Causes & risk factors for unscheduled readmissions in the paediatric ward of a major public hospital.

Background & objectives: Readmissions are often considered as an indicator of poor quality of care during previous hospitalization, although many of these are unavoidable or unrelated to the past admission. The identification of high-risk cases for readmissions and appropriate interventions will help not only reduce the hospital burden but also to establish the credibility of the hospital. So this study aimed to determine the readmission percentage in the paediatric wards of a tertiary care hospital and to identify the reasons and risk factors that can help minimize preventable re-hospitalizations. Methods: This prospective study from a public hospital included 563 hospitalized children, classified as first admission or readmissions. Readmissions were defined as one or more hospitalizations within preceding six months, excluding scheduled admissions for investigations or treatment. Reason-wise, the readmissions were classified into various categories, based on the opinion of three paediatricians. Results: The percentage of children getting readmitted within six, three and one month time from the index admission was 18.8, 11.1 and 6.4 per cent, respectively. Among readmissions, 61.2 per cent were disease-related, 16.5 per cent unrelated, 15.5 per cent patient-related, 3.8 per cent medication/procedure-related and 2.9 per cent physician-related causes. Patient- and physician-related causes were deemed preventable, contributing to 18.4 per cent. The proximity of residence, undernutrition, poor education of the caretaker and non-infectious diseases were associated with increased risk of readmission. Interpretation & conclusions: The findings of this study suggest that readmissions pose a substantial burden on the hospital services. The primary disease process and certain sociodemographic factors are the major determinants for the increased risk of readmissions among paediatric patients.

Clinical Profile and Outcome of Pediatric Tetanus at a Tertiary Care Center.

The aims and objectives of this study were to study clinical profile and factors affecting mortality in tetanus. This was a retrospective study of 25 tetanus patients (aged 6 months-12 years) admitted to pediatric intensive care unit of a tertiary center (over 3 years). In this study, 25 tetanus cases (mean age 6.6 years) were analyzed; 16 were males and 9 were females. Incubation period ranged from 2 to 30 days (mean 8.2 days), period of onset from 11 to 120 hours (mean 42.8 hours), and duration of spasms from 4 to 26 days (mean 14 days). The commonest portal of entry was posttrauma (52%), followed by otogenic (40%). Eighteen patients had moderate and 7 had severe tetanus. Fifteen were unimmunized and 10 were partially immunized. The commonest complaints were trismus and spasms (100%), hypertonia (72%), fever (60%), dysphagia (48%), and neck stiffness (44%). Eight patients required primary tracheostomy and 11 required primary endotracheal intubation. Complications encountered were pneumonia (58%), conjunctivitis (41%), gastrointestinal bleed (37.5%), urinary infection (33%), acute kidney injury (AKI) following rhabdomyolysis (33%), sepsis (29%), disseminated intravascular coagulation (DIC) (25%), bedsores (25%), and acute respiratory distress syndrome (ARDS) (20%). Oral diazepam was most commonly used, followed by midazolam, vecuronium, and magnesium sulfate. Mortality rate was 32% (five moderate and three severe cases died). Short period of onset (less than 48 hours), AKI following rhabdomyolysis, sepsis, DIC, ARDS, and inotrope need were significantly associated with higher mortality. It is concluded that the commonest portal of entry was posttrauma. None of the patients was completely immunized. Short period of onset, AKI, sepsis, DIC, ARDS, and inotrope need predicted a higher mortality.

Clinical Profile and Outcome of Guillain-Barre Syndrome in Pediatric Patients Admitted to a Tertiary Care Centre: A Retrospective Study.

