Acute iron poisoning: clinical picture, intensive care needs and outcome

In this retrospective study, we examined the prevalence of acute iron poisoning among children attending Pediatric Emergency service of a teaching hospital, and studied their clinical profile, treatment and outcome to define intensive care needs. During the 5 years' study period of 27125 patient visits to Pediatric Emergency, 337 (1.2%) were for accidental poisoning. Of these 21(7%) patients had iron poisoning; 18 were transferred to PICU. Three patients were asymptomatic, others had vomiting (n =15, 83%), diarrhoea (n =13, 72%), malena (n = 8, 44%), and hemetemesis (n=6, 33%) generally within 6 hours of ingestion. Nine progressed to shock and/or impaired consciousness; two had acute liver failure. Dose of ingested iron and clinical signs were most useful guide to iron toxicity and management decisions; serum iron did not help. Gastric lavage yielded fragments of iron tablets in 10 patients. On desferrioxamine infusion Vin-rose colour urine was not seen in 31% even in presence of high serum iron. Shock responded to normal saline (33 +/- 15 mL/kg) and dopamine (10 +/- 4 microg/kg/min) within 4-24 hours in 7 of 9 patients. Presence of shock or acute liver failure with coagulopathy and/or severe acidosis predicted all the four deaths. Desferrioxamine infusion and supportive care of shock was the mainstay.     

Morphometry of single small enhancing computed tomographic lesions: outcome and effect of albendazole therapy

Single small enhancing computerized tomographic (CT) lesions (SSECTLs) are common in children with focal seizures. However, there is a paucity of systematic information regarding their morphometry, effect of albendazole therapy and long-term outcome. The objectives were to study the pattern of SSECTL on radiological follow up, alterations made by albendazole therapy, and correlation with seizure recurrence. A randomized, placebo controlled, double blind trial was carried out at the Advanced Pediatric Center, PGIMER, an urban tertiary-care teaching hospital. Sixty-three children between 2 and 12 years of age with focal seizures for < 3 months and SSECTLs were included in the study. All children were randomly assigned to receive either albendazole (15 mg/kg/day) or placebo for 28 days. CT scan was done at 1 and 3 months after beginning treatment. Codes opened after 6 months of recruitment in the study showed that 31 had received albendazole and 32 had received placebo. Over a period of 3 months, natural resolution of SSECTL passed through many stages. Albendazole was seen to accelerate this natural process as evident by the progression of various morphometric markers. An increase in the size of the lesion was associated with early seizure recurrence.     

Bacterial meningitis in children: critical care needs

Acute bacterial meningitis (ABM) in children is associated with a high rate of acute complications and mortality, particularly in the developing countries. Most of the deaths occur during first 48 hours of hospitalization. Coma, raised intracranial pressure (ICP), seizures, shock have been identified as significant predictors of death and morbidity. This article reviews issues in critical care with reference to our experience of managing 88 children with ABM in PICU. Attention should first be directed toward basic ABCs of life-support. Children with Glasgow Coma Scale (GSC) score < 8 need intubation and supplemental oxygen. Antibiotics should be started, even without LP (contraindicated if focal neuro-deficit, papilledema, or signs of raised ICP). Raised ICP is present in most of patients; GCS < 8 and high blood pressure are good guides. Mannitol (0.25 gm/Kg) should be used in such patients. If there are signs of (impending) herniation short-term hyperventilation is recommended; prolonged hyperventilation (> 1 hour) must be avoided. Any evidence of poor perfusion, hypovolemia and/or hypotension needs aggressive treatment with normal saline boluses and inotropes, if necessary, to maintain normal blood pressure. Empiric fluid restriction is not justified. Seizures may be controlled with intravenous diazepam or lorazepam. Refractory status epilepticus may be treated with continuous diazepam (0.01-0.06) mg/kg/min) or midazolam infusion. Ventilatory support may be needed early for associated pneumonia, poor respiratory effort and/or coma, and occasionally to reduce work of breathing in shock. Provision of critical care to children with ABM may reduce the mortality significantly as experienced by us.     

