Publications in paediatric critical care medicine: Trends from Pakistan

Objective

To analyse the characteristics of research published from Pakistan on paediatric critical care medicine.

METHODS

The exploratory study was conducted at the Aga Khan University, Karachi from July 2021 to March 2022, and comprised a comprehensive search on MedLine, Google Scholar and PakMediNet databases for literature from Pakistan pertaining to paediatric critical care medicine published between January 2010 and December 2021. The search was done using appropriate key words. Conference abstracts and papers authored by paediatric intensivists with unrelated topics were excluded. Data was extracted on a structured spreadsheet, and was subjected to bibliometric analysis. Data was analysed using SPSS 20.

RESULTS

Of the 7,514 studies identified, 146(1.94%) were analysed. These were published in 51 journals with a frequency of 13.3 per year. There were 107(73.3%) original articles, 96(65.8%) were published in PubMed-indexed journals, and 35(24%) were published in locally indexed journals. Further, 100(69.4%) papers were published from 5 paediatric intensive care units in Karachi, and 81(56%) were contributed by a single private-sector hospital. The total citation count was 1072, with 2(1.4%) papers receiving >50 citations. There was a linear trend with some skewing and an annual growth rate of >15%.

Conclusion

Publications from Pakistan related to paediatric critical care medicine showed positive linear growth. There was a paucity of multicentre studies, randomised controlled trials, and high-impact publications.

Pneumonia classification: A limited data approach for global understanding

As the human race has advanced, so too have the ailments that afflict it. Diseases such as pneumonia, once considered to be basic flu or allergies, have evolved into more severe forms, including SARs and COVID-19, presenting significant risks to people worldwide. In our study, we focused on categorizing pneumonia-related inflammation in chest X-rays (CXR) using a relatively small dataset. Our approach was to encompass a comprehensive view, addressing every potential area of inflammation in the CXR. We employed enhanced class activation maps (mCAM) to meet the clinical criteria for classification rationale. Our model incorporates capsule network clusters (CNsC), which aids in learning different aspects such as geometry, orientation, and position of the inflammation seen in the CXR. Our Capsule Network Clusters (CNsC) rapidly interpret various perspectives in a single CXR without needing image augmentation, a common necessity in existing detection models. This approach significantly cuts down on training and evaluation durations. We conducted thorough testing using the RSNA pneumonia dataset of CXR images, achieving accuracy and recall rates as high as 98.3% and 99.5% in our conclusive tests. Additionally, we observed encouraging outcomes when applying our trained model to standard X-ray images obtained from medical clinics.

Evaluation of the Resources and Inequities Among Pediatric Critical Care Facilities in Pakistan

OBJECTIVES

To evaluate nationwide pediatric critical care facilities and resources in Pakistan.

DESIGN

Cross-sectional observational study.

SETTING

Accredited pediatric training facilities in Pakistan.

PATIENTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring.

CONCLUSIONS

There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure.

Red blood cell transfusion in critically-ill children and its association with outcome

OBJECTIVE

To determine the indications and threshold of haemoglobin levels for packed red blood cell transfusion and its association with outcomes in a paediatric intensive care setting.

METHODS

The retrospective study was conducted in the paediatric intensive care unit of the Aga Khan University Hospital, Karachi, and comprised medical records of all inpatients with age between 1 month and 16 years who received packed red blood cell transfusions between January and December 2017. Data was retrieved from the hospital database and was analyzed using SPSS 22.

RESULTS

Of the 147 subjects with a mean age of 67.89±65.8 months, 76(51.7%) were males. Mean paediatric risk of mortality score was 11.72±7.86. Major admitting diagnosis included sepsis and multiorgan dysfunction 50(34%), respiratory diseases 26(17.7%) and haematology/oncology diseases 22(15%). The indications for transfusion was low haemoglobin in 90(61.2%) patients, shock 29(19.7%) and hypoxia 28(19%). Acute transfusion reaction was observed in 1(0.7%) patient; 120(82%) required mechanical ventilation; and 94(64%) required inotropic support. Of the total, 88(59.9%) patients survived. Paediatric risk of mortality score, need for inotropic support and mechanical ventilation were associated with mortality (p<0.05).

