Use of Speckle-Tracking Echocardiography in Septic Cardiomyopathy in Critically Ill Children: A Narrative Review.

OBJECTIVES: In critically ill children with severe sepsis, septic cardiomyopathy (SCM) denotes the subset of patients who have myocardial dysfunction with poor response to fluid and inotropic support, and higher mortality risk. The objective of this review was to evaluate the role of speckle-tracking echocardiography (STE) in the diagnosis and prognosis of pediatric SCM in the PICU setting. DATA SOURCES: We performed detailed searches using PubMed, Scopus, Web of Science, and Google Scholar. Reference lists of all included studies were also examined for further identification of potentially relevant studies. STUDY SELECTION: Studies with the following medical subject headings and keywords were selected: speckle-tracking echocardiography, strain imaging, global longitudinal strain, echocardiography, sepsis, severe sepsis, septic shock, septic cardiomyopathy, and myocardial dysfunction. DATA EXTRACTION: The following data were extracted from all included studies: demographics, diagnoses, echocardiographic parameters, severity of illness, PICU management, and outcomes. DATA SYNTHESIS: STE is a relatively new echocardiographic technique that directly quantifies myocardial contractility. It has high sensitivity in diagnosing SCM, correlates well with illness severity, and has good prognosticating value as compared with conventional echocardiographic parameters. Further studies are required to establish its role in evaluating biventricular systolic and diastolic dysfunction, and to investigate whether it has a role in individualizing treatment and improving treatment outcomes in this group of patients. CONCLUSIONS: STE is a useful adjunct to conventional measures of cardiac function on 2D-echocardiography in the assessment of pediatric SCM in the PICU.

High-Risk ERT for Children With Cardiac Critical Illness.

BACKGROUND: A protocolized extubation readiness test (ERT), including a spontaneous breathing trial (SBT), is recommended for patients who are intubated. This quality-improvement project aimed to improve peri-extubation outcomes by using a high-risk ERT protocol in intubated cardiac patients in addition to a standard-risk protocol. METHODS: After baseline data collection, we implemented a standard-risk ERT protocol (pressure support plus PEEP), followed by a high-risk ERT protocol (PEEP alone) in cardiac subjects who were intubated. The primary outcome, a composite of extubation failure and rescue noninvasive respiratory support, was compared between phases. Ventilator duration and use of postextubation respiratory support were balancing measures. RESULTS: A total of 213 cardiac subjects who were intubated were studied, with extubation failure and rescue noninvasive respiratory support occurring in 10 of 213 (4.7%) and 8 of 213 (3.8%), respectively. We observed a reduction in the composite outcome among the 3 consecutive phases (5/29 [17.2%], 10/110 [9.1%] vs 3/74 [4.1%]; P = .10), but this did not reach statistical significance. In the logistic regression model when adjusting for admission type, the high-risk ERT protocol was associated with a significant reduction of the composite outcome (adjusted odds ratio 0.20, 95% CI 0.04-0.091; P = .037), whereas the standard-risk ERT protocol was not (adjusted odds ratio 0.48, 95% CI 0.15-1.53; P = .21). This was not accompanied by a longer ventilator duration (2.0 [1.0, 3.0], 2.0 [1.0, 4.0] vs 2.0 [1.0, 6.0] days; P = .99). CONCLUSIONS: In this quality-improvement project, a high-risk ERT protocol was implemented with improvement in peri-extubation outcomes among cardiac subjects.

Chronological age enhances aging phenomena and protein nitration in oocyte.

