N-Terminal Pro-B-Type Natriuretic Peptide as a Marker of Severity of Heart Failure in Children with Congenital Heart Diseases.

N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been used as a tool for diagnosis, severity assessment and prognostication of congestive heart failure (CHF) in adults, with specific cut off values for diagnosis and denoting points of intervention. However, there is scarcity of paediatric literature regarding role of NT-proBNP as a marker of heart failure severity and prognostication. So, this study was done to assess the utility of NT-proBNP as a marker of severity of heart failure in children with congenital heart diseases. Single centre, prospective observational study. Children (1 month to 5 years), with congenital heart disease, admitted in the paediatric wards with varying severity of CHF were enrolled. Heart failure severity grading was done according to Laer modification of Ross Classification at the time of presentation to hospital and children were classified as having no/grade I CHF (score: 0-2); mild/grade II CHF (score 3-6); moderate/grade III CHF (score 7-9) or severe/grade IV CHF (score 10-12). NT-proBNP levels were measured within 24 h of admission. Eighty children with congenital heart disease were enrolled in this study. As per modified Ross Classification, 11 had grade I/No heart failure (13.7%), 32 children had grade II/mild heart failure (40%), 36 had grade III/moderate heart failure (45%) and only 1 had grade IV/severe heart failure (1.25%). The median NT-proBNP levels (IQR) in the above mentioned grades of heart failure were found to be 321.11 (211.1-411.78 pg/ml), 750.62 (474.62-995.2 pg/ml), 4159.61 (1440.59-11,857 pg/ml) and 11,320.34 pg/ml, respectively. Seven children (8.75%) expired. Median NT-proBNP value in seven children who died was significantly higher than those who survived [median (IQR): 11,681.01 pg/ml (10,092.72-14,754 pg/ml) vs 839.4 pg/ml (456.67-3288.09 pg/ml), p value < 0.001]. NT-proBNP level of 520.2 pg/ml predicted grade II (mild heart failure) or more severe grades of heart failure with Sensitivity, Specificity, Negative Predictive Value and Positive Predictive Value of 83%, 91%, 57.1% and 98%, respectively. NT-proBNP levels increase progressively with increasing severity of CHF and can be used as a marker of severity of heart failure in children with congenital heart disease presenting with CHF.

Evidence-Based Guidelines for the Management of Allergic Bronchopulmonary Aspergillosis (ABPA) in Children and Adolescents with Asthma.

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) frequently complicates asthma. There is urgent need to develop evidence-based guidelines for the management of ABPA in children. The Evidence Based Guideline Development Group (EBGDG) of the Indian Academy of Pediatrics (IAP) National Respiratory Chapter (NRC) addressed this need. METHODS: The EBGDG shortlisted clinical questions relevant to the management of ABPA in asthma. For each question, the EBGDG undertook a systematic, step-wise evidence search for existing guidelines, followed by systematic reviews, followed by primary research studies. The evidence was collated, critically appraised, and synthesized. The EBGDG worked through the Evidence to Decision (EtD) framework, to formulate recommendations, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Seven clinical questions were prioritized, and the following recommendations formulated. (1) Children with poorly controlled asthma should be investigated for ABPA (conditional recommendation, moderate certainty of evidence). (2) Low dose steroid therapy regimen (0.5 mg/kg/d for the first 2 wk, followed by a progressive tapering) is preferable to higher dose regimens (conditional recommendation, very low certainty of evidence). (3) Oral steroid regimens longer than 16 wk (including tapering), should not be used (conditional recommendation, very low certainty of evidence). (4) Antifungals may or may not be added to steroid therapy as the evidence was neither in favour nor against (conditional recommendation, low certainty of evidence). (5) For clinicians using antifungal agents, the EBGDG recommends against using voriconazole instead of itraconazole (conditional recommendation, very low certainty of evidence). (6) No evidence-based recommendation could be framed for using pulse steroid therapy in preference to conventional steroid therapy. (7) Immunotherapy with biologicals including omalizumab or dupilumab is not recommended (conditional recommendation, very low certainty of evidence). CONCLUSIONS: This evidence-based guideline can be used by healthcare providers in diverse clinical settings.

Internet of Things-Based Optimized Routing and Big Data Gathering System for Landslide Detection.

An exponential progression in the miniaturization of communicating devices has proliferated the generation of a large volume of data termed as "big data." The technological advancements in the micro-electro/mechanical system has made it possible to design the low-cost, low-power consuming artificial intelligence (AI)-based wireless sensor nodes to gather the big data belonging to various attributes from their surroundings. These nodes help in the early detection and prediction for the occurrence of landslides, which are among the catastrophic hazards. A profusion of research has focused on exploiting the potential of sensors for continuous monitoring and detecting the landslides at the earliest. However, the limited energy resources of sensor nodes give rise to the huge challenge for the network longevity pertaining to landslide detection. To address this concern, in this article, we propose an optimized routing and big data gathering system for landslide detection using (AI)-based wireless sensor network (WSN) (ORLAW). Since we propose a distributed routing mechanism, AI has a major role to play in the intelligent detection of landslides that too without the intervention of an external entity. We use the Dynamic Salp Swarm Algorithm for the cluster head selection in ORLAW. Two data collecting sinks are deployed on the opposite sides of the network, which is assumed to be a mountainous area. It is discerned from the simulation examination that ORLAW elongates the reliability period by 23.9% compared with the recently proposed cluster-based intelligent routing protocol, and also outperforms many others in the perspective of energy efficient management of big data.

Revisiting the Perfluorinated Trityl Cation.

Although ultimately not isolable for X-ray structural characterization, the free perfluorinated trityl cation was shown to be observable in neat triflic acid, which represents milder conditions than previous reports of this cation in "magic acid" or oleum. A triflate-bound species could be generated in organic solvents using stoichiometric amounts of triflic acid and was shown to be synthetically viable for hydride abstraction from Et3 SiH. It was demonstrated that the para-position on the -C6 F5 rings is the primary point of attack for decomposition of the cation.

Asthma and Medicines - Long-Term Side-Effects, Monitoring and Dose Titration.

Asthma is a major pediatric respiratory morbidity requiring long-term management. A thorough knowledge of long-term medication side-effects in children is, thus, essential for every physician dealing with childhood asthma. Establishing diagnosis and initiating treatment is just a beginning of the journey. Ongoing monitoring is an essential component of comprehensive asthma management programme. Monitoring includes not only assessment of asthma control but also checking for adherence to treatment, technique of inhaler device use, associated co-morbities, if any, and potential environmental exposure. Various tools - both subjective and objective - are available for assessment of asthma control. However, evidence for their optimum use in different settings and patient groups is lacking and monitoring has to be customized depending on available resources and individual patient characteristics. Patient education is an important component of long-term asthma therapy. The ultimate aim is to achieve optimum asthma control i.e., achieve and maintain control of clinical symptoms, decrease future risk to patients (risk of exacerbations, progressive loss of lung function and development of fixed airflow obstruction, adverse effects of medications) and enabling the child to lead a life without restrictions, at lowest possible dose of drugs. This article reviews the side-effects of medications used for long-term management of asthma and discusses current literature on asthma monitoring and dose titration in pediatric population to help the asthma therapist not only prescribe the drugs rationally but also help the family make right choices for treatment.

Ophelia syndrome: Hodgkin lymphoma with limbic encephalitis.

BACKGROUND: Limbic encephalitis, an immune-mediated encephalitis, results from inflammation in the medial temporal lobes. The paraneoplastic form is rare in pediatric population, and frequently precedes tumor diagnosis. CASE CHARACTERISTICS: A 9-year-old boy receiving chemotherapy for Hodgkin lymphoma, developed headache, temporal lobe seizures, anxiety, hallucinations, short-term memory loss and autonomic disturbances. Magnetic resonance imaging of brain showed features suggestive of limbic encephalitis. Electro-encephalography showed diffuse slowing with no epileptiform discharges. OUTCOME: We diagnosed paraneoplastic form of limbic encephalitis. Treatment with steroids and intravenous immunoglobulin failed, and the child died 4 weeks after onset of symptoms. MESSAGE: Limbic encephalitis should be kept as differential diagnosis in a child with sub-acutely evolving neuropsychiatric symptoms.

Anti-N-methyl-D-aspartate receptor encephalitis: A case report and review of the literature.

Anti-N-methyl-D-aspartate receptor encephalitis is a well characterized immune-mediated encephalitis. It is increasingly being recognized as one of the common causes of encephalitis, but is frequently misdiagnosed especially in resource-constrained settings. With a simple test available to diagnose the disorder and prospects of good recovery following early immunotherapy, the disorder should be kept as a differential diagnosis in patients presenting with unexplained behavioral/psychiatric symptoms and progressive encephalopathy with movement disorders.

