Effect of Long-term Inhaled Corticosteroids on the Hypothalamic-Pituitary-Adrenal Axis in Children with Asthma

OBJECTIVES

To assess the effect of the long-term use of inhaled corticosteroids (ICS) on the hypothalamic-pituitary-adrenal (HPA) axis.

METHODS

Children (5-18 y) diagnosed with asthma and on ICS therapy for ≥6 mo were included. In the first step, screening with fasting at 8 AM, cortisol level was measured; a value <15 mcg/dl was considered low. Children with low fasting cortisol levels were subjected to adreno-corticotropic hormone (ACTH) stimulation test in the second step. Post-ACTH stimulation, cortisol level <18 mcg/dl was considered to have HPA axis suppression.

RESULTS

A total of 78 children (males 55, 70.5%) diagnosed with asthma, with a median age of 11.5 (8, 14) y, were enrolled. The median duration of ICS use was 12 (12-24) mo. The median value of post-ACTH stimulation cortisol level was 22.5 (20.6, 25.5) mcg/dl, and a value <18 mcg/dl was observed in 4 (5.1%; 95% CI 0.2-10%) children. There was statistically no significant correlation between low post-ACTH stimulation cortisol level with ICS dose (p = 0.23) and asthma control (p = 0.67). None of the children had clinical features of adrenal insufficiency.

CONCLUSIONS

In this study, a few children had low post-ACTH stimulation cortisol values; however, none had clinical evidence of HPA axis suppression. Therefore, ICS is a safe drug in children for treating asthma, even for long-term use.

A new onset drug induced diabetes mellitus presenting with diabetic ketoacidosis in a child undergoing treatment for B cell acute lymphoblastic leukemia. A case report and review of literature

OBJECTIVES

Hyperglycemia is a known side effect of anticancer chemotherapeutic drugs. This entity known as drug-induced diabetes mellitus usually does not present with the development of diabetic ketoacidosis (DKA). We hereby report a case of drug induced diabetes mellitus in a child with acute leukemia presenting with DKA.

CASE PRESENTATION

We report a case of a teenage boy diagnosed with B cell acute lymphoblastic leukemia and was started on induction phase chemotherapy as per the Indian Collaborative Childhood Leukemia group (ICICLe) acute lymphoblastic leukemia-14 protocol. On day 12 of the induction phase, he developed hyperglycemia and presented to us with severe diabetic ketoacidosis (DKA). Serum anti glutamic acid decarboxylase 65 antibody levels were negative with low serum C peptide levels. Initially, the possibility of drug-induced acute pancreatitis was kept which was ruled out. Keeping the possibility of drug-induced hyperglycemia, the child was started on subcutaneous regular insulin which was titrated as per sugar records. Continuation of remaining chemotherapy was done by PEGylated L-asparaginase with titration of insulin as per home-based sugar records. Insulin requirement increased from 0.3 unit/kg/day to a maximum of 1 unit/kg/day during consolidation phase 1 with PEGylated L-asparaginase suggesting drug-induced hyperglycemia but subsequently insulin requirement decreased and insulin was stopped.

CONCLUSIONS

Drug induced diabetes mellitus can present as DKA during induction phase of acute lymphoblastic leukemia (ALL) chemotherapy. A high index of suspicion and close monitoring are required. The insulin requirements in these patients can be very fluctuant and may become nil during the course of treatment.

Down-Klinefelter Syndrome With Concurrent Double Aneuploidy in an Indian Child

The genetics of Down syndrome (DS) and Klinefelter syndrome (KS) are a nondisjunction of autosomal and sex chromosomes, respectively, resulting in aneuploidies. Less than 70 cases of concurrent Down-Klinefelter syndrome (DS-KS) have been reported in the literature. We report the case of a five-month-old Indian child with a rare double aneuploidy resulting in DS-KS. A five-month-old boy born to non-consanguineously married parents presented with failure to thrive and dysmorphic facies. The family history was unremarkable. On examination, he had an upward eye slant, a depressed nasal bridge, a horizontal crease in the left hand, and a sandal gap. A clinical diagnosis of the Down phenotype was considered. Karyotype analysis revealed the presence of double aneuploidy (48, XXY,+21) suggestive of DS-KS. Down-Klinefelter syndrome presents with the DS phenotype at birth, and the characteristic KS phenotype develops in early infancy and apparently manifests during puberty only. Early diagnosis is required for parental counseling and planning for future pregnancies. In children with a typical Down syndrome phenotype, chromosomal analysis is highly recommended. The diagnosis of DS-KS at the earliest has implications for these children's short-term and long-term outcomes. It helps in planning the subsequent pregnancy with appropriate genetic testing and counseling to avoid the risk of another child with trisomy.