Background: The average age of childbearing has increased over the years contributing to infertility, miscarriages, and chromosomal abnormalities largely invoked by an age-related decline in oocyte quality. In this study, we investigate the role of nitric oxide (NO) insufficiency and protein nitration in oocyte chronological aging. Methods: Mouse oocytes were retrieved from young breeders (YB, 8-14 weeks [w]), retired breeders (RB, 48-52w) and old animals (OA, 80-84w) at 13.5 and 17 hours after ovulation trigger. They were assessed for zona pellucida dissolution time (ZPDT); ooplasmic microtubule dynamics (OMD); cortical granule (CG) status and spindle morphology (SM), as markers of oocyte quality. Sibling oocytes from RB were exposed to NO supplementation and assessed for aging phenomena (AP). All oocyte cumulus complexes were subjected to fluorescence nitrotyrosine (NT) immunocytochemistry and confocal microscopy to assess morphology and protein nitration. Results: At 13.5 h from hCG trigger, oocytes from RB compared to YB had significantly increased ZPDT (37.8 ± 11.9 vs 22.1 ± 4.1 seconds [s]), OMD (46.9 vs 0%), CG loss (39.4 vs 0%), and decreased normal SM (30.3 vs 81.3%), indicating premature AP that worsened among oocytes from RB at 17 hours post-hCG trigger. When exposed to SNAP, RB AP significantly decreased (ZPDT: 35.1 ± 5.5 vs 46.3 ± 8.9s, OMD: 13.3 vs 75.0% and CG loss: 50.0 vs 93.3%) and SM improved (80.0 vs 14.3%). The incidence of NT positivity was significantly higher in cumulus cells (13.5 h, 46.7 ± 4.5 vs 3.4 ± 0.7%; 17 h, 82.2 ± 2.9 vs 23.3 ± 3.6%) and oocytes (13.5 h, 57.1 vs 0%; 17 h, 100.0 vs 55.5%) from RB compared to YB. Oocytes retrieved decreased with advancing age (29.8 ± 4.1 per animal in the YB group compared to 10.2 ± 2.1 in RB and 4.0 ± 1.6 in OA). Oocytes from OA displayed increased ZPDT, major CG loss, increased OMD and spindle abnormalities, as well as pronuclear formation, confirming spontaneous meiosis to interphase transition. Conclusions: Oocytes undergo zona pellucida hardening, altered spindle and ooplasmic microtubules, and premature cortical granule release, indicative of spontaneous meiosis-interphase transition, as a function of chronological aging. These changes are also associated with NO insufficiency and protein nitration and may be alleviated through supplementation with an NO-donor.

Determination of chlorantraniliprole for managing Helicoverpa armigera and Spodoptera litura in cotton ecosystem.

Cotton bollworm incidence and damages are high in India. In addition, it causes considerable yield loss. A new insecticide formulation Chlorantraniliprole 600 g/L SC was used along with recommended insecticides for managing Spodoptera litura and Helicoverpa armigera in two consecutive experimental trials during the period October 2021 to September 2022. Two foliar applications of Chlorantraniliprole (40 and 30 g a. i/ha) at ten days interval period reduced significantly the larval populations of H. armigera, S. litura without any phytotoxic symptoms in cotton. Chlorantraniliprole application in open field condition was found to be harmless to natural enemy (coccinellids and spiders). Even though, a temporary lessening of natural enemy populations was noticed after spray, progressively the population was increased within a week time. Cotton yield was high in chlorantraniliprole @ 40 g a. i/ha treated plot (22.66, 22.12 q/ha) when compared to untreated control. Similar effect was also noticed in the dose at 30 g a. i/ha (22.35, 21.81 q/ha) and it was statistically on par in both experiments. Residue analysis results confirming that, cotton lint, cotton seed and soil samples collected from treated (30 and 60 g a. i/ha) and untreated samples during harvest were free from chlorantraniliprole residues (below detectable levels of 0.008 µg/g).

Diminishing oocyte quality with advancing age is associated with deficiency of nitric oxide synthase cofactors, tetrahydrobiopterin, and zinc, in mouse oocytes.

