Epileptic spasms in a child with infantile tremor syndrome: A rare case report and review of literature

Infantile tremor syndrome (ITS) is usually present in purely breastfed babies of vegetarian mothers with acute regression of developmental milestones, pallor with megaloblastic anemia, bleating goat like cry, knuckle, and other body site hyperpigmentation, apathy, listlessness, and brown scanty hair. This is usually due to Vitamin B12 deficiency and symptoms can be reversed with Vitamin B12 supplementation. There are only a few anecdotal case reports of seizure in children with ITS. Hereby, we are presenting a case of a child having epileptic spasms associated with ITS along with megaloblastic anemia with hypersegmented neutrophils in peripheral smear and high mean corpuscular volume. The child was successfully treated with Vitamin B12 supplementation and oral corticosteroids. This case report underscores the importance of considering the possibility of Vitamin B12 deficiency in any child presenting with megaloblastic anemia with either generalized tremulousness with or without seizures

Intermediate uveitis as an initial presentation of HLA B27 associated spondyloarthropathy in an adolescent boy: A rare case report and review of literature

Juvenile ankylosing spondylitis is less prevalent in children, and usually, children are presented to the hospital with chronic inflammatory back pain, enthesitis, and often hip and shoulder joint involvement. A significant proportion of these children develop ocular complications such as anterior and intermediate uveitis. Most of these children have HLA B27 positivity. On the other hand, in cases with anterior and intermediate uveitis, a considerable proportion has positivity for HLA B27 antigen. Few of these patients, later on, develop other clinical features suggestive of ankylosing spondylitis. However, there are only a few anecdotal case reports of similar HLA B27 associated intermediate uveitis, who later on developed juvenile ankylosing spondylitis. The current case is a 12-year old boy, who initially had bilateral intermediate uveitis with HLA B27 positivity without any other systemic or musculoskeletal features. However, on follow-up he developed enthesis and sacroiliitis suggestive of ankylosing spondylitis. Both rheumatological and visual complains had an excellent clinical response to corticosteroids in this child. The current case report demonstrates the importance of evaluation for HLA B27 positivity in all children with isolated intermediate uveitis, even if systemic and musculoskeletal examinations are normal

Fibreoptic intubation under conscious sevoflurane sedation in anticipated difficult intubation cases with unfavorable conventional airway preparation

Airway management in maxillofacial and head and neck cancer patients has remained a challenge even after significant development towards difficult airway management. When such patients have multiple difficult intubation predictors, management becomes more thought-provoking. Mucosal preparation and sedation play a vital role in producing co-operative patient and successful procedure but is not always feasible. On the other hand, intravenous sedation lacks titratability and reversibility. We describe awake fiberoptic intubation in three adult patients having multiple difficult intubation predictors whose airway preparation was not feasible due to obscured surface anatomy and nil mouth opening. The cases were done under titrated conscious sevoflurane sedation of MACage 0.4-0.6 using nasopharyngeal airway and closed circuit. This report highlights that Sevoflurane based conscious sedation is a feasible alternative for awake fiberoptic intubation in patients whose airway anesthesia and blocks are not possible

Assessment of phototherapy-induced hypocalcemia and its correlation with urinary calcium excretion in term and preterm newborns with neonatal hyperbilirubinemia: A cross-sectional study with controls

Introduction: Although hypocalcemia is often proposed to be associated with phototherapy in both term and preterm newborns, its exact incidence, clinical significance, and underlying mechanism still remain to be elucidated. Objective: The objective of this study was to determine the prevalence of hypocalcemia and its etiopathogenesis in terms of urinary calcium excretion. Methods: This study was carried out in a tertiary care center in North India with 50 neonates (29 term and 21 preterm) in the test group receiving single surface phototherapy. The other 50 age, sex, and gestational age-matched neonates were taken as controls who did not receive phototherapy. Serum calcium levels at 0 and 48 h and urinary calcium/creatinine ratio (mg/mg) at0 and 24 h of starting phototherapy were determined in both the groups and compared. Results: Total 12 preterm (57.1%) and 9 term newborns (31%) developed hypocalcemia after 48 h of phototherapy. The mean difference of serum ionized calcium between two groups was statistically significant at 48 h (4.58 mg/dl in the test group vs. 4.94 mg/dl in the control group, p<0.001). Percentage change in mean of urinary calcium/creatinine ratio at 24 h from baseline was 1.39% in the control group while it was 60.7% in the test group with statistically significant difference (p<0.001) between two groups. Only a weak negative correlation between serum ionized calcium and urinary calcium/creatinine ratio with correlation coefficient r=−0.316 could be established in the study among both term and preterm neonates. Conclusion: Both preterm and termneonates undergoing phototherapy are at increased risk for hypocalcemia and increased urinary calcium excretion. A universal recommendation regarding calcium supplementation in neonates undergoing phototherapy is yet to be established but seems like a reasonable intervention.&nbsp

An attempt at optimizing the flow characteristics of blast furnace slag by investigation of synthetic slags prepared in the laboratory using pure oxides

