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Acute epiglottitis is an airway emergency presenting with edema and inflammation of the epiglottis and aryepiglottic folds [1]. Infectious and other non-infectious etiologies may cause significant airway injury presenting with similar clinical symptoms and radiographic findings [1]. While many causes of thermal epiglottitis have been described in the pediatric and young adult population, we describe an unusual case of an adolescent patient with cannabis induced thermal epiglottitis. A 17-year-old previously healthy, vaccinated adolescent male presented to the pediatric emergency department with dysphagia, odynophagia, drooling, and muffled voice with fever, tachypnea, and leukocytosis. Lateral plain film imaging and computed tomography (CT) scan showed significant edema of the epiglottitis. Urinary drug screen in the emergency department was positive for benzodiazepine, opiates, and cannabinoids. Transnasal flexible laryngoscopy and direct laryngoscopy demonstrated significant erythema, edema, and copious secretions. Culture of the epiglottis culture showed normal oropharyngeal flora. The patient was diagnosed with thermal induced epiglottitis secondary to cannabinoid use based on positive substance use history, urinary drug screen, and negative bacterial cultures. Clinicians must consider thermal injury of the epiglottitis due to substance use, specifically marijuana in vaccinated adolescent patients presenting with positive substance use history, progressive dysphagia, odynophagia, and drooling with a muffled voice. It is essential to obtain a thorough history and physical examination and urinary drug screen in the pediatric emergency department since the clinical and radiographic findings are similar in epiglottitis due to infectious and non-infectious etiologies. Prompt management with intubation should occur to protect and maintain airway integrity.

Antimicrobial resistance (AMR) is a major public health problem in India. We surveyed medical students to assess their knowledge, attitudes, and factors associated with confidence in antibiotic prescribing intent. In this cross-sectional study, a convenience sample of 356 students were surveyed in July–August 2017 on AMR-related knowledge, attitudes, information sources and antimicrobial training. Antimicrobial resistance knowledge and attitude scores were calculated. Bivariate analysis using the chi-square test of independence and multivariate binary logistic regression analysis were used to investigate factors associated with confidence in antibiotic prescribing intent. A total of 347 students completed the survey; 64% agreed that strong knowledge of antibiotics is important in their medical careers; 61% stated that they would like more education regarding appropriate use of antibiotics. The mean total knowledge score was 11.5 out of 31 (SD = 3.4), and the mean attitude score was 6.0 out of 16 (SD = 4.2). Although 13% of students were “very familiar”/“familiar” with the term “antimicrobial stewardship,” only 35% of students felt “very confident” or “confident” in antimicrobial prescribing to patients in the future. On multivariate analysis, female gender, clinical vignette antimicrobial knowledge scores, positive attitude scores, awareness of Infection Control Policy, and > 3 years of antimicrobial prescribing clinical training were predictors of confidence in antimicrobial prescribing. A higher attitude score was independently associated with decreased confidence in antimicrobial prescribing intent. There is a need to improve education regarding AMR in the curriculum, and increase awareness of infection control policies and antimicrobial stewardship program in clinical settings.

Zika virus (ZIKV) infection is a public health problem in the Americas. We assessed ZIKV knowledge, attitudes, and future ZIKV vaccine intent among medical students. In this cross-sectional study, a convenience sample of medical students in San José, Costa Rica, were surveyed to assess knowledge, attitudes, vaccine intent, and sources of information about ZIKV. Knowledge and attitude scores were calculated. Factors associated with vaccine intent were determined by bivariate analysis using a chi-square test. Of 468 participants surveyed, majority were females (299, 63.8%) and lived in urban areas (411, 87%). The participant mean knowledge score was 12.2 (SD: 3.65) out of a possible 20. Students residing in suburban or rural areas (odds ratio [OR]: 0.432; CI: 0.24–0.78), first- or second-year students (OR: 0.423; CI: 0.27–0.67), and aged < 20 years (OR: 0.586; CI: 0.36–0.97) had significantly lower knowledge scores. The participant mean attitude score was 30.2 (SD: 4.76) on a scale of 13–65, with lower numbers indicating a concern for ZIKV severity. A majority of the participants indicated they would be likely or extremely likely to receive a ZIKV vaccine (420, 89.7%) and recommend the vaccine to their patients (439, 93.8%). Vaccine intent was not influenced by demographics, total knowledge, and attitude scores. Students (388, 83%) identified the Internet as their primary source of ZIKV information. A majority of students demonstrated a positive attitude toward ZIKV and willingness to accept and recommend a vaccine. Low knowledge scores underscore the need for ZIKV education, especially in the early years of medical school. Use of the Internet should be considered in dissemination of ZIKV education.