OBJECTIVE: To study the implications of decreased zinc and tetrahydrobiopterin (H4B) associated with chronological aging on oocyte quality using a mouse model. H4B and zinc are essential cofactors for nitric oxide synthase (NOS), because they aid in electron transfer and dimeric stability, and their bioavailability is crucial in regulating NOS coupling. We have previously shown that sufficient levels of nitric oxide (NO) are essential for maintaining oocyte quality and activation, and NO levels decrease in the oocyte as a function of age. Thus, it is plausible that zinc and H4B may decrease as a function of age, resulting in NOS dysfunction with subsequent depletion of NO. Additionally, increased production of reactive oxygen species from the monomeric form can further disrupt oocyte quality and NO bioavailability. DESIGN: Experimental laboratory study. SETTING: Laboratory. ANIMALS: B6D2F1 mice. INTERVENTION(S): Sibling oocytes were retrieved from super-ovulated B6D2F1 mice from 3 age groups: 8-14 weeks (young breeders [YBs]), 48-52 weeks (retired breeders [RBs]), and 80-84 weeks (old animals [OAs]). MAIN OUTCOME MEASURE(S): Oocytes were scored for ooplasmic/spindle microtubule (MT) morphology, chromosomal alignment, and cortical granule (CG) intactness using immunofluorescence and confocal microscopy with 3 dimension image reconstruction and subjected to an high-performance liquid chromatography assay to measure the concentrations of H4B and its metabolites, as well as the zinc measurement using atomic absorption spectrophotometry. RESULT(S): Oocyte scoring showed a reduction in "good" quality oocyte percentage as age increases, with YB having the highest percentage of quality oocytes followed by RB and OA. The high-performance liquid chromatography analysis showed a significant progressive decrease in total H4B in RB and OA (0.00098 picogram (pg)/oocyte and 0.00069 pg/oocyte, respectively) compared with YB (0.00125 pg/oocyte). Atomic absorbance spectrophotometry revealed a significant progressive decrease in zinc concentration in RB and OA compared with YB (8.45 pg/oocyte and 5.82 pg/oocyte vs. 10.05 pg/oocyte, respectively). CONCLUSION(S): Age-related diminution in oocyte quality is paralleled by a decline in the levels of H4B and zinc. The resultant deficiency in the oocytes can lead to the inability of NOS to maintain dimerization. Consequent uncoupling of NOS generates superoxide instead of NO, which participates in a multitude of reactions contributing to oxidative stress. Therefore, dysfunction of NOS secondary to zinc and H4B loss is a major mechanism involved in reactive oxygen species generation and oocyte quality deterioration related to the chronological age.

Necrotizing Pneumonia Due To Rhodococcus Hoagii In A Patient With Advanced Retroviral Disease.

Rhodococcus hoagii is a well-known zoonotic disease, especially in foals. Its occurrence in humans is uncommon and usually occurs in immunocompromised patients. We present a case of Rhodococcus hoagii infection resulting in necrotizing pneumonia in a patient with advanced retroviral disease who had defaulted treatment. Effective treatment of Rhodococcus hoagii infection requires a combination of antibiotics. We also highlighted the importance of effective communication between clinicians and microbiologists so that prompt treatment can be initiated to improve patient outcomes.

Enterococcus hirae bacteremia associated with perinephric collection and renal abscesses in a diabetic woman.

Enterococcus hirae infection accounts for about 1% of all enterococcal infections. This number is likely to be underestimated because of inadequate identification. Human infection due to E. hirae is rarely reported. We present the case of a young woman with diabetes mellitus who developed symptoms of pyelonephritis and diabetic ketoacidosis. Renal computed tomography scan revealed the presence of subcapsular perinephric collection and renal abscesses. Her blood culture yielded E. hirae. Our patient was successfully treated with antimicrobials based on the susceptibility result. To our knowledge, this is the first reported case of perinephric collection and renal abscesses associated with E. hirae bacteremia.

Necrotizing pneumonia requiring prolonged extracorporeal membrane oxygenation: Pushing the boundaries in pediatric ECMO.

Extracorporeal membrane oxygenation (ECMO) is a life-saving rescue therapy used in acute respiratory failure refractory to invasive mechanical ventilation. Recent studies on positive outcomes of extended ECMO therapy are promising. We describe a case of a 2-year 8-month-old female child with necrotizing pneumonia secondary to Streptococcus pneumoniae, Influenza A, and Mycoplasma pneumoniae, who survived with intact neurological function and no long-term adverse outcomes after a prolonged ECMO run of 86 days. To the best of our knowledge, this is one of the longer durations of ECMO with transplant-free survival in a pediatric patient requiring respiratory support with good recovery and a good functional outcome. Allowing time for native lung recovery is pivotal for optimal recovery, despite significant lung injury due to the underlying disease process. With evolving ECMO experience, clinicians may need to re-consider the conventional maximum duration of ECMO in children with severe respiratory failure on a case-by-case basis.

