area was similar for the SRL (3.03+/-0.92 and 3.34+/-0.99 mm(2)) as compared with control stents (3.45+/-1.09 and 3.65+/-1.23 mm(2)). Western blot analysis demonstrated an increased expression of p27(kip1) in the vessel wall at 90 days for the SRL versus control stents (p=0.05) but with increased levels of PCNA in the SRL as compared with control stents (p=0.003). CONCLUSION: SRL-eluting stents favorably modulate neointimal formation for 30 days in the porcine coronary model. Long-term inhibition of neointimal hyperplasia is not sustained presumably due to delayed cellular proliferation despite increased levels of the cyclin-dependent kinase p27(kip1) in the vessel wall.