CONCLUSIONS

Packed red blood cell transfusion, which is frequently prescribed in intensive care settings, was not found to be associated with favourable outcome.

Efficacy and Safety of Phosphate Enema as a therapeutic agent in Hypophosphatemia in Critically Ill Children

The aim of the study was to evaluate the safety and efficacy of oral administration of phosphorous enema in hypophosphatemia (HP) in critically ill children admitted in the pediatric intensive care unit (PICU) of The Indus Hospital, Karachi, from September 2018 to August 2019. This was a retrospective review of 31 critically ill children with hypophosphatemia who received 1 ml/kg/day of phosphate enema through nasogastric tube or orally for phosphate replacement, with serial phosphorus level monitoring along with observation for its side effects. The results showed that the rise of serum phosphorus level was observed in all cases and 64.5% of cases achieved target phosphorus level with no adverse reactions observed. Sample size although limited, it is safe to state that oral phosphate enema is safe and effective for correction of hypophosphatemia in critically ill children. Key Words: Hypophosphatemia, Enema, Pediatric intensive care unit.

Safety and Efficacy of Aminophylline in Intrathecal Methotrexate-related Neurological Toxicity in Large Pediatric Oncology Centre

Children with acute lymphoblastic leukemia, receiving intrathecal methotrexate (IT-MTX), develop acute and subacute neurological dysfunction in 3-15% of cases. Altered level of consciousness, seizure, and stroke-like manifestations are among the most common presentations. MRI of the brain in an early stage is consistent with white matter leukoencephalopathy. There are no specific guidelines for the treatment of such a syndrome. An elevated cerebrospinal fluid (csf) adenosine concentration causes vasodilatation in the brain and leads to cerebral ischemia, which may be reduced by aminophylline infusion. The study is a retrospective data analysis in which electronic data records of 30 patients, collected from September 2017 - August 2019. The primary objective of the study was to evaluate the safety and efficacy of aminophylline in IT-MTX induced neurotoxicity. Aminophylline infusion was used in 30 patients with IT-MTX neurotoxicity. Twenty-five patients (83.33%) showed dramatic improvement of neurologic signs and symptoms within 48 hours. Aminophylline was, hence, coined as a salvageable therapy. No noticeable side effects were observed during treatment with aminophylline infusion. Key Words: Intrathecal methotrexate, Neurotoxicity, Children, Cancer, Aminophylline.

Gastrointestinal Complications in Critically Ill Children: Experience from A Resource-Limited Country

Objectives:

To determine the frequency and predictors of outcome of gastrointestinal complications (GIC) in critically ill children.

Methods:

This descriptive study was prospectively conducted in The Pediatric Intensive Care Unit (PICU), The Aga Khan University Hospital (AKUH), Karachi, from September 2015 to January 2017. After obtaining approval from the Ethical Review Committee of AKUH and informed consent from the parents, all children (aged one month to 18 years), of either gender, admitted to the Pediatric Intensive Care Unit (PICU) during the study period were included. The frequency of the defined GIC: vomiting, high gastric residue volume (GRV), diarrhea, constipation, and gastrointestinal bleed were recorded daily for the first week of the PICU stay. The data was collected by the primary investigator on a predesigned data collection form with inclusion of variables and predictors in light of existing literature and local expertise. The questionnaire was shared with the Pediatric Critical Care Medicine faculty and a consensus was sought on the elements to be incorporated.