Single small enhancing computed tomographic lesion in Indian children--I: Evolution of current concepts

Single, small (<20 mm) enhancing CT lesions are the commonest cause of focal seizures in Indian children and are also frequently reported from other tropical countries. They often resolve spontaneously on follow-up and have therefore led to controversies regarding their etiology and appropriate management. Initially, these lesions were often considered to be tuberculomas. However, as research progressed over the last two decades, solitary cysticercus granuloma has been found to be the most likely cause for these lesions. In this article we discuss the evolution of current etiological concepts regarding single, small enhancing CT lesions among Indian children, and an approach towards management.     

Dilated Cardiomyopathy with Short QT Interval: Is It a New Clinical Entity?

Short QT syndrome is a rare autosomal dominant channelopathy of structurally normal hearts characterized by atrial fibrillation, ventricular arrhythmias, and sudden cardiac death. We report a case having short QT, dilated ventricles, and severe ventricular dysfunction, an unreported association so far.     

KOCH'S OR CROHN'S?

Abdominal tuberculosis is not uncommon in the UK, especially in Asian immigrants. It resembles Crohn's disease clinically and radiologically, and it may be difficult to differentiate between them, even at laparotomy or histology. The distinction is important, however, for proper management of the two conditions. Every effort must be made to exclude abdominal tuberculosis before the patient is diagnosed as having Crohn's disease and is treated with steroids.     

A high-titer,high-thermal-amplitude autoanti-B associated with acrocyanosis but no obvious hemolytic anemia

BACKGROUND: ABO autoantibodies are rare. Most reported examples have been antibodies with 4 degrees C titers not greater than 256 in patients without apparent hemolytic anemia. Most high-titer, high-thermal-amplitude, complement-activating cold agglutinins are associated with hemolytic anemia. STUDY DESIGN AND METHODS: A 52-year-old man presented with acrocyanosis and mild small-vessel brain disease, but no evidence of obvious hemolytic anemia. Regular plasmapheresis treatment was helpful in relieving the clinical symptoms associated with acrocyanosis. Serologic methods were used to study the patient's RBCs and sera. RESULTS: The patient's RBCs were strongly reactive with anti-C3 and anti-IgM and weakly reactive with anti-IgA. The patient's serum contained a high-titer, high-thermal-amplitude, IgMkappa autoanti-B, capable of activating complement in vitro. CONCLUSION: A patient with a powerful ABO autoantibody is described. This patient had acrocyanosis but did not appear to have an obvious hemolytic anemia. This case is a good example of the lack of correlation between in vitro serologic tests and in vivo reactions in individual patients.     

Renal Transplantation: Experience at a Single Centre

Background

Renal transplantation program in the Armed Forces commenced in Feb 1991 and till date 245 patients have undergone renal transplantation at INHS Asvini. We describe our protocols for donor and recipient evaluation and immunosuppression. Methods: 245 patients received renal transplants during this period, 243 (99.2%) being from live donors. Most of them were started on triple immunosuppression comprising of cyclosporine, azathioprine and prednisolone. Newer drugs like mycophenolate, tacrolimus and sirolimus were administered in a select population.

Result

69 (28.1%) of them had at least one episode of acute rejection, most of which were steroid responsive and 13 (18.8%) of them required either anti CD3 monoclonal or anti-thymocyte globulin (ATG). Complete recovery with normal renal function occurred in 54 (78.2%) cases and 15 (21.7%) recovered with residual dysfunction with maximum serum creatinine being 2.1mg/dl. There were three (1.2%) cases of accelerated rejection during the first week of transplantation and one had graft rupture. All three lost their grafts. There were eight (3.2%) cases of acute tubular necrosis, who recovered completely within 8–14 days. Immediate infections included wound sepsis, lower respiratory tract infection, disseminated candidiasis and disseminated aspergillosis. Late infections included pulmonary tuberculosis, disseminated tuberculosis, cytomegalovirus infection and recurrent urinary tract infection. 28 (11.4%) patients developed post transplant diabetes mellitus. At the end of one year and five years, graft and patient survival were 97.2%, 93%, 80.9% and 85.7% respectively.