Gap identification for improvement in maternal and early infant health care practices among tribal pregnant women in an aspirational tribal district Sirohi, Rajasthan

Background

Sirohi is one of the aspirational districts of Rajasthan which is also tribal-dominated. The maternal and early infant health indicators are worrisome compared to regional or national statistics. First-trimester registration of pregnant women is 54% in district Sirohi, which is much less as compared to registration in the state of Rajasthan (63%) and India (59%). Four antenatal care (ANC) visits of pregnant women are 32% in district Sirohi, which is also much less as compared to ANC visits in the state of Rajasthan (39%) and India (51%). However, there was no tribal-specific data regarding maternal and early infant health.

Objective

The study aims to identify gaps for improvement in maternal and early infant health care practices among tribal pregnant women in an aspirational tribal district of Sirohi, Rajasthan.

Materials and Methods

It was a cross-sectional study conducted among 560 tribal pregnant women to assess the existing maternal, and early infant health care knowledge and practices through a pre-validated questionnaire in the tribal population of district Sirohi Rajasthan.

Result

Nineteen per cent (19.5%, n = 109) of tribal pregnant women got married between the age of 10 and 17 (less than the legal age of marriage of 18 years). There is a significant relationship between early age at marriage and low educational status P < 0.001, r = 0.241 among participants. Measurement of weight, blood pressure and urine examination was done in 32.5% (n = 181), 19.5% (n = 109) and 7.1% (n = 39), respectively, among tribal pregnant women. The majority (94.6%) of the pregnant tribal women (385/407) were anaemic. Approximately 60% (n = 337) of mothers were unaware of thermal protection (skin-to-skin care). Sixty per cent (n = 334) of tribal pregnant women preferred to seek consultation regarding antenatal and infant health care from doctors, while 40.1% (n = 224) were more comfortable seeking advice from traditional birth attendants (TBAs).

Conclusion

The study finds inadequate knowledge and practice towards maternal and early infant care among tribal pregnant women. As TBAs influence tribal pregnant women, systematic training and involvement of TBAs in maternal and child health are indispensable.

Nasogastric tube insertion using conventional versus bubble technique for its confirmation in anesthetized patients: a prospective randomized study

BACKGROUND

Nasogastric tube insertion and confirmation of its position can be difficult in the anesthetized patient. The purpose of the present study was to compare the bubble technique with the conventional method for confirmation of nasogastric tube placement in these patients.

METHODS

Two hundred sixty adult patients, aged between 20...70 years, posted for surgeries requiring general anesthesia, tracheal intubation, and a nasogastric tube were enrolled in this study. Patients were randomized into 2 groups: Group B (Bubble group) and Group C (Control group). In Group C, a conventional technique using a lubricated nasogastric tube was positioned through the nostril with head remained neutral. In Group B, 2% lidocaine jelly was added to the proximal end to form a single bubble. The correct placement of the nasogastric tube in the stomach was confirmed by fluoroscopy by an independent observer intraoperatively.

RESULTS

The duration of nasogastric tube insertion was 57.2..13.3seconds in Group B and 59.8..11.9seconds in Group C (p=0.111). The confirmation rate of the bubble technique was 76.8% (95% CI: 68.7...83.3), which was significantly better than the conventional method where the confirmation rate was 59.7% (95% CI 50.9...67.9), p<0.001. When compared to fluoroscopy, bubble technique was found to have a sensitivity of 92.3% (95% CI: 85.6...96.1) with specificity of 81.0% (95% CI: 60.0...92.3), positive predictive value of 96.0% (95% CI: 90.2...98.4), and a moderate negative predictive value of 68.0% (95% CI: 48.4...82.8).

CONCLUSIONS

The bubble technique of nasogastric tube insertion has a higher confirmation rate in comparison to the conventional technique.

TRIAL REGISTRY NUMBER

Clinical Trial Registry of India (CTRI/2018/09/015864).