Results:

GIC developed within the first 48 hours of admission in 78 (41%) patients. Of the patients who developed GIC, 37 (47.4%) patients developed high GRV: 31 (39.7%) patients developed constipation, 18 (23.1%) patients developed vomiting, 14 (17.9%) patients developed abdominal distension. With regards to prevalence by occurrence, 32/78 (41%) of patients presented with two GI complications, followed by 21 patients (27%) who presented with a single GIC. Only 11 patients (14%) presented with more than three complications. Median length of stay was higher in patients with GIC (8 days) than with those who did not develop GIC (4 days). The frequency of gastrointestinal complications was significantly higher in children receiving mechanical ventilation, on sedatives and relaxants and those with multiorgan dysfunction syndrome (MODS) and inotropes

Conclusion:

GI complications are a frequent occurrence in the PICU and are associated with worse clinical outcomes. The use of sedative drugs and the presence of shock with MODS were amongst the important contributing factors.

High Flow Nasal Cannula Therapy in Children with Acute Respiratory Insufficiency in the Pediatric Intensive Care Unit of a Resource-limited Country: A Preliminary Experience

A retrospective study was performed in children (aged one month - 16 years) receiving HFNC to determine the frequency, efficacy and adverse effects of high flow nasal cannula (HFNC) therapy in the pediatric intensive care unit (PICU), from January to December 2017. Treatment failure was defined as clinical deterioration on HFNC therapy such that mechanical ventilation (MV) was required. Clinical parameters before and after HFNC were assessed using repeated measures analysis of variance. A total of 120 patients received HFNC therapy (21% of total admissions). Primary diagnosis were respiratory disease (50%), central nervous system diseases (14.2%), sepsis (10.8%), and postoperative care (10%). Mean duration of HFNC was 27.5 ±19.7 hours and mean PICU length of stay was 6 ± 6 days. Pneumothorax developed in four patients. MV was required in 28 patients, and subsequently, 15 deaths occurred in that group. HFNC is a frequently used, safe and effective therapy for children requiring respiratory support in PICU. Key Words: Respiratory insufficiency, Non-invasive ventilation, Paediatric intensive care unit.

Laboratory Blood Testing In Paediatric Intensive Care Unit Of A University Hospital: Are We Doing It Appropriately?

Retrospective chart review of all children (aged-one month to 16 years) admitted in our paediatric intensive care from June to November 2016 was done to determine the indication of different laboratory tests. LBT indications were defined into: diagnostic/case findings/screening tests to make a diagnosis; haemostatic tests (to monitor function or identify before clinical signs and symptoms) and therapeutic /monitoring tests to get the level of drug directly or getting level of marker as a guide to therapy. Laboratory tests reports which were within normal range more than once were labelled as in-appropriate tests. In total 274 patients, Haemostatic tests were performed for mean of 35.18±56.72 times (range of 0-429), monitoring for mean of 9.38±20 times (range 0-165), and therapeutic tests (3.26±11.25). Most common tests included serum Sodium levels (7.83±12.73), Serum Potassium (8.19±12.80), bicarbonate (7.75±11.9). 13.40±9.11 tests were done on first day and 13.0±8.49/day tests were performed afterwards. Cumulatively 54.31±74.21 tests were performed/ patients out of which 18.5±37.82 were inappropriate.

Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit

Objectives:

To describe the spectrum of complications of Diabetic Ketoacidosis (DKA) observed in children admitted with severe DKA.

Methods:

Retrospective review of the medical records of all children admitted with the diagnosis of severe DKA in Pediatric Intensive Care Unit (PICU) of the Aga Khan University Hospital, from January 2010 to December 2015 was done. Data was collected on a structured proforma and descriptive statistics were applied.

