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Background- Being a teaching hospital attached with a superspecialty school of Digestive and Liver disease a lot of gall bladder patients presents to us for treatment. This audit was done with the aim to understand the present epidemiological situation of carcinoma gall bladder in eastern India. Methods- All patients with carcinoma gall bladder who first presented in the year 2015 and 2016 were included in the study. Data was collected from the Departmental patient specific charts that are maintained in Departmental MR section. Results - there were 126 patients who were included in the audit. The average age of the patients were 52 years with 95% patients being in the age group of 40yrs 6 months and 63 years. 90(>75%) of these patients were Female while only 36 males. Contrary to the popular perception at the time of presentation only 10 patients out of 126 were obese. 60% of our patients (76) were smokers but only 11 had the habit of using chewable tobacco. Nearly half of them (65 out of 126) had either a prior or concurrent history of gallbladder stones. Concurrent history includes radiological evidence in inoperable carcinoma gall bladder. None of them were known to be typhoid carriers. In this group of patients 19 had periampullay carcinoma, one had concurrent GIST in stomach. The rest were proven carcinoma gall bladder with histologically / cytologically adenocarcinoma. 89 patients were non metastatic while 37 were metastatic. 31 of them were to liver, 3 to lung, one to lung and brain and 3 to distal paraaortic nodes. Most of the patients 95 out of 126, presented with pain abdomen. A fourth of them were clinically icteric and 52 out of 126 had raised bilirubin on biochemistry. Performace status was generally not good and there were no ECOG 0 or 1 patients. 38% of the patients had a perfornce status of ECOG 3. The rest (barring one whose ECOG was 4) had a PS of ECOG-2. Of the 89 non metastatic patients 19 were deemed surgically inoperable. 11 underwent Whipples procedure, to underwent surgical procedure which included liver bed resection, four were medically unfit for surgery. The rest of the patients underwent a cholecystectomy for carcinoma gall bladder of which nearly half (23) underwent lap cholecystectomy. 3 patients were found to be inoperable on table and the procedure had been abandoned. Out of the 37 metastatic patients, 10 were unfit for any therapy and was offered best supportive care. Rest were started on palliative chemotherapy with either GEMOX (21) or single agent Gemcitabine (6). 22 patients were kept on follow up post operatively while others had residual disease for which further chemotherapy was advised. OF these 22 patients with a median follow up time of 7 months, 6 had recurrence and had to be started on chemotherapy. Those offered post operative chemotherapy, the average number of cycles were 4.5 with 60% of them completing 6 cycles of chemotherapy. Conclusion- Cacinoma gall bladder is one of the common yet understated malignancies in India especially in females. The presentation is late with advanced disease. Treatment options are limited due to poor performance status and advanced disease status. [ABSTRACT FROM AUTHOR]

We studied with great interest the article titled "Acute diarrhea and severe dehydration in children: Does non-anion gap component of severe metabolic acidemia need more attention?" by Takia L et al. and would express our views about the same. Normal anion gap metabolic acidosis (NAGMA) is a common entity following stool loss of bicarbonate during an acute diarrheal illness. Several studies have shown that there is a higher incidence of hyperchloremic acidosis and acute kidney injury (AKI) with normal saline (NS) when compared to balanced crystalloids like Ringer's lactate (RL) or balanced salt solutions like plasmalyte. We would like to know about the type of resuscitation fluid used in the study population as it would affect the degree of resolution of acidemia. As per the World Health Organization (WHO) guidelines, rehydration therapy for children with severe acute malnutrition (SAM) is different from other children including the fluid used for bolus, i.e., RL and oral rehydration solution (ORS), i.e., rehydration solution for malnourished (ReSoMal). We would like to know if the study population included SAM children and a subgroup analysis of the same was done as SAM is an independent risk factor for mortality and morbidity. We suggest to plan studies on cognitive outcome of these children., How to Cite This Article: Pratyusha K, Jindal A. Normal Anion Gap: A Knowledge Gap. Indian J Crit Care Med 2023;27(4):298., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2023; The Author(s).)

