Predictors of Mortality in Hospitalized Children with Pandemic H1N1 Influenza 2009 in Pune, India

Objective

To analyse the factors associated with increased mortality among Indian Children with H1N1.

Methods

Data were abstracted from available hospital records of children less than 12?y of age, who were admitted to Sassoon General Hospital in Pune, India, with confirmed pandemic 2009 H1N1 influenza infection from August 2009 through January 2010. Logistic regression analysis was used to identify clinical characteristics associated with mortality.

Results

Of 775 pediatric cases admitted with Influenza Like Illness (ILI), 92 (11.8%) had confirmed H1N1 influenza infection. The median age of HIN1 cases was 2.5?y; 13 (14%) had an associated co-morbid condition. Median duration of symptoms was 4?d (interquartile range (IQR), 3?C7?d). All 92 H1N1 cases received oseltamivir and empiric antimicrobials on admission. Intensive care unit (ICU) admission was required for 88 (96%) children, and 20 (23%) required mechanical ventilation.Fifteen children (16%) died; mortality was associated with presence of diffuse alveolar infiltrate on admission chest radiography (odds ratio (OR) 45, 95%CI :5.4?C370; p?p?=?0.001), SpO₂ <80% on admission (OR 32.8, 95% CI: 5.8?C185.5; p?p?n?=?4 each, 27%) with gram positive organisms consistent with severe viral and bacterial co-infection.

Conclusions

Hypoxia, ARDS and use of corticosteroids in children with ARDS who were mechanically ventilated were the factors associated with increased odds of mortality. Necropsy also suggested bacterial co-infection as a risk factor.     

Prevalence and Predictors of Decreased Glomerular Filtration Rate in Tibetan Children with Congenital Heart Disease

Objectives

To assess the prevalence of decreased glomerular filtration rate (GFR) in Tibetan children with congenital heart disease (CHD) and its associated risk factors.

Methods

A total of 207 Tibetan children attending authors’ center for treatment of CHD from May 2012 through November 2012, were included in the study. GFR was estimated with the Schwartz formula (eGFR).

Results

The mean eGFR was 104.3?±?16.6 mL/min/1.73 m², and decreased in 21 children (10.1 %). In the cyanotic category, eGFR was decreased only in severely cyanotic individuals. In the acyanotic category with left ventricular overload, children with decreased eGFR were younger, more commonly lived in areas above 4,700 m, and had higher left ventricular internal dimensions indexed by body surface areas (LVID/BSA) (53.8?±?6.9 vs. 40.1?±?6.8 mm/m², P?P?P?2 (sensitivity: 75.0 %, specificity: 93.9 %). In the remaining category, decreased eGFR was only observed in those living above 4,700 m.

Conclusions

One tenth of Tibetan children with CHD had decreased eGFR. The risk factors included severe cyanosis, younger age, living above 4,700 m and higher LVID/BSA.     

Common Clinical Problems in Children Living with HIV/AIDS: Systemic Approach

Clinical manifestations in children living with HIV/ AIDS differ from those in adults due to poorly developed immunity that allows greater dissemination throughout various organs. In developing countries, HIV-infected children have an increased frequency of malnutrition and common childhood infections such as ear infections, pneumonias, gastroenteritis and tuberculosis. The symptoms common to many treatable conditions, such as recurrent fever, diarrhea and generalized dermatitis, tend to be more persistent and severe and often do not respond as well to treatment. The use of Anti Retroviral Therapy (ART) has greatly increased the long term survival of perinatally infected children so that AIDS is becoming a manageable chronic illness. As the immunity is maintained, the incidence of infectious complications is declining while noninfectious complications of HIV are more frequently encountered. Regular clinical monitoring with immunological and virological monitoring and the introduction of genotypic and phenotypic resistance testing where resources are available have allowed for dramatically better clinical outcomes. However, these growing children are left facing the challenges of lifelong adherence with complex treatment regimens, compounded by complex psycho-social, mental and neuro-cognitive issues. These unique challenges must be recognized and understood in order to provide appropriate medical management.     

Prevalence of Asymptomatic Microalbuminuria in HIV Positive Children in India

Objective

To study the prevalence of covert or early renal involvement among human immunodeficiency virus (HIV) positive children.