Congenital rubella syndrome surveillance in India, 2016-21: Analysis of five years surveillance data

Background

In India, facility-based surveillance for congenital rubella syndrome (CRS) was initiated in 2016 to estimate the burden and monitor the progress made in rubella control. We analyzed the surveillance data for 2016-2021 from 14 sentinel sites to describe the epidemiology of CRS.

Method

We analyzed the surveillance data to describe the distribution of suspected and laboratory confirmed CRS patients by time, place and person characteristics. We compared clinical signs of laboratory confirmed CRS and discarded case-patients to find independent predictors of CRS using logistic regression analysis and developed a risk prediction model.

Results

During 2016-21, surveillance sites enrolled 3940 suspected CRS case-patients (Age 3.5 months, SD: 3.5). About one-fifth (n = 813, 20.6%) were enrolled during newborn examination. Of the suspected CRS patients, 493 (12.5%) had laboratory evidence of rubella infection. The proportion of laboratory confirmed CRS cases declined from 26% in 2017 to 8.7% in 2021. Laboratory confirmed patients had higher odds of having hearing impairment (Odds ratio [OR] = 9.5, 95% confidence interval [CI]: 5.6-16.2), cataract (OR = 7.8, 95% CI: 5.4-11.2), pigmentary retinopathy (OR = 6.7, 95 CI: 3.3-13.6), structural heart defect with hearing impairment (OR = 3.8, 95% CI: 1.2-12.2) and glaucoma (OR = 3.1, 95% CI: 1.2-8.1). Nomogram, along with a web version, was developed.

Conclusions

Rubella continues to be a significant public health issue in India. The declining trend of test positivity among suspected CRS case-patients needs to be monitored through continued surveillance in these sentinel sites.

Anesthetic challenges for pheochromocytoma surgery in pediatric patients: A case series

Pheochromocytoma in children is an exceptionally uncommon cause of hypertension in this age group. These tumors pose a significant threat of adverse cardiovascular events during the perioperative phase. In this article, we describe three cases of pediatric pheochromocytoma to shed light on the difficulties associated with administering anesthesia to patients with this condition. The foundations for successful perioperative outcomes include preoperative blood pressure control, extensive intraoperative hemodynamic evaluation, and appropriate coordination with surgeons.

Is maternal anemia among tribal women being neglected? A study from Southern Rajasthan

Poor birth outcomes have been linked to maternal anemia. Tribal women are at higher risk of malnutrition and disease due to sociocultural barriers and poor educational status. The data on the prevalence of maternal anemia and its associated factors among pregnant tribal women are limited. A community-based cross-sectional study was conducted among 429 pregnant tribal women for maternal anemia from August 2021 to June 2022. A structured questionnaire was employed to collect sociodemographic data. The prevalence of anemia was 85.7%, with a mean hemoglobin level of 9.21 ± 1.3 g/dL. On applying WHO 2011 anemia criteria for pregnant women, 25.0% had mild anemia, 73.4% had moderate anemia, and 1.6% had severe anemia. The significant factors associated with anemic condition were household condition, monthly income, and husband's occupation. The higher prevalence of anemia among pregnant tribal women is alarming that necessitates a rethinking of health infrastructure and outreach in tribal dominant areas.

Medication errors in the practice of paediatric anaesthesia - a narrative review

Medication error has emerged as a significant problem in healthcare, especially in the past 2 decades. In anaesthesia, the paediatric age group is particularly at risk of such events because of complex age- and weight-based drug calculation, drug formulations, serial dilutions, and often limited staff experience in handling such patients. We searched PubMed, Cochrane, and Google Scholar for literature on medication errors in paediatric anaesthesia in children (< 18 years of age). Two authors searched for the articles independently, and a third author sorted any consensus differences. A total of 2979 articles were retrieved. We studied primary outcomes, the results, and conclusions of the various studies. A total of 21 relevant articles were selected finally. Following preventive strategies like colour coding, accurate dose calculations, verification by a second individual, and checking and encouraging self-reporting can improve perioperative safety in the paediatric population to a significant extent.

Rare Variant of PTH1R Mutation in an Indian Family

INTRODUCTION

Murk Jansen metaphyseal chondrodysplasia is an extremely rare form of skeletal dysplasia. It is caused by the mutation in PTH1R gene (1).