AIMS AND OBJECTIVES: To study clinical profile and outcome in Pediatric Guillain Barre Syndrome (GBS). MATERIALS AND METHODS: Retrospective study of 30 patients (age 1 month to 12 years) admitted with GBS enrolled over a period of 2 years (August 2016-July 2018) from Department of Pediatrics of tertiary centre. RESULTS: Mean age was 5.4 years (21 males; 9 females). Most common presenting complaints- symmetrical lower limb weakness (26 cases; 86.67% cases), respiratory complaints (6 cases; 20% cases), quadriparesis (4 cases; 13.33% cases) and facial palsy (2 cases; 6.67%). Antecedent illnesses- gastrointestinal (6 cases) and respiratory (3 cases). Two patients had varicella (in preceding one week) and one had mumps (one month prior to presentation). MRI-spine done in 12 patients; of whom 9 had features of GBS (thickening and contrast enhancement of the intrathecal and cauda equina nerve roots on T1 weighted MRI). Nerve conduction studies done in 16 patients, of which Acute Motor Axonal Neuropathy was seen in 10 cases. Intravenous immunoglobulin was given to 27 patients while 3 received methylprednisolone in addition. 90% patients receiving IVIG showed improvement. Sixteen patients were admitted to the intensive care unit and 7 required mechanical ventilation. Average hospital stay was 13 days. Two patients had recurrent episodes. Common complications included- pneumonia (6 cases; 2 aspiration and 4 ventilator associated) and autonomic disturbances (6 cases). Two patients died due to autonomic disturbances and presence of autonomic disturbances predicted higher mortality (P = 0.034). CONCLUSIONS: Gastrointestinal illness was common antecedent illness for GBS. Symmetrical lower limb weakness was commonest complaint. Pneumonia and autonomic disturbances were commonest complications. Presence of autonomic disturbances predicted higher mortality.

Glutaric Aciduria Type 1: A Case Report and Review of Literature.

An 8-month-old male infant patient was referred to our institution (from elsewhere) with a history of fever, convulsions, dystonic posturing, altered sensorium, and loss of motor and mental milestones since past 1 month. Upon admission to our institution, a neuroimaging (magnetic resonance imaging of the brain) revealed frontoparietal atrophy, "bat-wing appearance," and basal ganglia changes. Carnitine and acylcarnitine profile revealed low total carnitine, very low free carnitine, and low free/acylcarnitine ratio, with normal levels of plasma amino acids. Urine gas chromatography mass spectrometry showed an elevated level of ketones (3-hydroxybutyric acid and acetoacetate) and glutaric acid with the presence of 3-hydroxyglutaric acid, suggestive of glutaric aciduria type 1. Diet modification and pharmacotherapy with riboflavin and carnitine arrested the neurological deterioration in the patient.

Kerosene Poisoning Complicated by Acute Pancreatitis.

A 6-year-old male child patient was brought to the emergency pediatric room with alleged history of accidental ingestion of approximately 15 mL kerosene oil. The child developed vomiting shortly after the consumption. Chest radiograph taken 6 hours after ingestion did not show any abnormalities. On the second day of hospital stay, the patient started complaining of severe abdominal pain. His serum amylase and lipase levels were elevated significantly, suggesting the development of acute pancreatitis. He was investigated for the other possible causes of acute pancreatitis, which were normal. There is paucity of literature regarding occurrence of acute pancreatitis following kerosene poisoning, both in children, as well as adults, because of its rarity. A high index of suspicion should be kept in mind and a differential diagnosis of acute pancreatitis should be considered in cases of acute kerosene poisoning, who complain of pain in abdomen.

The Collaborative Ocular Tuberculosis Study (COTS) Consensus (CON) Group Meeting Proceedings.

An international, expert led consensus initiative was set up by the Collaborative Ocular Tuberculosis Study (COTS) group to develop systematic, evidence, and experience-based recommendations for the treatment of ocular TB using a modified Delphi technique process. In the first round of Delphi, the group identified clinical scenarios pertinent to ocular TB based on five clinical phenotypes (anterior uveitis, intermediate uveitis, choroiditis, retinal vasculitis, and panuveitis). Using an interactive online questionnaires, guided by background knowledge from published literature, 486 consensus statements for initiating ATT were generated and deliberated amongst 81 global uveitis experts. The median score of five was considered reaching consensus for initiating ATT. The median score of four was tabled for deliberation through Delphi round 2 in a face-to-face meeting. This report describes the methodology adopted and followed through the consensus process, which help elucidate the guidelines for initiating ATT in patients with choroidal TB.