Chronic hepatitis B virus (HBV) infection is a major public health problem in China. We evaluated the impact of psychosocial factors (stigma, disclosure, depression, and anxiety) on health-related quality of life (HRQoL) among people living with chronic HBV infection (CHB) in the city of Dalian, Liaoning Province, China. In this hospital-based cross-sectional study, 401 patients living with chronic HBV infection were enrolled as study participants. Study measures included the Beck depression and anxiety inventory, the WHO Quality of Life (WHOQOL-BREF) assessment, the Toronto Chinese HBV Stigma Scale, and disclosure of HBV status to sexual partners. The primary outcome was HRQoL score as measured by the WHOQOL-BREF. A linear regression model was used to examine the association between HRQoL and the potential risk factors including stigma, disclosure, depression, anxiety, and sociodemographic variables. Stigma, disclosure, depression, and anxiety were the covariates of interest. A majority of the participants were females (n = 251, 65.6%), married (81.6%), and had a college or higher degree (32.4%). Depression, anxiety, stigma, and disclosure of HBV infection were associated with low HRQoL in all four domains of the WHOQOL-BREF (physical, psychological, social, and environmental domains) (P < 0.05), when all psychological factors were included in the model separately. Depression was found to be independently associated with low HRQoL in people living with HBV, when all psychological factors were included in the model simultaneously (P < 0.0001). Our data indicate the urgent need for healthcare providers (HCPs) and policy-makers to implement psychological interventions to improve HRQoL among people living with CHB.

New Delhi metallo-β-lactamase-1 (NDM-1) is a novel type of metallo-β-lactamase (MBL) associated with Enterobacteriaceae constitutes an important growing public health threat. The present study aims to characterize the NDM-1 producing Gram-negative bacteria (GNB) from the effluents of two tertiary care hospitals in Mangalore, South India and to profile their antibiotic resistance pattern. A total of 134 GNB were isolated from 30 hospital wastewater samples (treated and untreated) and analyzed. High-level resistance among untreated effluent sample was found toward nalidixic acid (74.52%), followed by cefotaxime (72.64%) and ampicillin (66.03%). Among the treated effluent isolates, the high resistance was found toward ampicillin (85.71%) followed by cefotaxime (85.71%) and piperacillin-tazobactam (53.57%). From untreated effluent isolates, 9 were NDM-1 positive by PCR; no isolates from treated effluent samples harbored blaNDM-1 . Untreated hospital wastewater is found to be important reservoirs of antibiotic-resistant bacteria carrying blaNDM-1 , and the presence of such bacteria in the effluents is a matter of great concern because they can contribute the antibiotic resistance to the natural environment. However, the absence of NDM in treated effluents emphasizes the importance of effluent treatment in reducing the dissemination of antibiotic-resistant bacteria. PRACTITIONER POINTS: Hospital wastewater is the important reservoir of antibiotic-resistant bacteria especially metallo-β-lactamase producers (NDM-1). Wastewater treatment procedures in hospitals reduce the NDM isolates in the treated effluent. Thereby reduces the risk of resistance spread in the environment.

In India, cervical cancer associated with human papillomavirus (HPV) infection is a leading cause of cancer-related mortality among women. However, uptake of the vaccine in India is low. We assessed knowledge and attitudes towards HPV, assess participants' willingness to accept the vaccination for themselves and their children, and determine factors associated with intention to receive the HPV vaccine among women in Mangalore, India. This cross-sectional study surveyed a convenient sample of 237 women aged 18-45 years using a semi-structured questionnaire. All respondents reported being aware of HPV infection. However, 22.36% (n = 53) of the respondents have never heard about genital warts and 18.57% (n = 44) have never heard about HPV vaccine. Participants displayed good general knowledge of HPV infection (median score, 1.26; Interquartile Range (IQR): 1.04-1.52) and average knowledge of HPV vaccine (e.g., median score, 1.18; IQR: 0.73-1.45). HPV general knowledge and vaccine knowledge were associated with intention to receive the HPV vaccine and recommend it to children. Participant awareness of the HPV vaccine predicted vaccine intent for themselves. Participants' willingness to recommend the vaccine for their children was associated with older age, married status, having one or more children, and having a college education. Lack of awareness about genital warts was strongly associated with participants' refusal to get the HPV vaccine or recommend it for their own children (Relative Risk Ratio RRR: 12.21; 95% C.I.: 2.33-63.99). Our study validated the questionnaire as a reliable tool for assessing HPV and HPV vaccine knowledge, attitudes, awareness, and vaccine intentions in women aged 18-45 years. Public health education should focus on increasing awareness of genital warts as a sequela of HPV, as well as promote awareness of role and safety of HPV vaccination in -children.