Methods

A cross-sectional observational study was carried out on 250 HIV positive children (2–18 y) on follow-up in a tertiary care hospital from January 2014 through June 2015. Those who met the study criteria were evaluated for microalbuminuria and glomerular and tubular dysfunctions.

Results

Fifty-one out of two hundred fifty (20%) children were found to have microalbuminuria though none had any other evidence of renal dysfunction. The incidence of microalbuminuria in children on Anti Retroviral Therapy (ART) and those not on ART was 20% and 21% respectively. Neither was there any difference in those with a CD4 count ≤500/cu mm compared with those with counts >500/cu mm. However, the overall CD4 counts were significantly lower in children with microalbuminuria.

Conclusions

Microalbuminuria was detected in 20% of asymptomatic HIV positive children suggesting early glomerular dysfunction and need for regular screening and follow-up.

     

Risk Factors and Predictors of Mortality in Critically ill Children with Extensively-Drug Resistant Acinetobacter baumannii Infection in a Pediatric Intensive Care Unit

Objective: Acinetobacter baumannii is an important emerging cause for extensively-drug resistant (XDR) hospital associated infections (HAIs) in pediatric intensive care units (PICU). The study was done to evaluate the risk factors, outcome, antibiotic sensitivity pattern, and predictors of mortality in critically ill children with XDR A. baumannii infection. Methods: Retrospective case control study, done in the PICU of a tertiary care pediatric hospital of India from April 2010 to March 2012. Findings: Eighty-five children who developed XDR A. baumannii infection matched to 170 controls. Majority (76%) of the organisms were isolated from endotracheal lavage. The mortality rate was 28.2% (24/85). The factors found to be significantly associated with A. baumannii infection were prior use of broad-spectrum antibiotics, major surgeries done, prolonged PICU stay, use of central venous catheters, and mechanical ventilation. The predictors of mortality associated with A. baumannii infection were acute kidney injury, presence of septic shock, and disseminated intravascular coagulopathy. Colistin found to be the single most effective drug against XDR A. baumannii infection. Conclusion: XDR A. baumannii infections are associated with high morbidity and mortality in critically ill children. Early diagnosis and treatment are crucial. Implementation of infection control practices and rational use of antibiotics are required to control such infections.Key Words: Acinetobacter Baumannii, Extensively-Drug Resistant, Hospital Associated Infection, Children     

Survival of Children Living with Human Immunodeficiency Virus on Antiretroviral Therapy in Andhra Pradesh,India

Objectives

To assess the survival probability and associated factors among children living with human immunodeficiency virus (CLHIV) receiving antiretroviral therapy (ART) in India.

Methods

The data on 5874 children (55% boys) from one of the high HIV burden states of India from the cohort were analyzed. Data were extracted from the computerized management information system of the National AIDS Control Organization (NACO). Children were eligible for inclusion if they had started ART during 2007-2013, and had at least one potential follow-up. Kaplan Meier survival and Cox proportional hazards models were used to measure survival probability.

Results

The baseline median (IQR) CD4 count at the start of antiretroviral therapy was 244 (153, 398). Overall, the mortality was 30 per 1000 child years; 39 in the <5 year age group and 25 in 5-9 year age group. Mortality was highest among infants (86 per 1000 child years). Those with CD4 count ≥200 were six times more likely to die (adjusted HR: 6.3, 95% CI 3.5, 11.4) as compared to those with a CD4 count of ≥350/mm³.

Conclusion

Mortality rates among CLHIV is significantly higher among children less than five years when the CD4 count at the start of ART is above 200. Additionally, lower CD4 count, HIV clinical staging IV, and lack of functional status seems to be associated with high mortality in children who are on ART.

     

Predictors of Intubation in Children

Objective  

To estimate the relation of mentohyoid, thyromental and sternomental distances to height, weight and age of children with normal airway.     