MATERIALS

A 13 year old boy presented with history of progressive bowing of both legs since 5 years of age. He had no history of development delay, seizures, renal stones or abdominal distension. On examination, he was having prominent upper face, prominent tip of nose, long philtrum, small mandible and severe bowing of legs with deformed knee joint. His bone mineral profile came out to be normal. His skeletal survey showed severe metaphyseal dysplasia of long bones of lower limb. His genetic testing revealed heterozygous mutation in PTH1R gene, c.1562G&gt;A variant in exon 16. On extended evaluation, his father and paternal grandmother were also having similar phenotype, however not as severely affected as the index case.

RESULT

Murk Jansen metaphyseal chondrodysplasia is characterized by severe short stature, short bowed limbs, clinodactyly and dysmorphic facies with metabolic derangement of hypercalcemia and hypophosphatemia (2). The variant present in our patient has not been reported anywhere yet, hence revealing a new molecular mechanism to an already known rare disease.

CONCLUSION

Molecular diagnosis of skeletal dysplasia is of paramount importance as they are a clinically heterogenous group with varied presentation with non-specific radiological findings, however with different treatment and prognostic implications. References Nampoothiri S, Fernández-Rebollo E, Yesodharan D, et al. Jansen metaphyseal chondrodysplasia due to heterozygous H223R PTH1R mutations with or without overt hypercalcemia. J Clin Endocrinol Metab 2016;101(11):4283-4289. Schipani E, Langman CB, Parfitt AM, et al. Constitutively activated receptors for parathyroid hormone and parathyroid hormone- related peptide in Jansen's metaphyseal chondrodysplasia. N Engl J Med 1996;335(10):708-714.

Epidemiology, etiology and clinical associations of congenital heart disease identified during congenital rubella syndrome surveillance

BACKGROUND

Congenital heart disease (CHD) is a common congenital malformation. Antenatal rubella infection in the mother and genetic defects are important causes to which CHD are attributed. Exact contribution of antenatal rubella infection or genetic causes to CHD is still unknown.

OBJECTIVE

To study the epidemiology, etiology and clinical associations of echocardiographically confirmed congenital heart disease in infants in Western Rajasthan enrolled in the congenital rubella syndrome (CRS) surveillance project. To study the utility of clinical diagnostic criteria in identifying congenital rubella infection.

METHOD

This was a prospective observational study, in which 251 patients with echocardiographically confirmed CHD were enrolled. Detailed clinical evaluation was done in all patients. Rubella serology was done in all patients. Genetic and other testing was done as appropriate.

RESULT

The hospital-based prevalence of CHD in infants was 1% at our center. Fifty-seven percent of the babies had acyanotic septal heart defects of which ventricular septal defect (VSD) was the most common (35%). Anti-rubella immunoglobulin M (IgM) antibodies were positive in 8.5% of the CHD patients. A clinically identifiable genetic cause was present in 3.6% of the cases. In patients who tested positive for anti-rubella IgM antibodies also, VSD was the most common (33%) CHD followed by Tetralogy of Fallot (13.2%).

CONCLUSION

CRS contributes to 8.5% of CHD. CRS is associated with a wide spectrum of CHD. The etiology of a large number of CHD remains elusive. Detailed studies on the cause and mechanism of development of CHD need to be undertaken.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Thyroid Storm in an Adolescent Girl Precipitated by Empyema Thoracis

Thyroid storm is a rare, life-threatening condition in children. We report the case of a 16-year-old girl who presented with fever, cough, chest pain, and breathing difficulty. On the initial evaluation, a working diagnosis of left-sided pneumonia with empyema was made. She also had persistent tachycardia which was out of proportion to fever, and a staring look. She was found to have a thyroid storm. Timely diagnosis and appropriate management of thyroid storm proved to be lifesaving.

Guardian-Reported Impact of the COVID-19 Pandemic on the Lifestyle of Children with Diabetes Mellitus

INTRODUCTION

The coronavirus disease-2019 (COVID-19) pandemic has had an unprecedented impact on the lives and lifestyles of people of all ages worldwide. Lifestyle has an essential role in the management of diabetes mellitus in children.

METHODS

The study was carried out at a tertiary care centre in India. A telehealth survey was conducted among the parents/guardians of children with diabetes to study the impact of the COVID-19 pandemic. The survey evaluated the effects on lifestyle, diabetes management and challenges in connecting to a new telemedicine programme.