Health care-associated infections (HAI) directly influence the survival of children in pediatric intensive care units (PICU), the most common being central line-associated bloodstream infection (CLABSI) 25-30%, followed by ventilator-associated pneumonia (VAP) 20-25%, and others such as catheter-associated urinary tract infection (CAUTI) 15%, surgical site infection (SSI) 11%. HAIs complicate the course of the disease, especially the critical one, thereby increasing the mortality, morbidity, length of hospital stay, and cost. The incidence of HAI in Western countries is 6.1-15.1% and in India, it is 10.5 to 19.5%. The advances in healthcare practices have reduced the incidence of HAIs in the recent years which is possible due to strict asepsis, hand hygiene practices, surveillance of infections, antibiotic stewardship, and adherence to bundled care. The burden of drug resistance and emerging infections are increasing with limited antibiotics in hand, is still a dreadful threat. The most common manifestation of HAIs is fever in PICU, hence the appropriate targeted search to identify the cause of fever should be done. Proper isolation practices, judicious handling of devices, regular microbiologic audit, local spectrum of organisms, identification of barriers in compliance of hand hygiene practices, appropriate education and training, all put together in an efficient and sustained system improves patient outcome., (© 2022. The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation.)

How to cite this article: Venkatesan DK, Goel AK, Pratyusha, K. FOCUS more on POCUS. Indian J Crit Care Med 2023;27(3):225., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2023; The Author(s).)

Modified heart rate, acidosis, consciousness, oxygenation and respiratory rate (HACOR) score takes into consideration pneumonia, cardiogenic pulmonary edema, pulmonary acute respiratory distress syndrome (ARDS), immunosuppression, septic shock, and the sequential organ failure assessment (SOFA) score prior to non-invasive mechanical ventilation (NIV) that would impact the success of NIV and are commonly seen in patients presenting to the emergency. Propensity score matching could have been done for similar distribution of baseline characteristics. Specific objective criteria are needed to define respiratory failure requiring intubation., How to Cite This Article: Pratyusha K, Jindal A. Non-invasive Ventilation Failure - Predict and Protect. Indian J Crit Care Med 2023;27(2):149., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2023; The Author(s).)

How to cite this article: Pratyusha K, Jindal A. Paroxysmal Sympathetic Hypertension: An Underdiagnosed Entity or a Diagnostic Difficulty? Indian J Crit Care Med 2023;27(2):151., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2023; The Author(s).)

How to cite this article: Pratyusha K, Jindal A. Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance: Views. Indian J Crit Care Med 2023;27(1):79., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2023; The Author(s).)

Background & Aims: Myocardial dysfunction is one of the common complications in children with chronic kidney disease which results in significant morbidity and mortality. We aimed to find the impact of anemia with cardiac changes in children with chronic kidney disease (CKD)., Methods: In this cross-sectional pilot study, 54 children (38 males) up to the age of 16 years with different stages of CKD, not on dialysis, were enrolled. Cardiovascular functions were evaluated using 2D-echocardiography using EPIC-7 (Philips) machine by an independent trained Pediatric Cardiologist. The M-mode measurements of the left ventricle were measured, indexed for body surface area and z-scores were calculated. They were divided into two groups i. e with and without anemia., Results: Out of the 54 children with CKD, children with and without anemia were 34 and 20 respectively. The end-diastolic volume was significantly higher in patients with anemia when compared with those without anemia (46.43 ± 16.49 ml vs 32.51 ± 4.98 ml). The mean left ventricular mass (59.54 ± 23.99 vs 37.24 ± 7.88 g) and end-diastolic thickness of the interventricular septum (0.73 ± 0.14 vs 0.54 ± 0.05 cm) was significantly elevated in CKD children with anemia., Conclusions: Left ventricular hypertrophy along with left ventricular dimension and left ventricular diastolic dysfunction was found to be significantly correlating with the degree of anemia. CKD children with anemia should be screened for underlying cardiac dysfunction and appropriate dietary modification and nutritional rehabilitation for iron deficiency should be addressed., Competing Interests: Declaration of competing interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2021 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Primary distal renal tubular acidosis (dRTA) or Type 1 RTA in children is caused by a genetic defect (involved genes ATP6V0A4 , ATP6V1B1 , SLC4A1 , FOXI1 , or WDR72 ), which causes tubular transport defects characterized by an inability to appropriately acidify urine with resultant persistent hyperchloremic metabolic acidosis. Retrospective analysis of 28 children (14 males) under the age of 14 years with dRTA seen from 2010 to 2019 was reviewed, and detailed clinic records were analyzed. The clinical features, investigations, and response to treatment were recorded. The median age of the children at presentation was 30 months (range: 9.25-72 months), and the median age at onset of symptoms was 2 months. All the children had growth failure, polyuria, and polydipsia at presentation. Mean serum potassium, pH, bicarbonate, and anion gap at presentation was 2.3 ± 0.5 mmol/L, 7.22 ± 0.09, 13.28 ± 4.37 mmol/L, and 9.3 ± 2.18, respectively. Mean serum potassium, pH, bicarbonate at follow-up was 3.88 ± 0.6 mmol/L, 7.35 ± 0.06, and 20.13 ± 4.17 mmol/L, respectively. The median z-score for the weight for age and height for age at initial presentation was -4.77 (-7.68 to -3.74) and -4.21 (-5.42 to -2.37) and at follow-up was -3.35 (-5.29 to -1.55) and -3.84 (-5.36 to -1.63), respectively. Twenty-two (78.6%) children had medullary nephrocalcinosis. Four children had sensorineural hearing loss. Seven children had genetic testing done, and six had pathogenic or likely pathogenic variants in ATP6V1B1 and ATP6V0A4 gene. Children with dRTA have a guarded prognosis and ATP6V1B1 and ATP6V0A4 mutations are the most common implicated genetic defect in Indian children with distal RTA., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Introduction: Congenital Cytomegalovirus (CCMV) infection is estimated to occur in 0.5% to 2% of all deliveries across the world. According to the available literature about Human Cytomegalovirus (HCMV) infected children, 0.5% to 1% acquire Cytomegalovirus (CMV) in utero, 40% acquire the infection within the first decade of life, between 15% to 70% acquire CMV infection in group day care settings and continue to shed the virus for 6 to 48 months after primary infection. Although, 90% of the infected infants are clinically asymptomatic at birth, shreds of evidence show that these infants are at risk for audiological, neurological, and developmental sequelae. Despite this, HCMV still remains undetected due to silent or asymptomatic nature of the virus., Aim: The present study was aimed to test the hypothesis that HCMV can be a potential aetiologic factor in the development of cleft lip/palate, mental retardation and deafness., Materials and Methods: The study was carried out in a controlled setting under strict aseptic conditions. Blood samples were collected from 80 children, who were selected strictly adhering to the inclusion criteria and were divided into four groups containing 20 children each. Group 1: 20 children with cleft lip/palate, Group 2: 20 mentally retarded children, Group 3: 20 completely deaf children and Group 4: 20 normal Children (control). The samples were tested for HCMV-specific Immunoglobulin G (IgG) and Immunoglobulin M (IgM) antibodies by using solid phase enzyme-linked immunosorbent assay and the obtained data were analysed statistically using ANOVA and Post-Hoc Tukey's tests., Results: In the study group (Group1, 2 and 3) children, the overall positivity for HCMV- specific IgG was 100% and 5% borderline to IgM antibodies whereas in the control group (Group 4) it was 80% negative to HCMV- specific IgG and 100% negative to IgM antibodies., Conclusion: From the observations noted in the present study, HCMV could be suggested as the potent aetiologic factor in the development of cleft lip/palate, mental retardation and deafness.