Predictors of Long-Term Outcome in Children with Hypertrophic Cardiomyopathy

To date limited data are available to predict the progression to end-stage heart failure (HF) with subsequent death (non-SCD), need for heart transplantation, or sudden cardiac death (SCD) in children with hypertrophic cardiomyopathy (HCM). We aimed to determine predictors of long-term outcome in children with HCM. A total of 112 children (median 14.1, IQR 7.8–16.6 years) were followed up for the median of 6.5 years for the development of morbidity and mortality, including arrhythmic and HF-related secondary end points. HF end point included HF-related death or heart transplant, and arrhythmic end point included resuscitated cardiac arrest, appropriate ICD discharge, or SCD. Overall, 23 (21 %) patients reached the pre-defined composite primary end point. At 10-year follow-up, the event-free survival rate was 76 %. Thirteen patients (12 %) reached the secondary arrhythmic end point, and 10 patients (9 %) reached the secondary HF end point. In multivariate model, prior cardiac arrest (r = 0.658), QTc dispersion (r = 0.262), and NSVT (r = 0.217) were independent predictors of the arrhythmic secondary end point, while HF (r = 0.440), LV posterior wall thickness (r = 0.258), LA size (r = 0.389), and decreased early transmitral flow velocity (r = 0.202) were all independent predictors of the secondary HF end point. There are differences in the risk factors for SCD and for HF-related death in childhood HCM. Only prior cardiac arrest, QTc dispersion, and NSVT predicted arrhythmic outcome in patients aged <18 years. LA size, LV posterior wall thickness, and decreased early transmitral flow velocity were strong independent predictors of HF-related events.     

Prevalence of orphans among HIV infected children--a preliminary study from a pediatric HIV centre in Western India

The aim of this study was to determine the prevalence of orphaned HIV-infected children in Mumbai, India and analyze whether orphanhood affects care of these children. This study is a retrospective analysis of prospectively collected data of 147 HIV-infected children referred to our pediatric HIV clinic at B. J. Wadia Hospital for Children (Mumbai, India). All children underwent a detailed history and clinical examination. Transmission of HIV was determined by parental HIV status, history of blood transfusion or sexual exposure. Orphan status was determined by verbal autopsy of parent death (either mother or father or both). Factors affected by orphan status such as follow up, caregiver, antiretroviral treatment and age of the child when orphaned was determined. Fifty nine (40%) HIV-infected children were orphans. In 28 children (19%), father had died; in 20 children (13.6%), mother had died; in 11 children (7.5%) both parents had died and in 2 children (1.4%), parents death status was not known. Cause of death was AIDS in 19 parents (38%) and TB in 21 parents (42%). The mean age of the child when mother had died was 5.6 +/- 2.2 years; when father had died was 7.08 +/- 3.5 years and when both parents had died was 10.9 +/- 2.4 years (p < 0.0001). There was no statistical difference in follow up (p = 0.48) or initiation of antiretroviral therapy (p = 0.04) in orphaned and nonorphaned children. In orphaned children, grandparents (5.4%) and aunts (4.8%) took responsibility of taking care of the children. Only two children (1.4%) were put in orphanages. Prevalence of HIV-infected orphans is high (40%). However, there is no difference in HIV care between orphans and nonorphans.     

Children and adolescents living with HIV and AIDS: a review

Worldwide, more than one million children are infected with human immunodeficiency virus (HIV) and in the United States it has become the sixth leading cause of death among 15-24-year-olds. Despite the trend of increasing rates of infection, advances in therapies have led to survival past 5 years of age for more than 65% of infected children. This global health threat will therefore continue to have a significant impact on child and adolescent psychiatry and psychology. This paper reviews current studies and reports on the consequences of the acquired immunodeficiency syndrome (AIDS) epidemic in the psychiatric care and development of children and adolescents infected by HIV. From a search of all the English-language-based literature on pediatric AIDS, 140 studies are reviewed which address HIV infection and its psychological and social implications. Several topics of mental health significance are examined: (1) the epidemiology of HIV, (2) neurocognitive development among those infected, (3) psychological impact of infection, and (4) the family and social context of HIV. The transition of HIV from an acute, lethal disease to a subacute, chronic disease has enormous implications for the neurocognitive and psychosocial development of children and families. As children and adolescents infected with HIV continue to live longer, normal developmental milestones and educational needs will take on new significance. Many children will continue to be adversely impacted by non-HIV factors such as poverty, inadequate medical services, and a lack of social support. This review outlines recent developments that hold promise to effectively reduce the treatment burden on the infected, their families, and health care providers and to decrease the incidence of transmission to the uninfected.     