In the cohesive zone the ore layer becomes compacted due to softening-melting and the gas passes predominantly through the sandwiched coke layer (coke slits). Minimizing the size and lowering the position of the cohesive zone will improve productivity and decrease coke rate. This work is designed at arriving at a slag composition through actual experimentations which will ensure the lowering of the cohesive zone of the blast furnace with simultaneous decrease in the difference between the softening temperature (ST) and flow temperature (FT) of the slag. Slag samples from SAIL, Rourkela were brought and their flow characteristics were measured under the heating microscope. With the same composition as obtained from the plant, a synthetic slag was prepared in the laboratory. It was melted to 1600 °C and then water quenched to form the glassy state. Flow characteristics for the same were also determined. In addition, all slag samples were sent to DISIR, Rajgangpur for slag analysis as well as to determine the mineralogical phases present in them. For this, they heated the slag samples to 1500 °C followed by slow cooling to convert them to crystalline form. Then, XRD analysis was done to determine the mineralogical phases. Finally, with relevant phase diagram study, we arrived at a composition which will ensure the lowering of cohesive zone. Moreover, flow characteristics data of synthetic slag was compared with that obtained from Blast Furnace slag

Global injury morbidity and mortality from 1990 to 2017 : results from the Global Burden of Disease Study 2017

Correction:Background Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries. Methods We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs). Findings In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505). Interpretation Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.Peer reviewe

Adolescent transport and unintentional injuries: a systematic analysis using the Global Burden of Disease Study 2019

Background: Globally, transport and unintentional injuries persist as leading preventable causes of mortality and morbidity for adolescents. We sought to report comprehensive trends in injury-related mortality and morbidity for adolescents aged 10–24 years during the past three decades. Methods: Using the Global Burden of Disease, Injuries, and Risk Factors 2019 Study, we analysed mortality and disability-adjusted life-years (DALYs) attributed to transport and unintentional injuries for adolescents in 204 countries. Burden is reported in absolute numbers and age-standardised rates per 100 000 population by sex, age group (10–14, 15–19, and 20–24 years), and sociodemographic index (SDI) with 95% uncertainty intervals (UIs). We report percentage changes in deaths and DALYs between 1990 and 2019. Findings: In 2019, 369 061 deaths (of which 214 337 [58%] were transport related) and 31·1 million DALYs (of which 16·2 million [52%] were transport related) among adolescents aged 10–24 years were caused by transport and unintentional injuries combined. If compared with other causes, transport and unintentional injuries combined accounted for 25% of deaths and 14% of DALYs in 2019, and showed little improvement from 1990 when such injuries accounted for 26% of adolescent deaths and 17% of adolescent DALYs. Throughout adolescence, transport and unintentional injury fatality rates increased by age group. The unintentional injury burden was higher among males than females for all injury types, except for injuries related to fire, heat, and hot substances, or to adverse effects of medical treatment. From 1990 to 2019, global mortality rates declined by 34·4% (from 17·5 to 11·5 per 100 000) for transport injuries, and by 47·7% (from 15·9 to 8·3 per 100 000) for unintentional injuries. However, in low-SDI nations the absolute number of deaths increased (by 80·5% to 42 774 for transport injuries and by 39·4% to 31 961 for unintentional injuries). In the high-SDI quintile in 2010–19, the rate per 100 000 of transport injury DALYs was reduced by 16·7%, from 838 in 2010 to 699 in 2019. This was a substantially slower pace of reduction compared with the 48·5% reduction between 1990 and 2010, from 1626 per 100 000 in 1990 to 838 per 100 000 in 2010. Between 2010 and 2019, the rate of unintentional injury DALYs per 100 000 also remained largely unchanged in high-SDI countries (555 in 2010 vs 554 in 2019; 0·2% reduction). The number and rate of adolescent deaths and DALYs owing to environmental heat and cold exposure increased for the high-SDI quintile during 2010–19. Interpretation: As other causes of mortality are addressed, inadequate progress in reducing transport and unintentional injury mortality as a proportion of adolescent deaths becomes apparent. The relative shift in the burden of injury from high-SDI countries to low and low–middle-SDI countries necessitates focused action, including global donor, government, and industry investment in injury prevention. The persisting burden of DALYs related to transport and unintentional injuries indicates a need to prioritise innovative measures for the primary prevention of adolescent injury. Funding: Bill & Melinda Gates Foundation

Estimating global injuries morbidity and mortality : methods and data used in the Global Burden of Disease 2017 study

Background While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. Methods In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. Results GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. Conclusions GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.Peer reviewe

Mapping local patterns of childhood overweight and wasting in low- and middle-income countries between 2000 and 2017

A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1–70.8) million) to 6.4% (58.3 (47.6–70.7) million), but is predicted to remain above the World Health Organization’s Global Nutrition Target of <5% in over half of LMICs by 2025. Prevalence of overweight increased from 5.2% (30 (22.8–38.5) million) in 2000 to 6.0% (55.5 (44.8–67.9) million) children aged under 5 years in 2017. Areas most affected by double burden of malnutrition were located in Indonesia, Thailand, southeastern China, Botswana, Cameroon and central Nigeria. Our estimates provide a new perspective to researchers, policy makers and public health agencies in their efforts to address this global childhood syndemic

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens