Pediatric Osteoarticular Tuberculosis as a Diagnostic Dilemma and a Review of Literature.

Introduction Despite tuberculosis being rampant in the Indian subcontinent, most cases of osteoarticular (OA) tuberculosis (TB) are missed until significant bony destruction has occurred. Initial presentation of extra-pulmonary TB mimics many other disease entities while many diseases mimic TB. This may lead to an incorrect diagnosis and sometimes creates a dilemma in reaching the correct diagnosis. The aim of this study was to evaluate a series of pediatric cases of osteoarticular TB, which posed a diagnostic challenge to us. Material and methods Retrospective analysis of case records of pediatric OA-TB patients who had presented to two tertiary level centers of urban India between February 2016 and December 2020 was done. There were a total of 69 patients.  Observations There were 37 males and 32 females. The age range was from two to 17 years. Forty-four patients showed evidence of disease within the spine (dorsal region followed by lumbar, followed by the cervical spine), 16 showed disease of the extremities, six had disease of the girdle bones, and three showed disease of the short bones of hands or foot. In our series, patients presented to us between 15 days to six months from the onset of symptoms. From our series, six cases with atypical clinical pictures have been selected for presentation purposes. In all six cases, the initial presentation was not that of OA-TB. However, with a high degree of suspicion, differential diagnosis of TB was kept in mind, and the diagnosis was confirmed microbiologically. Conclusion A high degree of suspicion is required to avoid missing the diagnosis of osteoarticular TB. Non-invasive advanced radiological investigations such as MRI and microbiological analysis of biopsy specimens aid in arriving at the correct diagnosis.

Autoimmune hemolytic anemia in children: Clinical presentation and treatment outcome.

BACKGROUND: Autoimmune hemolytic anemias (AIHA) are characterized by the destruction of red cells following the production of autoantibodies directed against them. Although AIHA in children is usually self-limiting, many still succumb to the illness due to delay in the diagnosis and treatment. AIHA in children may be secondary to autoimmune diseases, drugs, or immune deficiencies. Early diagnosis and appropriate immunohematological evaluation can aid in the diagnosis and treatment. OBJECTIVE: To analyze the evaluation, treatment, and outcome of AIHA in children. METHODS: Prospective data of patients aged 0-18 years diagnosed with AIHA between June 2017 and May 2019 were collected. INTERVENTION: Prednisolone was the first-line agent in all; second-line agents included cyclosporine and rituximab. Red cell transfusion was given in those with severe anemia with cardiac decompensation. RESULTS: Eleven patients were diagnosed during the study period. Hemoglobin ranged from 1.2 to 9 g/dl. The initial presentation was severe anemia in 8 children and moderate anemia with thrombocytopenia in 3. The trigger was infection in 5. Polyspecific direct coomb's test (DCT) was positive in 10 patients. 2/10 polyspecific DCT-positive cases on further evaluation had immunoglobulin G (IgG) and C3d positivity, whereas rest 8 had only IgG. One infant was diagnosed with DCT-negative immunoglobulin A-mediated AIHA. 4/11 attained remission following the short course of prednisolone. Cyclosporine was used as the second-line agent in 2 and rituximab was used in 3. Seven children are in sustained remission and off medication. One died within 12 h of diagnosis. CONCLUSION: AIHA is not an uncommon problem in children and can vary in its clinical severity. Early and correct diagnosis helps in deciding appropriate treatment.

Spina Ventosa: An often Missed Diagnosis.

Rare and varied presentations of tuberculosis make it difficult for treating clinicians to arrive at the diagnosis. An adolescent female presented to the orthopedic outpatient department with slowly increasing swelling over the dorsum of the hand near the base of the third digit for 5 months. With multiple consultations, she was being treated with antibiotics as a case of abscess. On examination, the swelling was soft bulging with whitish watery discharge. Plain radiography revealed periosteal elevation with bony destruction of the proximal phalanx. Magnetic resonance imaging revealed signal intensity changes with collection suggestive of infection. Blood investigations were within the normal limits, except slightly raised erythrocyte sedimentation rate. A differential diagnosis of chronic osteomyelitis was performed. Since the swelling was growing with the overlying skin likely to give way, it was treated with incision and drainage. Cytology with Gram's and auramine staining helped in confirming the diagnosis of spina ventosa. Biopsy is the gold standard for diagnosis, and antitubercular therapy forms the mainstay of treatment.

Taking on a pandemic's challenge: Emergent solutions from a single Hemophlia treatment center in North India.

INTRODUCTION: The global pandemic caused by SARS-COV-2 infection has raised several unique concerns in the bleeding disorders community. Although the risk of COVID-19 infection is not increased in patients with inherited bleeding disorders, the indirect effects of this infection are many. METHODS: A cross sectional survey was conducted among patients registered to our centre with inherited bleeding disorders. A web-based based questionnaire was developed and shared with patients and families. RESULTS: 120 patients/ families answered the questionnaire completely. During the period of lockdown, many had bleeds that were left untreated due to either difficulty in travel or unavailability of treatment. The time to treatment ranged from 8 h to 15 days in those who had a bleed. 36 % faced financial difficulties and 40 % families reported losing their job or source of income during this period. DISCUSSION: Few solutions that emerged while treating patients during this period and recommendations are discussed. Even though haemophilia has been included under the essential health services and states mandated to continue treatment for these patients despite the global crisis, patients still face challenges in terms of transport and finance.

Aplastic Anemia: Non-COVID Casualties in the COVID-19 Era.

With the emergence of COVID-19 pandemic, health care for many non-COVID illnesses has inadvertently slid back. For most patients with life-threatening illnesses, the directive from the Ministry of Health and Family Welfare to continue the treatment for essential health services has come as a relief. However, for certain life-threatening illnesses such as aplastic anemia, the situation has been grim. We discuss the poor outcome of 2 children followed up at our center for aplastic anemia and analyze the reasons for the same.

Fine-needle aspiration cytology of pilomatrixoma: A short series of three cases.

Pilomatrixoma (PMX) (pilomatricoma, calcifying epithelioma of Malherbe) is a benign tumor with differentiation toward the hair matrix cells and is common in head and neck region. It is most commonly seen in the first two decades of life and presents as a subcutaneous, small, asymptomatic firm solitary nodule. Fine-needle aspiration cytology (FNAC) has been described as an important preoperative diagnostic investigation though on cytology the diagnosis of PMX is sometimes difficult and misdiagnosed. We describe two patients with gradually increasing asymptomatic swelling on pinna and middle finger. FNAC was done and a diagnosis of PMX was given, further confirmed by histopathological examination. The present cases highlight the importance of FNAC in considering PMX as differential diagnosis of dermal or subcutaneous nodules in locations other than head and neck. Cytopathologists who play an important role in the preliminary diagnosis should keep in mind the variability of the cellular composition of these types of lesions to avoid misdiagnosis.

The Prevalence of Transfusion Transmitted Infections in ABO Blood Groups and Rh Type System.

Screening of blood and blood products is important to reduce the risk of transfusion transmitted infections (TTIs). The transfusion of unscreened or inadequately screened blood and blood products are the major source of TTIs. The aim of this paper is to find out the prevalence of TTIs in ABO blood groups and Rh type system. A total of 4128 blood donors were screened from January 2010 to April 2014. Serological tests were performed for hepatitis B surface antigen (HBsAg), anti hepatitis C virus (Anti-HCV), anti HIV-1 and 2, venereal disease research Laboratory test (VDRL) and malaria parasite (MP) antigen. In seroreactive donors, HBsAg, Anti-HCV, VDRL, MP antigen and anti HIV were positive in 40 cases, 26 cases, 19 cases, 6 cases and 2 cases, respectively. Highest percentage of HBsAg, Anti HCV, VDRL, MP antigen and anti HIV was observed in blood group A negative (2/50), O negative (1/66), B negative (1/91), AB positive (2/377) blood group respectively. In the present study, the total number of Rhnegative donors is lower when compared to Rh-positive blood donors, but Rh-negative blood donors show higher percentages of seroreactivity for TTIs. Larger scale studies at molecular level are required to improve the knowledge of this aspect.

Prophylactic antibiotics for simple hand lacerations: time for a clinical trial?

BACKGROUND: Simple hand lacerations (not involving bones, tendons, nerves, or vessels) are a common emergency department (ED) complaint. Whilst the practices of irrigation, debridement, foreign body removal, and suture repair are well accepted, the use of prophylactic antibiotics is not. Without evidenced-based guidelines, practice is left to physician preference. OBJECTIVES: The aim of this study was to assess the need for, and the feasibility to perform, a randomised controlled trial to evaluate the role of prophylactic antibiotics in simple hand lacerations. METHODS: The study was done in three phases: (1) estimation of the national ED burden of simple hand lacerations and the use of antibiotic prophylaxis; (2) assessment of indications for antibiotic prophylaxis and (3) investigation of patient willingness to enrol in a randomised controlled trial and their preferred outcomes from simple hand lacerations. For Phase 1, we analysed the 2007 National Hospital Ambulatory Medical Care Survey. For Phase 2, we surveyed ED physicians in three urban teaching institutions (two in Brooklyn, NY and one in Washington, DC). For Phase 3, we surveyed ED patients at the same three institutions. RESULTS: Phase 1: out of 116.8 million ED visits nationally in 2007, 1.8 million (1.6%) were due to simple hand lacerations, of which 1.3 million (71%) required repair. Of those repaired, 27% (95% CI, 19-35%) were prescribed prophylactic antibiotics, most commonly cephalexin (73%). Phase 2: out of 108 providers surveyed, 69 (64%) responded. 16% (95% CI, 9-27%) reported prescribing prophylactic antibiotics routinely, most commonly cephalexin (84%, 95% CI, 67-93%). The degree of contamination was the most important factor (91%, 95% CI, 82-96%) in the physicians' decision to prescribe antibiotics. Phase 3: of the 490 patients surveyed, 64% (95% CI, 60-68%) expressed interest in participating in a study to evaluate the use of prophylactic antibiotics. Their primary concern was prevention of infection (77%, 95% CI, 73-81%). CONCLUSION: Simple hand lacerations represent a substantial number of ED visits in the United States. Absence of clear guidelines, disparity in physician practice, and patient interest in infection prevention all support performing a prospective randomised controlled trial to establish the role of antibiotic prophylaxis in simple hand lacerations.

Healthcare restructuring with a view to equity and efficiency: reflections on unintended consequences.

This paper is developed from a research study that examined the hospitalization and helpseeking experiences of diverse ethnocultural populations in the era of healthcare restraint. Interview data were gathered from 60 patients while hospitalized and after their discharge home. Fifty-six healthcare professionals, the majority of whom were nurses caring for these patients while they were in hospital, were also interviewed. The data gathered in this study provides evidence to illustrate how restructuring associated with fiscal restraint designed to enhance efficiencies while ensuring the provision of medically necessary services, has had unintended consequences for some groups of patients and for nurses. These consequences have created a context for inequities in care delivery for those most vulnerable. In this paper we trace the ways in which the changed context of care delivery has exerted its effects on both nurses and patients and illustrate how each has sought to bridge gaps created when organizational supports are lacking. Our study data offer insight into the complexities of the practice setting and difficulties that arise when resources cannot be mobilized to match patients' needs. Our analysis examines how tensions between ideologies of efficiency and accessibility are navigated at the front lines, and draws attention to unintended consequences of the current policy context.