Human Papillomavirus (HPV) has been identified as an important risk factor that predisposes to cervical cancer. Traditionally the Papanicolaou (Pap) smear test has been routinely used for the detection of premalignant lesions in the uterine cervix. However, due to the rise in false positive and negative results, advanced molecular techniques like PCR are more sensitive and reliable. This study aimed to assess the burden of HPV infection in women with normal and abnormal Pap testing attending a tertiary care hospital. Methods A total of 126 sexually active women were recruited for cervical examination in this cross sectional study. Cervical exfoliated cells were collected for cytology and HPV analysis. DNA was extracted and HPV detection was performed using nested PCR technique. Results HPV prevalence was higher in women with abnormal cytology infection (12.5%) compared with those who had normal Pap smear(3.8%); HPV 16 was found to be the most common subtype. Younger age at marriage, multiple sexual partners, and multiparity were found to be the most important confounding factors in the acquisition of HPV. Conclusion The current study demonstrated the presence of high-risk HPV in cervical smear specimens irrespective of normal and abnormal cytology, and hence emphasizes the need for implementation of effective national cervical cancer screening programs that could decrease the burden of cervical cancer in India.

Objective: Safe and effective human papillomavirus vaccines are available against cervical cancer and other human papillomavirus–associated diseases. Vaccine uptake is low in India given lack of universal vaccination programme. This exploratory study describes the medical, dental and nursing undergraduate student perspectives about human papillomavirus and intentions to receive the vaccine. Methods: Using a cross-sectional, explorative study design, we conducted two focus group discussions among a convenience sample of male (n = 11) and female (n = 9) student group aged ⩾18 years, respectively, at a medical college in South India. The focus group discussion sessions were recorded, transcribed and analysed using thematic content analysis. Results: Over half of the students showed adequate knowledge of cervical cancer and human papillomavirus. Medical students had much in-depth knowledge of cervical cancer, vaccine cost and its side effects compared to dental and nursing students. Human papillomavirus vaccine knowledge was relatively less among males compared to females; most male participants were unaware of the availability of the human papillomavirus vaccine. Intention to receive the vaccine was higher among females than males. All the participants had positive attitude in creating awareness in the community and making the vaccine cost-effective. Cultural concerns and high vaccine cost were cited major barriers for vaccine uptake. Suggestion of physician recommendation in promotion of human papillomavirus vaccine uptake was an emerging theme. Conclusion: Educating male students and those enrolled in dental and nursing courses about human papillomavirus vaccine, addressing cultural concerns and advocating provider recommendation for promoting vaccine uptake are potential strategies to improve future human papillomavirus vaccine intent among students and recommendations to patients in their role as future healthcare provider.

The study aimed to screen for the presence of multidrug-resistant Klebsiella pneumoniae from diarrheal stool and environmental water samples and to check the epidemiological link between the two categories. Isolates obtained after culturing on different media were tested for antibiotic resistance and extended-spectrum beta-lactamase (ESBL) production. Polymerase chain reaction (PCR) analysis was done for important β-lactamase encoding genes. Random amplified polymorphic DNA (RAPD) typing was done using two primers. Results showed a high prevalence of K. pneumoniae from fish market effluents compared with stool and well water. Stool isolates showed high resistance to ceftazidime (80.0%) and cefepime (80.0%), fish market effluent isolates to cefoperazone-sulbactam (92.1%), and erythromycin (78.9%), while well water isolates to erythromycin (72.7%) and cefuroxime (54.4%). The ESBL genes blaCTX , blaSHV , and blaTEM were detected in 22.85%, 14.28%, and 42.85% of K. pneumoniae isolates, respectively. The results of RAPD-PCR showed high genetic similarities between the isolates from different sources. PRACTITIONER POINTS: Detection of multi-drug resistant Klebsiella strains in hospital wastewater and drinking water sources has progressively increased since its emerging resistance to third-generation cephalosporins and carbapenems. Detection of beta-lactamase encoding genes by molecular techniques and typing by random amplified polymorphic DNA (RAPD) can be useful in identifying the genetic fingerprints for epidemiological study. Implementation of effective antimicrobial stewardship program and infection control policy thereby helps assess the risk factors associated with infections.