Post-traumatic Headache: An Uncommon but Treatable Entity.

Post-traumatic headache is a recognized sequel of all types of head injuries and reported in up to 6.8% of children with head-injuries. Two varieties, acute (resolving within 3 months) and persistent have been described. We report three cases and discuss pertinent issues for the clinicians.

Neurological Wilson's disease with refractory rickets.

Wilson's disease rarely presents with isolated neurological complaints without any hepatic involvement. Refractory rickets with Wilson's disease has been infrequently reported in literature. We are reporting a case of isolated neurological Wilson's disease associated with refractory rickets which on complete evaluation was diagnosed as familial hypophosphatemic rickets.

Validation of IMNCI algorithm for young infants (0-2 months) in India.

OBJECTIVE: To check the validity of Integrated Management of Neonatal and Childhood Illness (IMNCI) algorithm for young infants (0-2 months). DESIGN: Prospective observational study. SETTING: The outpatient department and emergency room of a medical college attached hospital. METHODS: 419 infants (176 between 0-7 days, 243 between 7 days to 2 months) underwent a detailed diagnostic assessment and treatment as per the standard protocol of treating unit. These infants also underwent assessment, classification and identification of treatment as per IMNCI algorithm. The diagnostic and therapeutic agreement between standard protocol and IMNCI was computed to assess the validity of IMNCI algorithm. RESULTS: The IMNCI algorithm performed well in identifying sick young infants with sensitivity of 97%, 94% and 95%, and specificity of 85%, 87% and 87% in 0-7 days, 7 days to 2 months and 0-2 months age groups, respectively. The algorithm covered majority (80%) of recorded diagnoses, and could identify bacterial infection with 88.5% sensitivity and 57.4% specificity. Complete diagnostic agreement with gold standard was seen in 50%; overdiagnosis and under diagnosis was seen in 13% and 19%, respectively. Low birthweight and upper respiratory infection were the main reasons for overdiagnosis whereas surgical conditions resulted in under diagnoses in majority. CONCLUSION: IMNCI algorithm for evaluation and management of young infants has good sensitivity and specificity for referring cases with severe illness.

Multi-drug resistant childhood tuberculosis.

Emergence of drug resistant tuberculosis is one of the major challenges faced by health community globally. Tuberculosis is an important cause of morbidity and mortality among children in endemic areas, yet little is known regarding epidemiology of pediatric tuberculosis and even far lesser information is available about epidemiology, diagnosis, management and treatment outcome of drug resistant tuberculosis in children. Despite limited data and difficulties in its management, drug resistant tuberculosis can be successfully treated even in resource poor settings with proper use of existing technologies. A high index of suspicion and early drug susceptibility testing is the key to early diagnosis and good treatment outcome. Difficulties in establishing the diagnosis, drug toxicities and absence of pediatric formulations add challenges to the management of Pediatric MDR TB Cases. Active research is required to answer the unresolved issues of finding optimal diagnostic tools, treatment regimens and duration and chemoprophylaxis in pediatric drug resistant tuberculosis.

Cumulative cardiac toxicity of sodium stibogluconate and amphotericin B in treatment of kala-azar.

Kala-azar or visceral leishmaniasis is a disseminated protozoal infection caused by parasites of the genus Leishmania (Leishmania donovani in India). Conventional therapy for visceral leishmaniasis continues to be pentavalent antimony (sodium antimony gluconate [SAG]). Amphotericin B is widely used for SAG-unresponsive cases and sometimes even as a first-line drug, especially in endemic areas. With the conventional regimen of SAG, cardiac toxicity has been reported in 8% to 17% of cases with 5% to 7% of them having fatal toxicity. Cardiac toxicity is uncommon with amphotericin B with only few isolated reports. We report some patients with kala-azar in whom coadministration of SAG and amphotericin B led to arrhythmia and sudden death.

Unifocal Granuloma of Femur due to Langerhans' Cell Histiocytosis: A Case Report and Review of the Literature.

The radiological diagnosis of osteolytic lesions of the long bones in pediatric population constitutes a challenge when the case history and clinical data are uncharacteristic. We believe that the description of few clinically and histologically proven cases to verify the existence of radiological signs useful for diagnosis may be of interest. Here, we describe a case of Langerhans' cell histiocytosis (LCH) presenting as unifocal eosinophilic granuloma of femur along with a brief review of the literature.