Cytokine Profiling in Patients With Exudative Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy.

Purpose: The purpose of this study was to investigate the cytokine profiles in plasma and aqueous humor of patients with choroidal neovascularization (CNV) due to exudative AMD and polypoidal choroidal vasculopathy (PCV). Methods: In this cross-sectional study, 16 patients clinically diagnosed with AMD, 18 patients with PCV, and 50 age- and sex-matched cataract patients without AMD/PCV (controls) were enrolled. Study subjects were treatment naïve, and 200 µL undiluted aqueous humor and 5 mL peripheral venous blood were collected from the study subjects. Clinical samples were analyzed for 41 different cytokines by Luminex bead-based multiplex assay. Cytokines concentrations with detection rates of 50% or more were included for the analysis, and the differences in plasma and aqueous humor cytokines levels between each group were analyzed. Results: The age of the patients with AMD and PCV was 70.62 ± 10.15 (mean ± SD) and 71.48 ± 9.08 years, respectively, and that in the control group was 62.8 ± 10.67 years. Aqueous humor cytokines growth-regulated oncogene (GRO), macrophage-derived chemokine (MDC), and macrophage inflammatory protein (MIP)-1α were significantly higher in AMD patients than controls (all P < 0.04), and GRO, MDC, MIP-1α, IL-8, IFN-γ-inducible protein 10, and monocyte chemotactic protein levels were significantly higher in PCV patients than controls (all P < 0.03). Soluble CD40 ligand and platelet-derived growth factor-AA levels were higher in plasma of healthy controls compared with AMD subjects. No significant differences in cytokine levels were observed between AMD and PCV patients for both plasma and aqueous humor. Conclusions: In AMD and PCV patients, our data suggest that the pathologic changes are primarily driven by dysregulation of local immune factors in the eye, whereas the plasma cytokine levels are not elevated.

Growth factors involve in cellular proliferation, differentiation and migration during prostate cancer metastasis.

Growth factors play active role in cells proliferation, embryonic development regulation and cellular differentiation. Altered level growth factors promote malignant transformation of normal cells. There has been significant progress made in form of drugs, inhibitors and monoclonal antibodies against altered growth factor to treat the malignant form of cancer. Moreover, these altered growth factors in prostate cancer increases steroidal hormone levels, which promotes progression. Though this review we are highlighting the majorly involved growth factors in prostate carcinogenesis, this will enable to better design the therapeutic strategies to inhibit prostate cancer progression.

Dataset of plasma and aqueous humor cytokine profiles in patients with exudative age related macular degeneration and polypoidal choroidal vasculopathy.

In this report the data was obtained from a prospective case-control study with a sample size of sixteen patients with exudative age related macular degeneration (AMD) due to choroidal neovascularization (CNV) and eighteen patients with polypoidal choroidal vasculopathy (PCV) and fifty controls (cataract patients without any other ocular diseases). Luminex bead based multiplex assay with a panel of 41 analytes was used to study the cytokine levels in plasma and aqueous humor.

Comparison of Pediatric Risk of Mortality III, Pediatric Index of Mortality 2, and Pediatric Index of Mortality 3 in Predicting Mortality in a Pediatric Intensive Care Unit.