Results:

Total 37 children were admitted with complicated DKA (1.9% of total PICU admission with 1.8% in 2010 and 3.4% in 2015). Mean age of study population was 8.1±4.6 years and 70% were females (26/37). Mean Prism III score was 9.4±6, mean GCS on presentation was 11±3.8 and mean lowest pH was 7.00±0.15. Complications observed included hyperchloremia (35.94%), hypokalemia (30.81%), hyponatremia (26.70%), cerebral edema (16.43%), shock (13.35%), acute kidney injury (10.27%), arrhythmias (3.8%), and thrombotic thrombocytopenic purpura (5.4%), while one patient had myocarditis and ARDS each. 13/37 children (35%) needed inotropic support, 11/37 (30%) required mechanical ventilation while only one patient required renal replacement therapy. Two patients (5.4%) died during their PICU stay.

Conclusion:

Hyperchloremia and other electrolyte abnormalities, cerebral edema and AKI are the most common complications of severe DKA.

Relationship of Serum Procalcitonin, C-reactive Protein, and Lactic Acid to Organ Failure and Outcome in Critically Ill Pediatric Population

Objective:

To evaluate the clinical and prognostic utility of procalcitonin (PCT), C-reactive protein (CRP), and lactic acid in children admitted to the Pediatric Intensive Care Unit (PICU) of a university teaching hospital.

Materials and Methods:

Medical records of children (1 month–16 years) tested for serum PCT at the time of admission in the PICU of our hospital from July 1, 2013, to January 15, 2015, were reviewed. Within 24 h of admission, the Pediatric Risk of Mortality Score, blood cultures, white blood cell count, neutrophil counts, serum CRP, plasma lactic acid, and PCT were noted. Patient outcome was assessed at hospital discharge, and the patients were divided into nonsurvivors and survivors.

Results:

A total of 167 children being admitted to the PICU were enrolled. The median age of the study population was 3 years (0–16 years), with 58.6% being males. Nonsurvivors had significantly higher lactic acid (4.7 mmol/L [2.07–7.6]; P < 0.05) than that of the survivors (2 mmol/L [1.3–3]; P < 0.05). In addition, nonsurvivors (94.4%; P < 0.05) had greater incidence of multiple organ dysfunction syndrome (MODS) than that of the survivors (38.05%; P < 0.05). Binary logistic regression showed age, MODS, and lactic acid to be associated with mortality.

Conclusions:

This study found that in comparison to PCT and CRP, high plasma lactic acid levels are associated with the development of all-cause MODS and worse outcome in critically ill children admitted in PICU. Prediction of prognosis based on the lactic acid alone may contribute to improve patient management, but further studies are required to endorse our findings.

Frequency and Outcome of Acute Neurologic Complications after Congenital Heart Disease Surgery

Objectives:

To determine the frequency and immediate outcome of acute neurologic complications (ANCs) in children undergoing congenital heart surgery (CHS).

Materials and Methods:

In this retrospective study, all patients undergoing CHS at our hospital from January 2007 to June 2016 were included. Patients were followed up for the development of seizures, altered level of consciousness (ALOC), abnormal movements, and stroke. Results are presented as mean with standard deviation and frequency with percentages.

Results:

Of 2000 patients who underwent CHS at our center during the study, 35 patients (1.75%) developed ANC. Seizures occurred in 28 (80%), ALOC in 5 (14%), clinical stroke in 2, brain death in 6 patients. Antiepileptic drugs (AEDs) were started in 32 patients, of which 13 patients required more than one AED. Mean length of stay was 10 ± 7.36 days. Of 35 patients who developed ANC, 7 expired during the study.

Conclusion:

Neurological complications are scarce but significant morbidity after CHS at our center.

Hyperlactetemia And Its Trends In Critically Ill Children Admitted In Pediatric Intensive Care Unit Of A Developing Country

BACKGROUND

There is increasing evidence that in setting of critical ailments clinical signs lag biomarkers like Lactate and hyperlactetemia can be the only marker for this disorder. This study was conducted to describe the incidence of hyperlactatemia in critically ill children and its association with outcome.

METHODS

Retrospective review of medical records of all children who had their lactic acid (LA) levels measured during their admission in PICU from January 2014 to December 2015 was done. Demographic and clinical variables were recorded along with PICU therapies, outcome (Survived or expired) and development of multi-organ dysfunction. Results are presented as frequency with percentages and mean with standard deviation. Appropriate statistical tests were applied and p-value of <0.05 was taken as significant.