RESULTS

The survey was completed by guardians of 91 patients. The mean age of the patients was 13.0 ± 3.8 years in boys and 11.9 ± 4.5 years in girls. Fifty-seven per cent of them were boys, and 63.7% stayed in rural areas. The pandemic has resulted in a significant increase in screen time and sleep duration. The median non-educational screen time has gone up from 1.00 (0.5-2.0) to 2.50 (1.0-4.0) h. The mean sleep duration in children increased from 9.1 ± 1.4 to 9.7 ± 1.4 h. Telemedicine services have been established with minimum resources, but they have limitations, and awareness about them is also limited.

CONCLUSION

The COVID-19 pandemic has made the lifestyle of children with diabetes more sedentary. Some of them have also faced challenges with regard to diabetes-related supplies and management. It would be fair to anticipate more complications related to this sedentary lifestyle in the future and work towards identifying and treating them.

A Case of Neonatal Diabetes Mellitus Due to INS Gene Mutation with Maternal Mosaicism and Atypical Presentation

Neonatal diabetes mellitus is a single gene defect that results in diabetes mellitus in the first 6 months of life. We report a child who was diagnosed to be hyperglycemic at 13 months of life and assumed to have type 1 diabetes mellitus and started on insulin. The child came to us at 2 and 1/2 years of age. He had exceptionally good blood glucose control. His history revealed that he was symptomatic with a voracious appetite and poor weight gain since the second half of infancy. Genetic testing revealed a heterozygous mutation of the INS gene (the gene that codes for insulin). The condition has autosomal dominant inheritance. Testing the parents revealed that the mother had 7.8% mosaicism for this variant in her lymphocyte DNA. Though this did not alter the management of the patient, it did help in counseling the parents regarding risk of recurrence in future pregnancies.

Children and COVID19: Understanding impact on the growth trajectory of an evolving generation

The COVID19 pandemic has forced the world to be closed in a shell. It has affected large population worldwide, but studies regarding its effect on children very limited. The majority of the children, who may not be able to grasp the entire emergency, are at a bigger risk with other problems lurking behind the attack of SARS-CoV-2 virus. The risk of infection in children was 1.3%, 1.5%, and 1.7% of total confirmed COVID-19 cases in China, Italy and United States respectively which is less compared to 2003 epidemic of severe acute respiratory syndrome (SARS), when 5-7% of the positive cases were children, with no deaths reported while another recent multinational multicentric study from Europe which included 582 PCR (polymerase chain reaction) confirmed children of 0-18 year of age, provide deeper and generalize incite about clinical effects of COVID19 infection in children. According to this study 25% children have some pre-existing illness and 8% required ICU (intensive care unit) admission with 0.69% case fatality among all infected children. Common risk factor for serious illness as per this study are younger age, male sex and pre-existing underlying chronic medical condition. However, we need to be more concerned about possible implications of indirect and parallel psychosocial and mental health damage due to closure of schools, being in confinement and lack of peer interaction due to COVID19 related lockdown and other containment measures. The effects can range from mood swings, depression, anxiety symptoms to Post Traumatic Stress Disorder, while no meaningful impact on COVID19 related mortality reduction is evident with school closure measures. The objective of this paper is to look at both the positive & negative effects in children due to COVID19 related indirect effects following lockdown and other containment measures. There is a need to gear up in advance with psychological strategies to deal with it post the pandemic by involving all stakeholders (parents, teachers, paediatricians, psychologists, psychiatrists, psychiatric social workers, counsellors), proposing an integrated approach to help the children to overcome the pandemic aftermath.

Disseminated tuberculosis in children-a difficult diagnose depends on how far we can go

Tuberculosis (TB) is an important public health problem in developing countries. In India, despite substantial efforts targeting TB and its associated risk factors, the number of cases remains high with 2.7 million new cases per year with a minimum 10% case contributed by paediatric TB. Disseminated TB has been increasingly recognised in children in recent times due to the increased prevalence of immune suppression secondary to AIDS and immunosuppressive therapies for various medical disorders and increasing awareness. Here we describe a 5-year-old girl who presented with fever of unknown cause, and her diagnosis of disseminated TB was delayed due to atypical presentation and the paucibacillary nature of paediatric TB. It was a bone marrow examination report which led us to clinch the diagnosis. The case highlights the difficulty in diagnosing disseminated TB and the importance of bone marrow examination in such cases.