Cervical cancer is the second leading cause of cancer and one of the leading causes of cancer-related death in women in India. Human papillomavirus (HPV) vaccine uptake in India is low due to cost, low awareness of HPV, social stigma, and other factors. We assessed the awareness, attitudes, and beliefs regarding HPV and HPV vaccination and explored the barriers and challenges to HPV vaccine intent among women in Mangalore, India. An exploratory study was conducted using two focus group discussions (FGDs) and six in-depth one-on-one interviews. FGD-1 comprised nine women aged 18 to 26 years, and FGD-2 comprised seven women aged 27 to 45 years. The FGDs were recorded, transcribed, and analyzed using thematic content analysis. Themes identified were limited knowledge of HPV and vaccine, stigma associated with receiving HPV vaccine, vaccine safety concerns, and cost as a barrier to receiving vaccine. Participants expressed desire for physician and government recommendation of the HPV vaccine to validate vaccine intent. Contrasting themes between the two FGDs include support for vaccination at a younger age and lower perception of stigma and judgment in the 18- to 26-year-old group; however, participants in the 27- to 45-year-old group support vaccination at an older age and endorse greater fear of stigma and judgment associated with obtaining vaccination. Education regarding HPV-associated diseases and the HPV vaccine for the general public, physicians, and government officials in conjunction with lowering vaccine cost, improving vaccine access, and encouraging strong physician recommendations are key strategies to scale up HPV vaccine implementation in India.

Postoperative pain after total knee arthroplasty (TKA) is an important determinant of hospital stay and rehabilitation and thereby functional outcome. Adductor canal block (ACB) and intraarticular analgesic infiltration through catheters (IAC) are techniques of multimodal analgesia which have shown to control postoperative pain satisfactorily. The aim of this study is to evaluate the efficacy of ACB versus IAC in reducing immediate postoperative pain and thereby allow early rehabilitation. A multicenter quasi-experimental study was conducted on 511 patients undergoing unilateral primary TKA from March 2016 to April 2017 who either received ACB with catheter (Group I, n = 350 patients) or IAC (Group II, n = 172 patients) for postoperative pain control. All the patients were assessed for severity of pain by Visual Analogue Scale at 8, 24, 48, 72 h postoperatively and knee range of motion (ROM) on the day of discharge. There was no significant difference in pain scores on postoperative day (POD) 0 (1.09 ± 0.30 vs. 0.98 ± 0.46, p = 0.45) and POD 1 (1.21 ± 0.45 vs. 1.00 ± 0.00, p = 0.11) and in mean ROM on the day of discharge between ACB and IAC (88.40° ± 7.96° vs. 88.34° ± 5.74°; p = 0.93) groups. This study shows that both ACB and IAC provide satisfactory postoperative analgesia with sparing of quadriceps function and good knee ROM leading to early rehabilitation and reduced hospital with no advantage of one technique over another.

This case highlights the need for accurate and rapid testing for SARS-CoV-2 and also underscores the need for caregivers to remain vigilant for COVID-19 in the post-operative setting despite negative pre-operative testing.

A previously healthy 15-year-old boy from a rural county in the southeastern United States was evaluated in the emergency department with fever and worsening toe pain in the absence of trauma. He initially presented to his primary care physician 4 weeks before with upper respiratory symptoms and was treated with corticosteroids for presumed reactive airway disease. His respiratory symptoms resolved. One week after this presentation, he developed fever and right great toe pain and presented to an outside hospital. Inflammatory markers were elevated. MRI confirmed a diagnosis of osteomyelitis with associated periosteal abscess. He was treated with intravenous antibiotics and drainage of the abscess. Ten days after his discharge from the outside hospital, he developed fever and had increasing drainage of the toe and pain refractory to oral pain medications. He presented to our facility for further evaluation. Repeat MRI and inflammatory markers corroborated his worsening disease, and he was admitted to the hospital for intravenous antibiotics and underwent serial surgical debridement. He developed painful subcutaneous nodules on his lower extremities and was found to have lung abnormalities on chest radiograph. A multispecialty team collaborated in the management of this patient and unveiled a surprising diagnosis.