Aims To compare and validate the Pediatric Risk of Mortality (PRISM) III, Pediatric Index of Mortality (PIM) 2, and PIM 3 scores in a tertiary care pediatric intensive care unit (PICU) (Indian setting). Materials and Methods All consecutively admitted patients in the PICU of a public hospital (excluding those with unstable vital signs or cardiopulmonary resuscitation within 2 hours of admission, cardiopulmonary resuscitation before admission, and discharge or death in less than 24 hours after admission) were included. PRISM III, PIM 2, and PIM 3 scores were calculated. Mortality discrimination for the three scores was calculated using the receiver operating characteristic (ROC) curve, and calibration was performed using the Hosmer-Lemeshow goodness-of-fit test. Results A total of 350 patients were included (male:female = 1.3:1) over the study duration of 18 months (median age: 12 months [interquartile range: 4-60 months]). Nearly half were infants (47.4%). Patients with central nervous system disease were the highest (22.8%) followed by cardiovascular system (20.6%). Mortality rate was 39.4% (138 deaths). The area under the ROC curve for the PRISM III score was 0.667, and goodness-of-fit test showed no significant difference between the observed and expected mortalities in any of these categories ( p > 0.5), showing good calibration. Areas under the ROC curve for the PIM 2 and PIM 3 scores were 0.728 and 0.726, respectively. For both the scores, the goodness-of-fit test showed good calibration. Conclusions Although all the three scores demonstrate good calibration, the PIM 2 and PIM 3 scores have an advantage regarding the better discrimination ability, ease of data collection, simplicity of computation, and inherent capacity of not being affected by treatment in PICU.

Bead Based Multiplex Assay for Analysis of Tear Cytokine Profiles.

Tear film is a complex mixture of lipids, proteins and minerals which covers the external surface of the eye, thereby providing lubrication, nutrition and protection to the underlying cells. Analysis of tears is an emerging area for the identification of biomarkers for the prediction, diagnosis, and prognosis of various ocular diseases. Tears are easily accessible and their collection is non-invasive. Therefore, advancing technologies are gaining prominence for identification of multiple analytes in tears to study changes in protein or metabolite composition and its association with pathological conditions. Tear cytokines are ideal biomarkers for studying the health of the ocular surface and also help in understanding the mechanisms of different ocular surface disorders like dry eye disease and vernal conjunctivitis. Bead based multiplex assays have the capability of detecting multiple analytes in a small amount of sample with a higher sensitivity. Here we describe a standardized protocol of tear sample collection, extraction and analysis of cytokine profiling using a bead based multiplex assay.

Precycle Estradiol in Synchronization and Scheduling of Antagonist Cycles.

Antagonist cycles have an inherent issue of lack of flexibility. As a result where batching of cycles is desired, it is not the preferred protocol in ART cycles. There is also the limitation of ovarian response in antagonist cycle due to the size heterogenesities of antral follicles at the start of stimulation. Among the different options available, use of estrogen in the luteal phase of the preceding cycle has definitely shown benefits with regard to better control of cycle as well as synchronization of follicles available for stimulation. The article gives a detailed analysis of the different options available for timing the egg collection in antagonist cycles, the advantages and drawbacks, and the method of use of estrogen. Whereas in the majority of the trials where estrogen pretreatment was used, the goal of scheduling of egg collection was definitely achieved, increased duration and dose of gonadotropin stimulation were required. There was definite advantage of higher oocyte yield in these cycles. The possibility of premature LH rise later during stimulation and subsequent poor implantation in these cycles has to be further evaluated. Nevertheless, batching of patient friendly antagonist cycles can be effectively possible by use of precycle estrogen treatment.

A Novel Glycogen Synthase Kinase-3 Inhibitor Optimized for Acute Myeloid Leukemia Differentiation Activity.