RESULTS

Total 300 patients had their LA measured and 202 were included in the study. Males were 130 (64%) and mean age was 5.7±4.6 years. Hyperlactatemia was found in 68 (33%) patients and another 75 (37%) had a second LA level >4 mmol/L. Increasing LA trend was found in 79 (39%) patients. Diagnostic categories included cardiovascular diseases (45, 22%), central nervous system diseases (40, 20%), respiratory diseases (31, 15%), sepsis (28, 14%), and gastrointestinal diseases14 (7%). 168 (83%) needed mechanical ventilation. Mean pH was 7.31±0.15 and metabolic acidosis was observed in 91 patients (45%). Mean LA levels in survivors and non survivors were 3.3±3.12 and 5.35±5.47 respectively. Hyperlactatemia was associated with death (p=0.01) and development of MODS (p=0.03) on univariate analysis. On multivariate logistic regression rising lactate and development of MODS were significantly associated with death (p=<0.05, odds ratio (OR) 9.24 (95% confidence interval 1.55-55.20).

CONCLUSIONS

Hyperlactatemia and increasing LA trend in critically ill children are associated with worse outcome in PICU.

Frequency and Outcome of Meningitis in Pediatric Intensive Care Unit of Pakistan

Meningitis is a leading cause of morbidity and mortality worldwide in intensive care settings. The aim of this study was to assess the frequency and outcome in children with meningitis through a retrospective chart review done in pediatric intensive care unit of a tertiary care hospital from January 2000 to December 2014. During these 14 years, 64 patients were admitted with meningitis in pediatric intensive care unit. Out of 64, 36 were diagnosed with pyogenic meningitis, 18 patients with viral meningitis, and 10 with tuberculous meningitis. Most complications were observed in the initial 48 hours. Most common presentation was altered level of consciouness in 50 (78.1%), seizure in 38 (59.4%), and shock in 23 (35.9%) patients. Ventilatory support was required in 30 (46.9%) patients and inotropic support in 26 (40.6%). During stay in pediatric intensive care unit, there was 7.8% mortality. Although meningitis was an infrequent cause of hospitalization at the study centre, but it was an important infectious cause of mortality and morbidity in pediatric age group and associated with high neurological sequelae.

Use of N-acetylcysteine in children with fulminant hepatic failure caused by acute viral hepatitis

OBJECTIVE

To determine the efficacy of N-acetylcysteine (NAC) in children aged > 1 month to 16 years admitted with Fulminant Hepatic Failure (FHF) secondary to Acute Viral Hepatitis (AVH) in a tertiary care center of a developing country.

STUDY DESIGN

Analytical study.

PLACE AND DURATION OF STUDY

Department of Paediatrics, The Aga Khan University Hospital, Karachi, Pakistan, from January 2007 to December 2011.

METHODOLOGY

Medical records of children (> 1 month - 16 years) with FHF admitted with AVH of known etiology who received NAC were reviewed retrospectively. Liver function tests (mean ± SD) at baseline, 24 hours after NAC and before or at the time of discharge/death were recorded and compared via using repeated measures ANOVA(r-ANOVA). Efficacy of NAC is defined in improvement in biochemical markers, liver function test and discharge disposition (survived or died). Mortality associated risk factors were identified by using logistic regression analysis. P-value and 95% confidence interval were recorded.