1. Margaret A. Singer, MD* 2. Ashton Chen, DO† 3. Avinash Shetty, MD† 4. Steve Hodges, MD‡ 1. *University of Minnesota 2. †Department of Pediatrics, 3. ‡Department of Urology, Wake Forest University Medical Center, Winston-Salem, NC 1. Address correspondence to Ashton Chen, DO, Department of Pediatrics, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: achen{at}wakehealth.edu This is a fascinating case report that demonstrates findings and treatment of urinary schistosomiasis while also revealing variations in patient care across varying settings. In the United States, this child received what the authors describe as “gold standard” care—involving a diagnostic surgical procedure and multiple visits with multiple subspecialists. If this child had stayed in Mali, he most certainly would have had received a clinical diagnosis of schistosomiasis and effective treatment with oral praziquantel—without any diagnostic testing. Outside of the endemic area, some reasonable clinicians would still have treated presumptively, and others would have opted for treatment based on symptoms and serologic confirmation of schistomal infection, realizing, as the authors point out, that positive serology alone does not prove an active infection. Still, other clinicians might have opted to test multiple concentrated urine samples (especially the urine produced at the end of voiding) without a surgical search for the definitive diagnosis. All readers of Index of Suspicion can learn from this case and then decide how best to implement diagnostic and therapeutic interventions in their own settings based on careful analysis of the various risks and benefits. Phil Fischer, Former Section Editor, Index of Suspicion A 13-year-old boy presents with a 7-year history of recurrent, gross hematuria. Referred by his pediatrician, he is being evaluated by a pediatric nephrologist. Each episode of hematuria, which he experiences about every 2 months, occurs mid-urine stream and without associated dysuria, fever, or abdominal pain. He is under guardianship of …

The caregivers of HIV-positive children either delay or avoid disclosure of HIV status to the child due to several reasons. Keeping the child's HIV status a secret puts them at considerable risk of stopping therapy and transmitting HIV to others. Hence this study was conducted to assess the determinants of disclosure of HIV status to infected children in coastal Karnataka. A cross-sectional study was conducted in a District Hospital in Coastal Karnataka from October 2014 to July 2015. One hundred eighty-five caregivers were recruited for the study purposively and interviewed using a pre-tested, semi-structured questionnaire after written informed consent. Of the 185 caregivers interviewed, 78 (42%) caregivers had not disclosed the HIV status to the child. The child being too young was the most common reason for non-disclosure of HIV status. The majority of the caregivers intended to disclose the HIV status fully to the child after the child attained ten years of age. Nearly two-thirds of the caregivers wanted to disclose it themselves in their own homes. The significant determinants of disclosure of HIV status were the age of the child, and person involved in childcare, and the venue of the disclosure.

Background: Children with disabilities are expected to have poor nutritional status in comparison to children without disabilities. However, limited data on nutritional status of children with and without disabilities in rural settings in India. Objective: To assess and compare the nutritional status of children with and without disability. Methods: A cross-sectional study among children aged 5–15 years was conducted in the rural practise area of a medical college in Karnataka. 290 children (145 with and 145 children without disability) of similar age and sex were studied. Age and sex-specific World Health Organization (WHO) BMI centiles, 24 h dietary calorie and protein intakes were assessed and compared. Median and interquartile ranges were calculated for quantitative variables. Mann–Whitney U test was used to assess the differences in quantitative variables among the two groups. Results: As per WHO BMI centiles, 33.1% with and 37.20% without disabilities were undernourished. The median calorie consumed by children with disabilities was 1169.0 (946.5–1586.0) significantly lower compared to that of children without disability, that is, 1362.0 (1167.0–1641.0). The median protein consumed by children with disabilities was 28.0 (22.5–38.0) significantly lower compared to that of children without disability, that is, 32.0 (28.0–40.0). Conclusions: Children with disabilities had similar rates of undernutrition as that of their non-disabled peers and their lesser dietary intake in terms of calories and proteins.

Introduction: Community Acquired Pneumonia (CAP) is associated with high morbidity and mortality worldwide. Knowledge of common microbial patterns in CAP is crucial for making initial therapeutic decisions for empiric antimicrobial treatment. Aim: To determine the bacterial aetiology of CAP among hospitalised patients in a tertiary care hospital of Southern India. Materials and Methods: A descriptive study was carried out among 220 adult subjects, enrolled from a period of August 2012 to August 2014, admitted to a tertiary care hospital of Southern India, with a provisional diagnosis of CAP. Subjects were recruited based on chest radiography and clinical criteria. Blood, sputum, pleural fluid, Bronchoalveolar Lavage (BAL) and tracheal aspirates were obtained for microbiological investigations. Antimicrobial susceptibility testing was carried out on Streptococcus pneumoniae and Staphylococcus aureus isolates. The clinical specimens were further subjected to Polymerase Chain Reaction (PCR) to confirm the bacterial aetiology of S.pneumoniae and Haemophilus influenzae. Study data were summarised by frequency and percentage using SPSS (Statistical Package for Social Sciences) version 16.0. Results: A total of 220 subjects who were diagnosed for CAP of which 154 (70%) were culture negative and 66 (30%) were culture positive cases of CAP. The most commonly isolated pathogens were 29 (44%) of S.pneumoniae followed by 21 (32%) of S.aureus, 10 (15%) of H.influenzae and 6 (9%) of Klebsiella pneumoniae. Resistance to penicillin occurred in 24 (82.75%) of S.pneumoniae isolates. Methicillin-Resistant Staphylococcus aureus (MRSA) was demonstrated among 10 (48%) of the 21 total S.aureus CAP cases. Conclusion: Culture-based aetiologic diagnosis of CAP was made in only one-third of the cases. Ongoing antimicrobial resistance surveillance to S.pneumoniae and S. aureus is recommended. Determining the resistance profile of Klebsiella pneumoniae and H.influenzae is needed as pneumonia caused due to Gram negative aetiology is rising in the community setting. Rapid screening of bacterial CAP pathogens from clinical samples using PCR may be beneficial for clinicians to make a prudent antibiotic choice for CAP.

Late presentation to healthcare by HIV infected patients’ is common in India despite access to free combination antiretroviral therapy (cART). We assessed risk factors for late presentation among patients with a recent HIV diagnosis in an academic university–based antiretroviral treatment center. This retrospective study included 474 recently diagnosed HIV-infected patients registered for cART between 2012 and 2013. Subjects with CD4(+) T-lymphocyte (CD4) count ≤ 350 cells/μL or with an AIDS defining event were defined as late presenters (LP) and patients with CD4 count ≤ 200 cells/μL or with an AIDS defining event were defined as LP with advanced HIV disease (LPAD). Multivariable logistic regression analysis was used to investigate factors associated with late presentation. Of the 474 patients, 356 (75.1%) were LP. Of these, 299 (83.99%) were LPAD and 57 (16.01%) LP were AIDS-free. Median CD4 count among LP was 134 cells/μL (interquartile range 72.25–219). Mean age of LP was 42.50 ± 8.88 years; 256 (71.9%) were males. Increasing age (> 51 years; Adjusted odds ratio [aOR] 4.19; P = 0.014) and rural residence (aOR 3.19; P = < 0.001) were independently associated with late presentation. HIV-positive housewives (aOR 0.34; P = 0.027), HIV-positive individuals with negative partners (aOR 0.48; P = 0.006), and partners with unknown HIV status (aOR 0.43; P = 0.007) were less likely to present late compared with positive partners of people living with HIV/AIDS (PLWHA). Most patients were LP despite free access to cART. Rural population and older PLWHA should be targeted while implementing HIV care. There is a need to strengthen the HIV care cascade by linking PLWHA to cART immediately after diagnosis.

Background Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory condition in children that may acutely mimic septic shock. Sudden out-of-hospital cardiac arrest in children is also uncommon and may be of unclear etiology upon initial presentation. Case Report A 10-year-old previously healthy child presented with sudden cardiac arrest after an insidious course of throat pain, fever, and progressive altered mental status. He was subsequently diagnosed with Epstein-Barr virus-associated HLH and suffered cerebral edema and death. Why Should an Emergency Physician be Aware of This? HLH has not previously been described as a cause of sudden out-of-hospital cardiac arrest in children. Rapid diagnosis of underlying cause of an unexpected cardiac arrest may help guide appropriate therapy to salvage organ function.

Aim To evaluate the local treatment-seeking behaviors of diabetics with a focus on the root causes of culture-specific barriers to treatment compliance and define targets for intervention. Methods A cross-sectional survey was administered in the local language to 204 diabetic adults in rural and urban clinical settings. Fasting blood glucose level was measured in all participants prior to the survey. Questions included sociodemographic characteristics, treatment-seeking behavior, and perceptions of obstacles. Results Out of 204 participants, predictors of at target status included age (OR 1.06, 95% CI 1.02–1.11) and rural living area (OR 1.92, 92% CI 1.02–3.60). Participants were commonly diagnosed with symptoms of diabetes (44.6%). Participants demonstrated frequent healthcare provider contact (51% in last one month, 74.5% in last three months). Accidental or purposeful deviation from the recommended medications or treatment plan was reported by 18.7% and 12.8%, respectively. From the sample, 111 participants (54.4%) were capable of receiving SMS messages and 79 (71.1%) were willing to receive messages about diabetes. The most frequently self-reported obstacles to diabetes management were: medication costs (49.3%), treatment costs (46.6%), diabetic diet (33.8%), lack of relief on current treatment (17.4%), and transportation (16.7%). Conclusion Though most diabetics have frequent encounters with healthcare providers and report compliant behaviors, the majority do not meet recommended diabetes management guidelines. Screening of at-risk populations, targeted SMS campaigns, or diabetes-specific training for healthcare providers may improve clinical outcomes.