Epicardial adipose tissue CD4+ T cells as novel drivers in the development of atrial fibrillation

Background

Epicardial adipose tissue (EAT) is now a well-established independent risk factor for all forms of atrial fibrillation (AF). However, the cellular profile and immune mediators within EAT remain poorly defined.

Purpose

This study sought to define the immunological signature of EAT critical to its role in the development of both persistent AF and de novo post-operative AF (POAF).

Methods

Adult patients undergoing elective cardiac surgery with no prior AF history and those with pre-existing AF were recruited to undergo EAT sampling alongside subcutaneous adipose tissue (SAT) and pre-operative blood (adipose tissue and systemic controls respectively) sampling. The blood and tissue samples were immediately taken to the laboratory for immune cell isolation, flow cytometry and quantitative polymerase chain reaction (qPCR) analysis.

Results

A total of 71 patients were recruited including 9 patients with a prior history of AF. Of the 62 a priori sinus rhythm (SR) patients, 42 remained in SR post-operatively and 20 developed de novo POAF. No differences in absolute numbers of immune cells in the blood, EAT or SAT were detected on flow cytometry analysis between the three groups of patients. However, there was a significant increase (p&lt;0.01) in EAT-resident CD4+ memory T cell populations in pre-existing AF patients and a trend towards significance (p=0.09) in POAF patients. qPCR analysis of immune mediator expression in EAT demonstrated pre-existing AF patients uniquely showed a significant reduction (p&lt;0.005) in the pro-fibrotic mediator transforming growth factor-β (TGF-β) compared to the pre-existing AF patients (graph 1).

Conclusions and implications

Resident CD4+ memory T cell populations are locally and exclusively elevated in the EAT of pre-existing AF and POAF patients. This would suggest primed antigen-specific CD4+ T cells are present prior to the development of AF in patients who go on to develop de novo POAF. The reduced TGF-β levels observed in the EAT of AF patients indicates the EAT immune mediator profile differs to the underlying myocardial tissue, where increased TGF-β levels have previously been described in the persistent AF cohort. Therapies targeting this EAT-resident CD4+ T cell population would provide a novel approach to the management of the inflammatory components of AF genesis.

Graph 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Barts Charity, Abbott

Clonidine and Morphine as Adjuvants for Caudal Anaesthesia in Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Objective

The aim of this systematic review and meta-analysis is to compare the outcomes of morphine vs. clonidine use as adjuvants in caudal anaesthesia. We are specifically focused on analgesic and side effect profiles.

Methods

We searched databases and trial registration sites and include here randomised controlled trials that compare the analgesic effects of caudal clonidine vs. morphine as adjuvants on postoperative pain. The risk ratio for evaluating pain scores, the need for rescue analgesia and all adverse effects were assessed. The i2 statistic was used to assess heterogeneity. We also assessed risk of bias with Cochrane’s Collaboration tool. The quality of evidence was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results

Four randomised controlled trials (including 166 patients) that evaluated the use of clonidine vs. morphine as adjuvants in caudal block were included in this systematic review and meta-analysis. The pooled estimate for postoperative analgesia revealed no statistically significant differences between the clonidine group compared to morphine group (MD=2.90; 95% CI 4.05 to 9.85; i2 93%). Significantly less postoperative nausea and vomiting were reported among the patients that received clonidine vs. those that were treated with morphine (RR 0.57, 95% CI −0.36 to −0.90, i2 26%). There were no statistically significant differences between the two groups in assessments that included urinary retention, pain scores or need for rescue analgesia at 24 hours.

Conclusion

Clonidine is just as effective as morphine when used an adjuvant to local anaesthetic for caudal block, and has a more desirable side effect profile, particularly with respect to postoperative nausea and vomiting.

Atypical Presentation of Crimean-Congo Hemorrhagic Fever as Ascending Paralysis with Rhabdomyolysis

Crimean–Congo hemorrhagic fever (CCHF) is a tick-borne disease caused by a arbovirus. It is asymptomatic in infected animals but a serious threat to the health of individuals. In human, it starts with nonspecific febrile diseases and progresses into severe hemorrhagic syndrome with high-casual fatality. Here, we report a case of CCHF with atypical presentation of ascending paralysis and rhabdomyolysis.