RESULTS

Forty children (mean age was 80 ± 40 months) with FHF secondary to AVH received NAC. Majority were males (n=25; 63%). Vomiting (75%) and jaundice (65%) were the main presenting symptoms, one-third had hypoglycemic, while 40% had altered sensorium at the time of admission. There was significant statistical difference in liver enzymes and prothrombin time on admission comparing at discharge in children received NAC (p < 0.001). Fifteen (38%) children died. Severe vomiting {Odds Ratio (OR) 0.22, 95% Confidence Interval (CI) 0.05 - 0.8}, jaundice (OR 9.3, CI 1.1 - 82.6), inotropic support (OR 20.6, CI 3.5 - 118.3) and mechanical ventilation (OR 4.3, CI 1.1 - 16.6) at the time of admission are associated with risk factors for mortality in children with FHF secondary to AVH.

CONCLUSION

NAC used in children with FHF secondary to AVH is associated with markedly improved liver function tests and recovery. FHF with complications is high risk for mortality.

Adult polycystic kidney disease: a disorder of connective tissue?

Adult polycystic kidney disease (APCKD) is one of the most common serious inherited disorders. Many affected patients succumb to the renal and non-renal manifestations of this autosomal dominant disease. The disease is characterized by cyst formation in several organs, most obvious of which is in the renal parenchyma. Other features associated with the disease include hepatic fibrosis, hepatic, pancreatic and splenic cyst formation, Berry aneurysms, colonic diverticulae, hernias and cardiac valvular disorders. Rupture of Berry aneurysm is a sudden and often fatal manifestation in some unsuspected cases of APCKD. We recently examined one surgically removed kidney from a 15-year-old male patient with APCKD. In addition to the classical cystic change, extensive changes in renal parenchymal matrix and vasculature are also present. The excessive and weak matrix may contribute to dilatations of both renal tubules giving rise to cysts and the blood vessels. Our findings suggest that APCKD may be a connective tissue disorder in which alteration of extracellular matrix may be a common denominator for the manifestations and organ pleotropism of APCKD.

Giant cell tumor of bone: a neoplasm or a reactive condition?

Giant cell tumor of bone (GCTB) is a benign but locally aggressive bone tumor of young adults. It typically presents as a large lytic mass at the end of the epiphysis of long bones. Grossly it is comprised of cystic and hemorrhagic areas with little or no periosteal reaction. Microscopically areas of frank hemorrhage, numerous multinucleated giant cells and spindly stromal cells are present. Telomeric fusions, increased telomerase activity and karyotypic aberrations have been advanced as a proof of its neoplastic nature. However such findings are not universal and can be seen in rapidly proliferating normal cells as well as in several osseous lesions of developmental and/or reactive nature, and the true neoplastic nature of GCTB remains controversial. The ancillary studies have generally not reached to the point where these alone can be taken as sole diagnostic and discriminatory criteria. While giant cells and stromal cells have been extensively studied, little attention has been paid to the overwhelming hemorrhagic component. If examined carefully intact and partially degenerated red blood cells are almost invariably seen in many giant cells as well as in the stroma. While hemorrhage in many patients may be resolved without leaving any trace over time, in some it gives rise to giant cell formation, and in others it may lead to proliferation of fibroblasts and histiocytes. At times one sees xanthomatous cells due to intracytoplasmic cholesterol deposits and sharp cholesterol clefts. Individual genetic makeup, local tissue factors as well as the amount of hemorrhage may play a key role in the final effects and outcome. Malignancy usually does not occur in GCTB and when discover, it usually represents primary bone sarcomas missed at original diagnosis. Embolization therapy to curtail hemorrhage and insertion of cement substance to support matrix are helpful in reducing recurrences. Aneurysmal bone cyst (ABC) shares many features with GCTB. There had been unique karyotypic changes in some aneurysmal bone cysts making it distinct from GCTB. However these changes may be in the endothelial cells which are quite different from stromal or giant cells. It had been concluded that the poor matrix support to the vessels may lead to frequent and profuse intraosseous hemorrhage attracting blood-derived monocytes with active conversion into osteoclasts, resulting in GCTB formation. On the other hand, dilatation of the thin-walled blood vessels results in formation of ABCs. If hemorrhagic foci are replaced by proliferation of fibroblasts and histiocytes, then a picture of fibrous histiocytic lesion is emerged. Enhanced telomerase activity and karyotypic aberrations may be necessary for rapid division of the nuclei of the giant cells in order to be able to deal with significant in situ intraosseous hemorrhage.