Profile of Typhoid Fever in Children from a Tertiary Care Hospital in Chennai-South India

Aim  

To study the clinical profile and outcome of hospitalized children with typhoid fever.     

Morbidity and Mortality in Iranian Children with Juvenile Systemic Lupus erythematosus

Objective: Juvenile systemic lupus erythematosus (JSLE) is a common rheumatologic disorder that involves multi organ systems. Prognosis of lupus in children may be poorer than in adults. In this study, we determined mortality and morbidity rates in the pediatric SLE in Iran. Methods: In a cross sectional study, we evaluated 120 children with SLE who had registered in our pediatric rheumatology database within 2004-2010. Data including sex, age, remission, age at the time of diagnosis, age at the time of study, various types of organ involvement, mortality and remission were extracted from this database. Findings : From 120 cases, 77% (92 cases) were females and 23% (28 cases) males (F:M=3.3). Mean follow up period was 56±32 months and mean age at the time of manifesting disease 10.34±2.9 years. Mortality rate was 10% (12 cases) in our investigation. Musculoskeletal involvement showed significant difference between various age groups (P<0.01), that was more frequent in group of 7 years and older. Frequency of oral ulcer and ophthalmic involvement in boys was significantly higher than in girls (P<0.05). Frequency of cardiovascular involvement (P<0.01) and renal involvement (P<0.01) was significantly higher in the patients who had no remission. There was a significant association between mortality rate and cardiac (P<0.02, OR=4.9), pulmonary (P<0.01, OR=10.167) and liver (P<0.05, OR=1.19) involvement. Conclusion: In our investigation 1-year survival rate was 97% and 5-year survival rate 89%. Liver, cardiac and pulmonary involvements have an association with higher mortality in JSLE patients.Key Words: Systemic Lupus Erythematosus, Mortality, Morbidity, Juvenile, Children, Iran     

Predictors and Outcome of Acute Kidney Injury in Children with Diabetic Ketoacidosis

Objective

To identify predictors and outcome of acute kidney injury (AKI) in children with diabetic ketoacidosis (DKA) admitted to a Pediatric Intensive Care Unit (PICU).

Methods

Retrospective case review of 79 children with DKA admitted between 2011-2014.

Results

28 children developed AKI during the hospital stay; 20 (71.4%) recovered with hydration alone. Serum chloride at 24 hours was independently associated with AKI. Children with AKI had prolonged acidosis, longer PICU stay, and higher mortality.

Conclusions

Majority of children with AKI and DKA recover with hydration. Hyperchloremia at 24 hours had independent association with AKI, although cause-effect relation could not be ascertained.

     

Predictors of Pre-operative Anxiety in Indian Children

Objective

To identify the predictors of pre-operative anxiety in school-going children in India.

Methods

A prospective observational study was done at a tertiary care teaching hospital. Children aged 7–12 y scheduled for elective surgery and their parents were enrolled. Pre-operative anxiety in children and parents was assessed using STAI-C and STAI-P questionnaires respectively. The child’s anxiety in pre-op room, at the time of parental separation and induction of anesthesia were assessed using m-YPAS scale. Possible predictors of anxiety under ‘individual’, ‘social’ and ‘healthcare’ domains were analyzed using logistic regression. The quality of mask induction of anesthesia was assessed using Induction Compliance Checklist.

Results

Sixty children completed the study successfully. Receiver operating characteristic (ROC) curve indicted mYPAS score?≥?30 (observed score) to identify children with high anxiety as identified by STAI-C ≥37 (self-reported score). The incidence of high anxiety escalated from pre-operative time (48%) to the time of parental separation (72%) and increased further at anesthetic induction (95%). Parental anxiety (p?=?0.03) and socioeconomic background (p?=?0.03) were significant predictors of the child’s pre-operative anxiety. The presence of >4 people at induction (p?=?0.002), but not pre-operative anxiety, was found significantly more in children with poor quality of mask induction.

Conclusions

The incidence of peri-operative anxiety in Indian children is significant. Parental anxiety and socioeconomic background were found significant predictors of high pre-operative anxiety in our set-up.

     

Risk Factors and Predictors of Mortality in Culture Proven Neonatal Sepsis

Objective  

To determine the risk factors associated with culture-proven neonatal sepsis and identify predictors of mortality among them.