The Effect of Transversus Abdominis Plane Block for Analgesia in Patients Undergoing Liver Transplantation: A Systematic Review and Meta-Analysis

Objective

Ultrasound-guided regional anaesthesia using transversus abdominis plane (TAP) block is a newer and safer method that can be used in patients undergoing liver transplant surgeries. This systematic review and meta-analysis was done to quantify the analgesic potential and opioid-sparing capability of TAP block in these patients.

Methods

The studies comparing TAP-block to conventional analgesic regimens for liver transplant were searched. The studies evaluating the comparative 24-h morphine consumption during postoperative period in patients undergoing liver transplant surgeries were searched and included as the primary outcome in the analysis.

Results

We found two randomised controlled trials and two retrospective studies that on meta-analysis showed that TAP block group had significantly lower requirement of morphine (WMD=27.59 mg; 95% CI: 33.47-21.70) at 24 h for pain mitigation. Also, postoperative nausea and vomiting was lower (RR=0.76; 95% CI: 0.47-1.22) but not statistically significant.

Conclusion

Ultrasound-guided TAP block provides postoperative analgesic efficacy in patients undergoing liver transplant surgeries. This study was registered in International prospective register of systematic reviews [PROSPERO: CRD42018094595].

Preoperative Glycated Haemoglobin Level and Postoperative Morbidity and Mortality in Patients Scheduled for Liver Transplant

BACKGROUND

There is high prevalence of diabetes mellitus in patients of end stage liver disease and it has been implicated for complications in post-transplant patients. Glycated hemoglobin is now targeted as a modifiable preoperative risk factors for postoperative complications. Data describing the course and severity of postoperative liver transplant complication and their relation with pre-operative glycated hemoglobin level is sparse. In this study, we looked for co-relation between the preoperative HbA1c level and post-operative mortality and morbidity in patients scheduled for liver transplant.

MATERIALS AND METHODS

Retrospective data in 400 adult patients operated for liver transplant were retrieved. After exclusion, data were analyzed for 224 patients. Patients were divided into two groups on the basis of glycated hemoglobin levels (Group 1 (HbA1C ≥6.5) and Group 2 (HbA1C <6.5)).

RESULTS

Glycated hemoglobin levels were not associated with postoperative death during stay in intensive care unit, incidence of postoperative cardiovascular, renal, and central nervous complications. No difference was seen between 2 groups for need for renal replacement therapy, incidence of infections, rejection, need for re-exploration surgery and duration of intensive care unit and hospital stay. Glycated hemoglobin cannot predict 30 day survival (Area under curve {AUC} = 0.629, P value 0.05).

CONCLUSION

Preoperative glycated hemoglobin level is not associated with postoperative morbidity and mortality in patients scheduled for liver transplant.

TRIAL REGISTRATION NUMBER

CTRI/2018/04/012966.

Should We Use DSI or not-What does the PADIS 2018 Guidelines Recommend?

How to cite this article: Sharma A, Bhatia P, Vyas V. Should We Use DSI or not—What does the PADIS 2018 Guidelines Recommend? Indian J Crit Care Med 2019;23(10):491.

Use of ultrasound-guided preoperative diaphragmatic thickness as a predictor of postoperative weaning failure in recipients and donors scheduled for living donor liver transplant surgery

Background and Objectives:

The present study was designed to explore the utility of ultrasound-guided diaphragmatic thickness in the preoperative period in healthy controls scheduled for live-related donor hepatectomy and patients suffering from chronic liver disease scheduled for liver transplantation (LT) and its use as a predictor of postoperative weaning failure.

Materials and Methods:

This prospective observational study was conducted in a tertiary health care center and 65 adult (18–70 years) participants (30 healthy liver donors and 35 liver transplant recipients) were enrolled for this study. Right diaphragmatic thickness of both donors and recipients was measured by B-mode ultrasound using a 10 MHz linear array transducer in the supine position in the operation theater just before induction of anesthesia. For subgroup analysis of the recipients, we further divided them into two groups – Group 1 (diaphragmatic thickness < 2 mm) and Group 2 (diaphragmatic thickness > 2 mm), and comparison was done for duration of mechanical ventilation. Intergroup comparison was made for duration of mechanical ventilation and various other parameters.