Socioeconomic characteristics and melanoma incidence

PURPOSE

This investigation examines the relationship between socioeconomic status (SES) and melanoma incidence in counties included in the Surveillance, Epidemiology, and End Results Registry (SEER) in the United States from 1973 to 1993.

METHODS

Cases included whites, aged at least 15 years, with a morphologic diagnosis of malignant melanoma, residing in one of 199 counties at the time of diagnosis. County level measures of SES including median household income, percentage of high school graduates, and percentage of families below poverty were abstracted from the 1950, 1960, 1970, 1980, and 1990 U.S. Census data. The relationship between SES factors and melanoma rates was examined by hierarchical Poisson regression.

RESULTS

The percentage of high school graduates was significantly and positively associated with the incidence of melanoma (relative risk (RR), 1.28; 95% confidence interval (CI), 1.21-1.35), after controlling for age at diagnosis, gender, time period, latitude, and percentage of Hispanics in the county. Percentage of families below poverty was significantly inversely associated with the incidence of melanoma (RR, 0.66; 95% CI, 0.55-0.78). When education and poverty were included in the same model, both the positive effects of education (RR, 1.23; 95% CI, 1.16-1.31) and the negative effects of poverty (RR, 0.85; 95% CI, 0.74-0.98) persisted. In contrast, median household income was not associated with melanoma incidence in a similar multivariable model (RR, 1.00; 95% CI, 0.99-1.00).

CONCLUSION

Whether the effect of education on incidence of melanoma reflects lifestyle behaviors that modify exposure to sunlight or some other factor remains unclear. Nonetheless, the findings of this study suggest that the determinant is primarily related to education, not income.

Splenic autotransplant and residual partial spleen: prevention of septicemia

Postsplenectomy septicemia carries an ominous prognosis. Accompanying disseminated intravascular coagulation and adrenal hemorrhage result in a high mortality, despite aggressive treatment by antibiotics. The efficacy of prevention by in situ partial spleen and splenic auto-transplant were evaluated in Sprague-Dawley rats. All totally splenectomized rats died following intravenous challenge of live pneumococcus. Both partial spleens and autotransplants gave substantial protection. The rats which succumbed to pneumococcal sepsis demonstrated massive fibrin thrombi in renal glomeruli and frank adrenal hemorrhage, strikingly similar to clinical observations.

Sarcoidosis presenting as an intramedullary spinal cord mass

A patient with sarcoidosis of the spinal cord showing cord enlargement upon myelography is presented. The literature regarding spinal cord involvement with sarcoidosis, the indications for operation, and treatment is reviewed.

Gastric hyalinization associated with peptic ulceration

Gastric hyalinization, the severe hyaline thickening of the stomach wall that predominantly involves the submucosa, seems to have been described only in autopsy cases. Although initially thought to be a consequence of radiation or chemotherapy, subsequent studies suggested that it results from an artifactual postmortem chemical denaturation of the protein of the gastric submucosa, possibly related to an agonal tear in the gastric submucosa. We studied the clinicopathologic and ultrastructural findings in a case that had morphologic features of gastric hyalinization but that, in contrast with previous reports, was present in a surgically removed stomach and was associated with a small, chronic, peptic ulcer, with clinical manifestations of gastromegaly and borderline gastric retention. Ultrastructurally, the severe submucosal hyaline thickening that focally involved the muscularis and serosa largely consisted of proteinaceous material, ground substance, and collagen fibers, with occasional interspersed fibroblasts and myofibroblasts. This case indicated that gastric hyalinization can be a nonartifactual and clinically significant entity that may be associated with peptic ulcer disease and that should be distinguished from neoplastic (linitis plastica) and other processes.