Conclusion

Our outcomes show that the transplantation is a viable mode of renal replacement therapy in patients of end stage kidney disease with a near normal rehabilitation.Key Words: Kidney, Transplantation, Immunosuppression, Complications     

Household Water Purification: Low-Cost Interventions

Numerous studies have shown that improving the microbiological quality of household water by point-of-use treatment reduces diarrhoea and other waterborne diseases. The most promising and accessible of the technologies for household water treatment are filtration with ceramic filters, chlorination with storage in an improvised vessel, solar disinfection in clear bottles by the combined action of UV radiation and heat, thermal disinfection (pasteurization) in opaque vessels with sunlight from solar cookers or reflectors and combination systems employing chemical coagulation-flocculation, sedimentation, filtration and chlorination. However each of these technologies have limitations and effectiveness can be increased by use of two or more treatment systems in succession for improved treatment and the creation of multiple barriers. In particular those treatments that provide no residual disinfectant, such as boiling, solar treatment, UV disinfection with lamps and filtration could be followed by chlorination to provide a multibarrier approach. Water purifiers based on multiple interventions such as filtration/ultra filtration/activated carbon adsorption / UV rays disinfection are available in the market which can be used to purify the water at point of use. Water purifiers based on single interventions like candle filters, resins filters or ultraviolet lamp can be used in most places being supplied water after purification. Troops on operational move can purify water by fabric/resins filtration and chlorine disinfection or by flocculent-disinfectant.Key Words: Household water purification, Low-cost interventions, Effectiveness     

Care of post-traumatic spinal cord injury patients in India: An analysis

Background:

The spinal cord injured patients if congregated early in spinal units where better facilities and dedicated expert care exist the outcome of treatment and rehabilitation, can be improved. The objective of this study is to find out the various factors responsible for a delay in the presentation of spinal injury patients to the specialized spinal trauma units and to suggest steps to improve the quality of care of the spinal trauma patients in the Indian setup.

Materials and Methods:

Sixty patients of traumatic spinal cord injury admitted for rehabilitation between August 2005 and May 2006 were enrolled into the study and their data was analyzed.

Results:

Eighty-five per cent of the spinal cord injured patients were males and the mean age was 34 years (range 13-56 years). Twenty-nine (48.33%) of the spinal injuries occurred due to fall from height. There was an average of 45 days (range 0-188 days) of delay in presentation to a specialized spinal unit and most of the time the cause for the delay was unawareness on the part of patients and/or doctors regarding specialized spinal units. In 38 (62.5%) cases the mode of transportation of the spinal cord injured patient to the first visited hospital was by their own conveyance and the attendants of the patients did not have any idea about precautions essential to prevent neurological deterioration. Seventeen (28.33%) patients were given injection solumedrol with conservative treatment, 35 (60%) patients were given only conservative treatment and seven patients were operated (11.66%) upon at initially visited hospital. Of the seven patients operated five were fixed with posterior Harrington instrumentation (71.42%) and two (28.57%) were operated by short segment posterior pedicle screw fixation. None of the patients were subjected to physiotherapy-assisted transfers or wheel chair skills or even basic postural training, proper bladder/ bowel training program and sitting balance.

Conclusion:

Awareness on the part of the general population, attendants of the patients, clinical and paraclinical team regarding spinal cord injury needs to be addressed. Safe mode of transportation of spinal cord injured patient and early presentation at tertiary spinal care center with comprehensive spinal trauma care team should be stressed upon.