Cryptococcus gattii meningitis complicated by immune reconstitution inflammatory syndrome in an apparent immunocompetent host in Malaysia.

Cryptococcosis is a systemic fungal infection caused by Cryptococcus neoformans or Cryptococcus gattii. Cryptococcus causes a wide range of diseases, ranging from asymptomatic pulmonary lesions to disseminated disease involving the central nervous system, particularly meningoencephalitis. C. gattii infection has rarely been reported in Malaysia. We present a case of C. gattii meningitis with pulmonary cryptococcosis complicated by immune reconstitution inflammatory syndrome in an apparently immunocompetent person with no prior travel history.

Acute abdomen revealed Streptococcus gordonii infective endocarditis with systemic embolism.

Infective endocarditis can result in potentially fatal complications such as heart failure, systemic embolization, mycotic aneurysm and neurological complications. Staphylococci and streptococci are the most common causative agents of infective endocarditis, with Streptococcus gordonii being a rare cause. We present a case of infective endocarditis in a young patient who presented with an acute abdomen 2 months after being diagnosed with cerebrovascular accident. An abdominal computed tomography revealed superior mesenteric artery thrombosis, and infarct in the right kidney and spleen as a result of systemic septic embolism. Echocardiography showed numerous vegetations at the aortic and mitral valves. Infective endocarditis was diagnosed based on echocardiographic findings and positive blood cultures for S. gordonii. He was treated with intravenous benzylpenicillin and was also referred for surgical intervention.

Extracorporeal Life Support Organization (ELSO): Guidelines for Pediatric Cardiac Failure.

These guidelines are applicable to neonates and children with cardiac failure as indication for extracorporeal life support. These guidelines address patient selection, management during extracorporeal membrane oxygenation, and pathways for weaning support or bridging to other therapies. Equally important issues, such as personnel, training, credentialing, resources, follow-up, reporting, and quality assurance, are addressed in other Extracorporeal Life Support Organization documents or are center-specific.

Mandibular Canine Calcification Stages as an Indicator of Skeletal Maturity.

AIMS: The aim of this study was to verify whether there is significant relationship between stages of mandibular canine calcification and skeletal maturation and to determine whether the same can be used as a reliable diagnostic aid to assess skeletal maturity. MATERIALS AND METHODS: The sample consisted of 50 males and 50 females aged between 8 and 15 years. Two radiographs namely orthopantomograph and handwrist radiograph were taken for this study. Skeletal age was ascertained from handwrist radiographs according to the method introduced by Fishman L.S. The developmental stages of mandibular canine were assessed according to Demirjian's stages of dental calcification. RESULTS: The relationship between canine stage calcification and skeletal maturity index was statistically significant in all stages. INTERPRETATION AND CONCLUSION: Mandibular canine calcification stages can be recommended as a supplemental diagnostic aid. Similar studies may be conducted in different population to rule out any possible racial and regional influences on growth characteristics.

Pediatric Palliative Transport in Critically Ill Children: A Single Center's Experience and Parents' Perspectives.

The transfer of critically ill children from intensive care units (ICUs) to their homes for palliation is seldom described. We report our 10-year pediatric palliative transport experience and conducted a survey to gain parents' perspectives of their child's transport experience. Over the study period, eight patients were transported from our pediatric ICU to their homes or hospice facilities. There were no intratransport adverse events. Parents who participated in the survey responded positively to the transport experience. The availability of a dedicated critical care transport service allowed for palliative transfers to be performed safely. Facilitating transport to allow withdrawal of life support at home is an acceptable option to families as part of holistic end-of-life care.

Sociodemographic profile and predictors of outpatient clinic attendance among HIV-positive patients initiating antiretroviral therapy in Selangor, Malaysia.