Results:

The sonographic measurement of diaphragm revealed that its thickness is decreased in patients with chronic liver disease patients (2.12 ± 0.54 mm) as compared to healthy donors (3.70 ± 0. 58 mm). On multiple logistic regression, higher duration of mechanical ventilation was associated with diaphragmatic thickness < 2 mm (Group 1 of recipients) (adjusted odds ratio 0.86; 95% confidence interval: 0.75–0.99; P = 0.013) after adjusting for age, gender, and body mass index.

Conclusions:

Diaphragmatic thickness is decreased in patients with chronic liver disease as compared to healthy liver donors. Preoperative measurement of ultrasound-guided right hemidiaphragm thickness can be used to predict weaning failure in patients undergoing LT. Other studies are needed to confirm these finding on different group of patients.

Growth Hormone Deficiency in Children: From Suspecting to Diagnosing

Isolated Growth hormone deficiency is an important and treatable cause of short stature. However, it is often difficult to diagnose the condition with certainty due to the lack of a single robust diagnostic test. Short children, other than those with the classical phenotype of immature chubby facies, truncal obesity and micropenis in boys, or those with history of cranial lesions with known association with hypopituitarism, should be evaluated for growth hormone deficiency only after excluding the other more common conditions. These children typically have height markedly below that expected for their midparental height with low height velocity and delayed bone age. Growth hormone levels should be checked by provocative testing, after ensuring that the child is euthyroid, and after priming with sex steroids if indicated. Low levels of Insulin-like growth factor 1 and Insulin-like growth factor binding protein 3 and pituitary abnormalities on neuroimaging provide important corroborative evidence to the diagnosis.

Three's a Crowd - An Extremely Rare Case of Cor Triatriatum Dexter

INTRODUCTION

Cor triatriatum is a congenital cardiac anomaly in which the left (sinister) or right (dexter) atrium is divided into two compartments by residual embryonic tissue, resulting in a tri-atrial heart. As cor triatriatum dextrum can present clinically in various ways and have multiple associated cardiac anomalies, this report attempts to contribute to what is known about this exceedingly rare disorder.

CASE

A 40 year old Hispanic man with a medical history of gastritis presented with complaints of palpitations, dizziness and bilateral lower extremity edema. He was found to have atrial fibrillation and new onset heart failure. The patient was admitted for rate control and further evaluation, which revealed several cardiac anomalies. Initial 2D echocardiography demonstrated severe right atrial enlargement, right ventricular hypertrophy and an engorged coronary sinus, which prompted further assessment of the patient's cardiovascular anatomy. Transesophageal echocardiography (TEE) revealed a severely enlarged, septated right atrium with a possible unroofed coronary sinus and a small patent foramen ovale (PFO). Left- and right-heart catheterization established a coronary-cameral fistula between the right coronary artery (RCA) and right atrium, as well as left-to-right shunt. The patient improved clinically with conservative management including diet modification, furosemide and digoxin for fluid and rate control, and was referred to cardiothoracic surgery for further evaluation.

DISCUSSION

Cor triatriatum dextrum is an extremely rare cardiac condition: In high-volume echocardiographic laboratories, prevalence is less than 0.01 percent. This case highlights the association between cor triatriatum and other congenital cardiac anomalies, including persistent left superior vena cava with an unroofed coronary sinus, PFO and left-to-right shunt; all of which were found in this patient. While cases of cor-triatriatum sinistrum often require correction in infancy (due to left sided heart failure, pulmonary edema and cyanosis), cor-triatriatum dextrum is sometimes diagnosed in adulthood due to the lack of left heart and pulmonary involvement.

FOOD FOR THOUGHT: MITRAL STENOSIS WITH A SIDE OF MAC AND CHEESE

Caseous mitral annular calcification (CMAC) is a rare variant of mitral annular calcification (MAC), most commonly seen in elderly women on the posterior mitral annulus. CMAC is usually diagnosed incidentally and has a benign course. However, it may cause abnormal blood flow across the mitral valve resulting in mitral regurgitation, and rarely, functional mitral stenosis. MAC occurs in 10 percent of the population, while CMAC occurs in 0.06 percent. Most cases of CMAC are misdiagnosed as other intracardiac masses, such as tumors, abscesses, thrombi, and vegetation.

Surgical ward rounds: a missed opportunity for multidisciplinary working?

While guidelines have been established for doctors’ and nurses’ ward rounds, there is no protocol in place for surgeons.