Assessment of health-related quality of life (HRQoL) in children with HIV is crucial to improve the psychosocial well-being of this vulnerable population. The objective of this study was to assess the HRQoL of children with HIV infection aged between 5 and 18 years. The study was conducted in 144 children with HIV attending an antiretroviral therapy (ART) center in Karnataka to assess the HRQoL, using the PedsQL questionnaire. Total 144 children were included in the study, who had HRQoL with good physical (75.99 ± 13.46), psychosocial (71.01 ± 12.83), and total (72.43 ± 12.73) scores according to the child's perspective. Number of boys and children raised in foster homes were 51.3% (74) and 56% (81), respectively. Even though all children had complete adherence and had a good immunologic and clinical profile, we found that their HRQoL did not vary with stage of infection, duration of treatment, or immunologic status. Our findings underscore the importance of family-centered care for children living with HIV and advocate enhancing psychosocial and mental development to improve the HRQoL of children.

The role of parents is very pivotal in a child’s overall development. Discussing about adolescent changes especially reproductive health (RH) is still considered a taboo in our society. Even imparting sex education at schools has remained a debatable topic in India. The aim of our study was to study the perception of parents and teachers about adolescent upbringing with a special focus on RH, services and schemes provided for RH of adolescents. A qualitative study was conducted in rural–urban settings in two districts of Coastal Karnataka. By the technique of stratified purposeful sampling, 50 parents and 40 teachers in the age group of 30–60 years participated in 10 focus group discussions (FGD). All participants were related to adolescents. For data collection, a pre-tested FGD guide was used. All tape-recorded data was fully transcribed and thematic analysis was done. Bad peer company, excessive restrictions, bad habits, misconceptions about sex, mobiles, internet-negative influence, and sexual harassment were few factors that parents were worried about. When compared to males, they believed that female adolescents suffer both physically and mentally. Male adolescents do not have any “reproductive health problems”. All parents were unaware of any health care services provided for adolescents by the government.

Background: Antibiotic overuse is a major public health challenge worldwide. Data from India related to physician antibiotic prescribing patterns are limited. Aims: We assessed antibiotic prescribing knowledge, attitudes, and practices among physicians in Mangalore, South India. Materials and Methods: Using a cross-sectional descriptive study design, physicians at academic tertiary hospitals completed an anonymous on-site survey. The survey items incorporated Likert scales, and data were analyzed using SPSS version 15.0. Results: Of the 350 physicians approached using a convenient sampling method, 230 (66%) consented and interviewed. The physician's knowledge of resistance patterns of common bacteria was related to receiving periodic updates on resistance patterns of bacteria (P = 0.019) and participation in courses on antibiotics (P = 0.026). Individuals with more number of years of experience (mean of 11 years) were less likely to justify antibiotic use for uncomplicated bronchitis (P = 0.015) and acute gastroenteritis (P = 0.001). Most respondents (n = 204, 89%) believed that physicians overprescribed antibiotics in routine clinical practice. Forty-five percent (n = 104) stated that their hospitals did not have an infection control policy in place. Conclusions: This study provides some understanding of physician's antibiotic prescribing patterns from teaching hospitals in India. Judicious antimicrobial use through educational and antimicrobial stewardship programs remains critical to control the spread of antibiotic resistance.

Key Clinical Message The diagnostic utility of fine needle aspiration cytology to detect a wide variety of opportunistic pulmonary infections in an immunocompromised host has been studied. Fine needle aspiration cytology techniques are safer, cost‐effective and provide rapid results.

In recent years, there has been a substantial increase in refugee and asylum-seeking adults, adolescents and children to high-income countries. Infectious diseases remain the most frequently identified medical diagnosis among U.S.-bound refugee children. Medical screening and immunization are key strategies to reduce the risk of infectious diseases in refugee, internationally adopted, and immigrant children. Notable infectious diseases affecting refugee and other newly arriving migrants include latent or active tuberculosis, human immunodeficiency virus type 1 (HIV), hepatitis B, hepatitis C, vaccine-preventable diseases, malaria, and other parasitic infections. The U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics have published guidelines for health assessment of newly arriving immigrant, refugee, and internationally adopted children. Although, data on the health risks and needs of refugee exists in some high-income countries, there is an urgent need to develop robust evidence-informed guidance on screening for infectious diseases and vaccination strategies on a broader scale to inform national policies. Innovative approaches to reach migrant communities in the host nations, address health and other complex barriers to improve access to high-quality integrated health services, and strong advocacy to mobilize resources to improve health, safety, and wellbeing for refugee children and their families are urgent priorities.