Standard therapies used for the treatment of acute myeloid leukemia (AML) are cytotoxic agents that target rapidly proliferating cells. Unfortunately, this therapeutic approach has limited efficacy and significant toxicity and the majority of AML patients still die of their disease. In contrast to the poor prognosis of most AML patients, most individuals with a rare subtype of AML, acute promyelocytic leukemia, can be cured by differentiation therapy using regimens containing all-trans retinoic acid. GSK3 has been previously identified as a therapeutic target in AML where its inhibition can lead to the differentiation and growth arrest of leukemic cells. Unfortunately, existing GSK3 inhibitors lead to suboptimal differentiation activity making them less useful as clinical AML differentiation agents. Here, we describe the discovery of a novel GSK3 inhibitor, GS87. GS87 was discovered in efforts to optimize GSK3 inhibition for AML differentiation activity. Despite GS87's dramatic ability to induce AML differentiation, kinase profiling reveals its high specificity in targeting GSK3 as compared with other kinases. GS87 demonstrates high efficacy in a mouse AML model system and unlike current AML therapeutics, exhibits little effect on normal bone marrow cells. GS87 induces potent differentiation by more effectively activating GSK3-dependent signaling components including MAPK signaling as compared with other GSK3 inhibitors. GS87 is a novel GSK3 inhibitor with therapeutic potential as a differentiation agent for non-promyelocytic AML. Mol Cancer Ther; 15(7); 1485-94. ©2016 AACR.

Nanoporous Cathodes for High-Energy Li-S Batteries from Gyroid Block Copolymer Templates.

This study reports on a facile approach to the fabrication of nanoporous carbon cathodes for lithium sulfur batteries using gyroid carbon replicas based on use of polystyrene-poly-4-vinylpyridine (PS-P4VP) block copolymers as sacrificial templates. The free-standing gyroid carbon network with a highly ordered and interconnected porous structure has been fabricated by impregnating the carbon precursor solution into the gyroid block copolymer nanotemplates and subsequently carbonizing them. A wide range of analytical tools have been employed to characterize fabricated porous carbon material. Prepared nanostructures are envisioned to have a great potential in myriad areas such as energy storage/conversion devices owing to their fascinating morphology exhibiting high surface area and uniform porosity with interconnected three-dimensional networks. The resulting carbon nanoporous structures infused with elemental sulfur have been found to work as a promising electrode for lithium sulfur batteries demonstrating a high cycling stability over more than 200 cycles.

Acute Respiratory Distress Syndrome Caused by Mercury Inhalation: A Case Report.

Inhalation of mercury vapor is an uncommon cause of acute respiratory distress syndrome. It may go unnoticed if appropriate environmental/occupational history is not taken. A 2-year-old child presented with severe respiratory distress and progressed to develop acute respiratory distress syndrome, necessitating high-pressure mechanical ventilation. On detailed enquiry, history of exposure to mercury fumes was obtained (at home), during gold extraction by the father. Diagnosis of mercury poisoning was confirmed by blood levels, and despite treatment with dimercaprol (mercury chelator) and high-frequency ventilation, the child subsequently succumbed within 26 hours. This case reiterates the need for awareness regarding unusual environmental toxic exposures and need for stricter regulations for sale or use of toxic products.

Tumor anficrino de antro gástrico-comunicación de un caso / Amphicrine tumor of gastric antrum—A case rport

Los tumores anficrinos malignos son un grupo de tumores en los que las células tumorales muestran evidencia de diferenciación tanto epitelial como neuroendocrina. Los tumores anficrinos malignos de estómago aunque han sido reportados no son muy comunes. El examen histopatológico de los tumores muestra características de adenocarcinoma o tumor neuroendocrino grado 1 a 2. Mediante inmunohistoquímica, estos tumores son positivos para ambos, marcadores neuroendocrinos así como marcadores epiteliales, indicando su naturaleza anficrina. Los tumores anficrinos malignos se clasifican ahora como un nuevo subgrupo en clasificación de la OMS. La rareza de este tumor en el antro gástrico nos motivó a publicarlo(AU)

Malignant amphicrine tumors are a group of tumors in which tumor cells show evidence of both epithelial as well as neuroendocrine differentiation. Malignant amphicrine tumors of gastric region though have been reported are not very common. Histopathological examination of these tumors show features of adenocarcinoma or grade 1 to 2 neuroendocrine tumor. Immunohistochemically, these tumors are positive for both neuroendocrine as well as epithelial markers indicating their amphicrine nature. Malignant amphicrine tumors are now classified as a new subgroup based on WHO classification. The rarity of this tumor in gastric antrum made us to report the case(AU)