BACKGROUND: Inconsistent literature evidence suggests that sociodemographic, economic, and system- and patient-related factors are associated with clinic attendance among the HIV-positive population receiving antiretroviral therapy (ART) around the world. We examined the factors that predict outpatient clinic attendance among a cohort of HIV-positive patients initiating ART in Selangor, Malaysia. PATIENTS AND METHODS: This cross-sectional study analyzed secondary data on outpatient clinic attendance and sociodemographic, economic, psychosocial, and patient-related factors among 242 adult Malaysian patients initiating ART in Selangor, Malaysia. Study cohort was enrolled in a parent randomized controlled trial (RCT) in Hospital Sungai Buloh Malaysia between January and December 2014, during which peer counseling, medication, and clinic appointment reminders were provided to the intervention group through short message service (SMS) and telephone calls for 24 consecutive weeks. Data on outpatient clinic attendance were extracted from the hospital electronic medical records system, while other patient-level data were extracted from pre-validated Adult AIDS Clinical Trial Group (AACTG) adherence questionnaires in which primary data were collected. Outpatient clinic attendance was categorized into binary outcome - regular attendee and defaulter categories - based on the number of missed scheduled outpatient clinic appointments within a 6-month period. Multivariate regression models were fitted to examine predictors of outpatient clinic attendance using SPSS version 22 and R software. RESULTS: A total of 224 (93%) patients who completed 6-month assessment were included in the model. Out of those, 42 (18.7%) defaulted scheduled clinic attendance at least once. Missed appointments were significantly more prevalent among females (n=10, 37.0%), rural residents (n=10, 38.5%), and bisexual respondents (n=8, 47.1%). Multivariate binary logistic regression analysis showed that Indian ethnicity (adjusted odds ratio [AOR] =0.235; 95% CI [0.063-0.869]; P=0.030) and heterosexual orientation (AOR =4.199; 95% CI [1.040-16.957]; P=0.044) were significant predictors of outpatient clinic attendance among HIV-positive patients receiving ART in Malaysia. CONCLUSION: Ethnicity and sexual orientation of Malaysian patients may play a significant role in their level of adherence to scheduled clinic appointments. These factors should be considered during collaborative adherence strategy planning at ART initiation.

Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial.

BACKGROUND: Adherence to treatment remains the cornerstone of long term viral suppression and successful treatment outcomes among patients receiving Antiretroviral Therapy (ART). OBJECTIVE(S): Evaluate the effectiveness of mobile phone reminders and peer counseling in improving adherence and treatment outcomes among HIV positive patients on ART in Malaysia. METHODS: A single-blind, parallel group RCT conducted in Hospital Sungai Buloh, Malaysia in which 242 adult Malaysian patients were randomized to intervention or control groups. Intervention consisted of a reminder module delivered through SMS and telephone call reminders by trained research assistants for 24 consecutive weeks (starting from date of ART initiation), in addition to adherence counseling at every clinic visit. The length of intended follow up for each patient was 6 months. Data on adherence behavior of patients was collected using specialized, pre-validated Adult AIDS Clinical Trial Group (AACTG) adherence questionnaires. Data on weight, clinical symptoms, CD4 count and viral load tests were also collected. Data was analyzed using SPSS version 22 and R software. Repeated measures ANOVA, Friedman's ANOVA and Multivariate regression models were used to evaluate efficacy of the intervention. RESULTS: The response rate after 6 months follow up was 93%. There were no significant differences at baseline in gender, employment status, income distribution and residential location of respondents between the intervention and control group. After 6 months follow up, the mean adherence was significantly higher in the intervention group (95.7; 95% CI: 94.39-96.97) as compared to the control group (87.5; 95% CI: 86.14-88.81). The proportion of respondents who had Good (>95%) adherence was significantly higher in the intervention group (92.2%) compared to the control group (54.6%). A significantly lower frequency in missed appointments (14.0% vs 35.5%) (p = 0.001), lower viral load (p = 0.001), higher rise in CD4 count (p = 0.017), lower incidence of tuberculosis (p = 0.001) and OIs (p = 0.001) at 6 months follow up, was observed among patients in the intervention group. CONCLUSION: Mobile phone reminders (SMS and telephone call reminders) and peer counseling are effective in improving adherence and treatment outcomes among HIV positive patients on ART in Malaysia. These findings may be of potential benefit for collaborative adherence planning between patients and health care providers at ART commencement.