Purpose: To evaluate knowledge, attitudes and factors associated with acceptability of human papillomavirus (HPV) vaccine among undergraduate medical, dental, and nursing students in South India. Methods: Using a post-test study design, a convenience sample of 988 students (age 18–26 years) were surveyed. The primary outcome was vaccine acceptability (likely to intend to receive the vaccine). Bivariate analysis using Chi-Square test of independence and multivariate binary logistic regression analysis was used to examine factors associated with vaccine acceptability. Results: Out of 988 students surveyed, majority had heard about cervical cancer (95%), HPV (89.3) or genital warts(77.5). Only 59.7% had heard of HPV vaccine prior to the survey; 65.2% intended to receive the vaccine and 68.3% were willing to recommend the vaccine to others. Participants aged

Background: The epidemiology of acute hematogenous osteomyelitis (AHO) in children has changed. Methods: We reviewed the current literature regarding the epidemiology, microbiology, pathogenesis, clinical presentation, diagnosis, and antimicrobial management of AHO in children. Results:Staphylococcus aureus is the most common microorganism causing pediatric AHO, followed by group A Streptococcus (GAS). AHO due to community-associated methicillin-resistant Staphylococcus aureus (MRSA) can cause severe and complicated disease. Pathogen isolation by culture is key for targeted antibiotic therapy. Polymerase chain reaction assay in tissue sample or joint fluid may enhance the yield of Kingella kingae. C-reactive protein is useful in diagnosis and monitoring the course of AHO. Magnetic resonance imaging is the preferred diagnostic imaging study for AHO. Clindamycin or vancomycin (for serious disease) is recommended for empiric therapy of suspected AHO due to MRSA depending on the geographic prevalence. Penicillinase-stable penicillins or first-generation cephalosporins are preferred antibiotics to treat methicillin-sensitive S aureus (MSSA) infection. Beta-lactam agents are the drugs of choice for treating AHO due to K kingae, GAS, or Streptococcus pneumoniae. For uncomplicated AHO due to MSSA, a short parenteral antibiotic course followed by oral therapy for a minimum total duration of 3-4 weeks is adequate. Complicated AHO due to MRSA may warrant prolonged therapy with surgical intervention. Conclusion: Given the evolution of pathogens, the variability in clinical presentations and course ranging from simple to complex disease, and response to treatment, the management of AHO continues to evolve and warrants an individualized, multidisciplinary approach.

Septic arthritis in children is a medical emergency, needing prompt diagnoses, drainage of the synovial space, and antimicrobial therapy to prevent poor outcomes. The most common mode of transmission is hematogenous dissemination to the synovial joint. Septic arthritis is most commonly seen in boys and mainly affects the weight-bearing joints. The most common bacteria are dependent on age, but across all age groups, Staphylococcus aureus is the most common. To appropriately diagnose and treat septic arthritis, a multidisciplinary approach with microbiology support, radiologists, pediatricians, rheumatologists, infectious disease specialists, and orthopedic surgeons is ideally needed. Septic arthritis in a child, especially of the hip, is a medical emergency and requires urgent orthopedic consultation for surgical drainage and joint space irrigation (Laine, J PediatrOrthop B24(2):95–98, 2015). Prompt initiation of empiric parenteral antibiotics at high doses against Staphylococcus aureus is needed in all age groups. Empiric intravenous therapy against Kingella kingae is recommended in patients 3 months to 5 years of age, as it is becoming the predominant organism in this age group in some settings. A transition to oral therapy is made by clinical/laboratory/microbiological improvement with expected duration of therapy from 2 to 4 weeks. It is essential for patients to have close follow-up to prevent poor outcomes such as limb length discrepancy, hip dislocation, osteoarthritis, avascular necrosis of the femoral head, and ankylosis.

Considerable progress has been made towards reducing under-5 childhood mortality in the Millennium Development Goals era. Reduction in newborn mortality has lagged behind maternal and child mortality. Effective implementation of innovative, evidence-based, and cost-effective interventions can reduce maternal and newborn mortality. Interventions aimed at the most vulnerable group results in maximal impact on mortality. Intervention coverage and scale-up remains low, inequitable and uneven in low-income countries due to numerous health-systems bottle-necks. Innovative service delivery strategies, increased integration and linkages across the maternal, newborn, child health continuum of care are vital to accelerate progress towards ending preventable maternal and newborn deaths.

Acute appendicitis is a common disease afflicting the pediatric population. There are textbook presentations of periumbilical abdominal pain that migrates to the right lower quadrant with following nausea, possible diarrhea, anorexia, fever and eventual sepsis. The abnormal presentations are difficult to sort at times and varying presentations have been noted. The differential should remain broad in evaluating patients as our case illustrates. Keywords: Acute appendicitis, Amyand hernia, Scrotal abscess